1. Surgical unit-ii Benazir Bhutto hospital Rawalpindi
Case Presentation
Surgical unit-ii
Benazir Bhutto hospital
Rawalpindi

2. History Pain Epigastrium 8 months
Patient XYZ, a 30 years old Male, resident of Kashmir, Driver by Profession, presented in Surgical OPD in December 2015 with the complaints of:
Pain Epigastrium 8 months
Bloating 5 years
Indigestion 6 years

3. The Pain was of mild to moderate intensity, radiated to the Left Hypochondrium, stabbing in character.
The patient experienced the pain usually immediately after waking up and it was relieved to some degree by taking PPIs.
The pain worsened on lying down straight and the patient had been sleeping with the head-end of his bed elevated for the past 6 months.

4. The pain was also aggravated after taking large meals which had led the patient to eat cautiously and take small, unfulfilling meals.
The patient frequently had woken up from his sleep due to his pain over the past 6 months.

5. The pain was occasionally associated with nausea and vomiting.
The vomitus which accompanied the pain was yellowish in color and almost 50 ml in quantity.

6. The patient described the pain as being a badgering nuisance in his life which had led him to eat less and disturbed his sleep many a times.
This Profound disturbance also manifested behavioral changes in the patients life.
The patient had become irritable and some what anti-social in the last 4-5 months.

7. Despite taking treatment for the past 3 years and changing his life style and eating habits significantly in the last 6 months the patient did not experience significant improvement in his symptoms.
According to the patient his quality of life had significantly deteriorated in the past couple of months.

8. The patient had a history of Extra Pulmonary Tuberculosis 13 years back for which he took Anti Tuberculous Therapy for 9 months.
The patient underwent 3 Upper GI endoscopies, the latest of which was done in November 2015.
The patient had been taking regular PPIs for the last 3 years.
The patient had consulted numerous Physicians for his symptoms in the past 3 years.
He had taken H. Pylori Eradication regimen in November 2015.

9. Systemic Inquiry of the patient was unremarkable.
The patient DID NOT SMOKE and had no addictions.

10. CLINICAL EXAMINATION A THIN, young man sitting comfortably in his bed.
Pulse: 70/min
BP: 110/70
Temperature: Afebrile
Respiratory rate: 18/min
Rest of the General Physical Examination was unremarkable.

11. Respiratory System: Unremarkable
Cardiovascular System: Unremarkable
Abdominal Examination: Mild tenderness in the Epigastric region.
Neurological Examination: Unremarkable

12. DIFFERENTIAL DIAGNOSES
The Differential Diagnoses included:
GERD
Hiatal Hernia
Cholelithiasis
Peptic Ulceration

13. INVESTIGATIONS
The CBC, Liver Function, Renal Function Tests and Ultrasound Abdomen of the patient were Normal.
Upper GI Endoscopy showed Pan Gastritis with a Suspicion of Hiatus Hernia.
A Barium Meal Study was ordered.

14. AP
LAT

15. The Barium Meal study showed a Sliding Hiatal Hernia.
A final diagnosis of GERD with Sliding Hiatal Hernia was made

16. Plan
The FAILURE OF CONSERVATIVE MANAGEMENT and the severely IMPAIRED QUALITY OF LIFE of the patient led us to consider Surgical Intervention in our patient.

17. Management The patient was extensively counselled by the Surgeon.
The counselling session included a detailed discussion of the extent of Benefits offered by Surgery.
The patient was insistent and repeatedly demanded that surgery be done as he had grown weary of the disease and its effects on his life.

18. A Laparoscopic Nissen Fundoplication was planned.
Informed Consent for the Surgery was taken from the patient.
The surgery was performed under General Anesthesia.

19. Operating Room layout

20. Port placement

21. Key Steps