Open Rives-Stoppa retrorectus mesh repair resolves gastric outlet obstruction in a patient with class III obesitySurgery Helps Resolve Gastric Obstruction in Patient With Severe Obesity

BackgroundGastric outlet obstruction (GOO) caused by a paraumbilical hernia is exceptionally rare. The stomach is normally tethered by its peritoneal attachments and seldom migrates into a midline ventral defect; reported cases have almost exclusively involved elderly patients, in whom acquired ligamentous laxity has been invoked as a permissive factor.Case descriptionA 38-year-old man with lifelong class III obesity (peak BMI 48.2 kg/m2), severe obstructive sleep apnoea and a sliding hiatal hernia presented with a one-year history of daily post-prandial non-bilious vomiting, learned self-induced emesis to relieve hernia distension, profound unintentional weight loss (from 126.4 to 89 kg, a 30% reduction) and chronic constipation. Examination revealed a giant irreducible paraumbilical hernia. Contrast-enhanced computed tomography (CT) demonstrated a fascial defect measuring 5.6 × 7.5 cm (transverse × cranio-caudal) containing small bowel, transverse colon, omentum and stomach, with a transition point at the distal antrum and pylorus indicating extrinsic GOO and no evidence of malignancy. Endoscopy showed two-level extrinsic compression at the gastric body and pylorus, retained food in the proximal stomach, and could not easily be passed across the pyloric constriction; a nasojejunal feeding tube was placed under direct visualisation. Pre-operative biochemistry was unremarkable apart from hypokalaemia (potassium 2.78 mmol/L), which was corrected before surgery; serial bioelectrical impedance and hand-grip dynamometry suggested preserved muscle mass during prehabilitation. An open Rives–Stoppa retrorectus mesh repair was performed; the intra-operative defect measured 5 × 10 cm (transverse × cranio-caudal) and the contents were viable. Recovery was uneventful. At the most recent review, he was asymptomatic with a full oral diet and regular bowel function.ConclusionGOO from a stomach-containing paraumbilical hernia can occur in young patients with severe obesity, where chronically raised intra-abdominal pressure and progressive intra-sac extrusion of viscera through a stable but capacious defect, rather than ligamentous laxity, account for migration of the stomach into the sac. A high index of suspicion, multi-detector CT, formal volumetric loss-of-domain assessment, multidisciplinary optimisation, and retromuscular (Rives-Stoppa) repair offered satisfactory short-term resolution in this patient, with longer follow-up required to confirm durability. The case is reported in accordance with the CARE 2013 reporting guidelines.