Delayed Strangulated Hiatal Hernia Post-gastrectomy Masquerading as Diaphragmatic Hernia: A Diagnostic Pitfall.

Abstract

Strangulated diaphragmatic hernia (DH) is an uncommon but life-threatening complication that can occur years following major upper gastrointestinal (GI) surgery. Its delayed presentation often leads to diagnostic delays and increased morbidity. Unlike common traumatic or congenital diaphragmatic hernias, this case illustrates a delayed hiatal herniation secondary to postoperative anatomical alteration and lack of crural repair after total gastrectomy. We report a 36-year-old man who developed acute epigastric pain and vomiting two years after undergoing total gastrectomy with Roux-en-Y reconstruction for Siewert III gastroesophageal junction adenocarcinoma. Imaging revealed a strangulated left diaphragmatic hernia with herniation of the Roux and biliopancreatic limbs, including the oesophagojejunostomy. Emergency surgery required conversion to a thoracoabdominal approach for safe reduction and repair. The patient recovered uneventfully. Delayed DH should be considered in patients with a history of hiatal dissection presenting with acute symptoms. Early cross-sectional imaging and prompt surgical intervention are essential. Prophylactic crural closure during initial surgery may reduce future hernia risk.