Acute coronary syndrome was ruled out with cardiac evaluation . Abdominal computed tomography ( CT ) revealed a large diaphragmatic hernia containing portions of the stomach , transverse colon , pancreas , and abdominal fat ( Figure 1 , Figure 2 ). The patient underwent robotic-assisted hiatal hernia revision . Intraoperatively , the entire stomach , half of the transverse colon , the splenic flexure , the pancreas neck , and a portion of the pancreas body were intrathoracic . The abdominal contents were liberated from the thoracic cavity and the crura were re-approximated . Postoperatively the patient reported significant symptom improvement and denied any further symptoms at her three-month follow-up .
DISCUSSION
Hiatal hernias are characterized by the herniation of abdominal contents through the esophageal hiatus of the diaphragm into the thoracic cavity . 1 They are common and evaluated and managed by general and thoracic surgeons . Approximately 55- 60 % of individuals over the age of 50 years have a hiatal hernia , with roughly 9 % experiencing symptoms . 1 Hiatal hernias are classified into four types based on the displacement of the gastro-esophageal junction and contents of the hernia . 1 , 2 Type I hiatal hernias constitute 95 % of cases , occurring when the gastroesophageal junction is displaced superiorly through the diaphragm . 1 , 2 Type II hiatal hernias are defined as paraesophageal displacement of the fundus of the stomach , with a non-displaced gastroesophageal junction . 1 , 2 Type III hiatal hernias consist of both a paraesophageal hernia and a displaced gastroesophageal junction . 1 , 2 Type IV hiatal hernias account for only 0.1 % of all hiatal hernias and occur when the stomach as well as an additional abdominal organ herniate into the chest . 1 , 2 Type IV hiatal hernias described in the literature most commonly involve bowel extension into the thoracic cavity . Because the head , neck , and body of the pancreas are retroperitoneal , intrathoracic herniation is extremely rare . Most reported cases describe herniation of the tail or the body , with only three reported cases of herniation of the neck . 3 , 4 , 5
Symptoms of type IV hernias may include dysphagia , dyspepsia , nausea , vomiting , dyspnea , and epigastric or chest pain . 2 Diagnostic imaging includes barium swallow radiography , endoscopy , and manometry . 1 , 6 While CT imaging is not typically recommended , hiatal hernias are often incidentally discovered on abdominal or thoracic CT scans . 6 Surgical intervention is recommended for symptomatic patients with Type II , III , or IV hernias due to the risk of gastric volvulus , as well as for persistently symptomatic Type I hiatal hernias . 6
CONCLUSION
This case describes the presentation of a severe Type IV hiatal hernia involving portions of multiple intrathoracic organs . We report the extremely rare herniation of the neck of the pancreas into the thoracic cavity .
ACKNOWLEDGMENTS
We gratefully acknowledge the contributions of all individuals and institutions who have supported and contributed to this research project and acknowledge the patient for granting permission to present their case .
REFERENCES
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Intrathoracic major duodenal papilla with transhiatal herniation of the pancreas and duodenum : A case report and review of the literature . World J Gastrointest Surg . 2013 ; 5 ( 6 ): 202-206 . doi : 10.4240 / wjgs . v5 . i6.202
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