Giant Type IV Paraesophageal Hernia with Sever Loss of Domain: A Case Report and Review of Surgical Principles

Abstract

Background: Type IV paraesophageal hernia represents the most advanced and least common form of hiatal hernia, characterized by herniation of the stomach along with additional abdominal viscera into the thoracic cavity. Chronic intrathoracic displacement may result in significant loss of abdominal domain, increasing operative complexity and the risk of postoperative intra-abdominal hypertension. Preoperative radiological quantification plays a crucial role in surgical planning. Case Presentation: A 51-year-old hypertensive postmenopausal female presented with progressive dyspnea on exertion and intermittent retrosternal discomfort. Examination revealed reduced air entry over the left lower lung zone. Contrast-enhanced computed tomography demonstrated herniation of the stomach, transverse colon, small bowel loops, distal pancreas, and splenic vessels up to the D5 vertebral level with mediastinal shift. Volumetric analysis revealed a Tanaka index of 0.75, consistent with severe loss of domain. Elective open transabdominal repair with complete sac excision, posterior cruroplasty, and 360° fundoplication was performed successfully. Conclusion: Giant Type IV paraesophageal hernias with severe loss of domain require meticulous preoperative assessment and individualized operative planning. Open repair provides controlled reduction and durable reconstruction in high-complexity cases.