近期，吴淼教授、彭孟寅医师、周世波医师团队近期为一位罕见的Ⅳ型食管裂孔疝、胃食管反流、双侧胸腔受挤压的患者实施了腹腔镜微创手术（无张力疝修补术+胃底Nissen折叠术）。术中见疝内容物为：胃底、部分胃体、部分横结肠及大网膜，且疝内容物疝入侧双侧胸腔，尤其是大范围疝入右侧胸腔、压迫右肺。

Recently, the team of Professor Wu Miao, Dr. Peng Mengyin, and Dr. Zhou Shibo performed a laparoscopic minimally invasive surgery (tension-free herniorrhaphy + Nissen fundoplication) on a patient with a rare type IV esophageal hiatal hernia, gastroesophageal reflux, and bilateral thoracic cavity compression. During the procedure, the herniated contents were found to include the gastric fundus, part of the gastric body, part of the transverse colon, and the greater omentum. These contents had herniated into both thoracic cavities, with a large portion extending into the right thoracic cavity and compressing the right lung.

突入双侧胸腔的疝（图片3D处理）

Hernia protruding into bilateral thoracic cavities (3D image processing)

术后胃镜下见“折叠瓣”---重建的抗反流重要解剖结构

Postoperative gastroscopy revealed the reconstructed key anti-reflux anatomical structures.

食管裂孔疝的危害：

一、功能紊乱（Ⅰ型滑动疝多见）  

顽固性胃食管反流：因His角变钝、膈肌脚“弹簧夹”作用丧失，酸反流导致反流性食管炎、巴雷特食管（癌前病变）。

呼吸道误吸：夜间反流物进入喉咽部，表现为慢性咳嗽、哮喘、反复吸入性肺炎。很多患者首诊在呼吸科而漏诊。

二、机械性梗阻与缺血

糜烂与贫血：疝入胃壁黏膜在膈肌裂孔处往返摩擦，导致隐匿性慢性失血、缺铁性贫血。

胃扭转风险：胸内胃倒转超过180°即出现 “三联征” ：剧烈胸骨后痛、干呕、胃管置入困难。

三、胸内占位效应与脏器损伤（Ⅳ型独有）

这层危害是也最凶险：

心肺挤压：右侧胸腔被疝入的横结肠、胃体占据，导致右肺不张、纵隔左移、回心血量减少。患者平卧即感胸闷气紧，严重时可致梗阻性休克。

隐匿性结肠绞窄：横结肠系膜血管在疝环处受卡压。因结肠血供比胃差，Ⅳ型疝是唯一容易直接导致结肠缺血坏死的分型。术中发现横结肠颜色变暗需高度警惕延迟性穿孔。

右侧脓胸隐患：结肠疝入纵隔一旦发生微小穿孔或系膜撕裂渗血，脓液和肠道菌群直接落入右侧胸膜腔，形成包裹性脓胸，处理极为棘手。