UNASSIGNED: Diaphragmatic hernias with strangulated contents are a surgical challenge. Thoracoabdominal incisions are commonly used for a variety of thoracic and vascular cases, although rarely used for diaphragmatic hernias, which are typically repaired with laparotomy, thoracotomy, or minimally invasive approaches.
UNASSIGNED: We present the unique case of a 60-year-old, critically ill unstable patient with severe heart failure with a reduced ejection fraction (15-25%) and severe valve disease presenting with a left-sided diaphragmatic hernia containing strangulated small intestine and requiring urgent surgical exploration. This was safely and efficiently repaired via a thoracoabdominal approach at the index surgery, with intestines left in discontinuity and placement of temporary chest and abdominal closure. At the second planned operation, good continuity was successfully restored.
UNASSIGNED: The patient had early extubation, gradual diet advancement with full recovery, and discharge home on postoperative day 17.
UNASSIGNED: A thoracoabdominal incision can safely be used in large strangulated diaphragmatic hernias, including in critically unstable patients. This approach provides rapid access to both the chest and abdomen with excellent, speedy, and safe exposure, which can save a life in extreme conditions.

Approximately 3-6% of patients undergoing anti-reflux surgery require \"redo\" surgery for persistent gastroesophageal reflux disease (GERD). Further surgery for patients with two failed prior anti-reflux operations is controversial due to the morbidity of reoperation and poor outcomes. We examined our experience with surgical revision of patients with at least two failed anti-reflux operations.
Adults undergoing at least a second-time revision anti-reflux surgery between 1999 and 2017 were eligible. The primary outcomes were general and disease-specific quality-of-life (QoL) scores determined by Short-Form-36 (SF36) and GERD-Health-Related QoL (GERD-HRQL) instruments, respectively. Secondary outcomes included perioperative morbidity and mortality.
Eighteen patients undergoing redo-redo surgery (13 with 2 prior operations, 5 with 3 prior operations) were followed for a median of 6 years [IQR 3, 12]. Sixteen patients (89%) underwent open revisions (14 thoracoabdominal, 2 laparotomy) and two patients had laparoscopic revisions. Indications for surgery included reflux (10 patients), regurgitation (5 patients), and dysphagia (3 patients). Intraoperative findings were mediastinal wrap herniation (9 patients), misplaced wrap (2 patients), mesh erosion (1 patient), or scarring/stricture (6 patients). Procedures performed included Collis gastroplasty + fundoplication (6 patients), redo fundoplication (5 patients), esophagogastrectomy (4 patients), and primary hiatal closure (3 patients). There were no deaths and 13/18 patients (72%) had no postoperative complications. Ten patients completed QoL surveys; 8 reported resolution of reflux, 6 reported resolution of regurgitation, while 4 remained on proton-pump inhibitors (PPI). Mean SF36 scores (± standard deviation) in the study cohort in the eight QoL domains were as follows: physical functioning (79.5 [± 19.9]), physical role limitations (52.5 [± 46.3]), emotional role limitations (83.3 [± 36.1]), vitality (60.0 [± 22.7]), emotional well-being (88.4 [± 8.7]), social functioning (75.2 [± 31.0]), pain (66.2 [± 30.9]), and general health (55.0 [± 39.0]).
An open thoracoabdominal approach in appropriately selected patients needing third-time anti-reflux surgery carries low morbidity and provides excellent results as reflected in QoL scores.