Laparoscopic treatment of a non-congenital diaphragmatic hernia

Authors

Abstract

A step-by-step approach is explained for the laparoscopic management of a diaphragmatic hernia in a patient with a past surgical history of Nissen fundoplication. Preoperative and postoperative CT-scans are shown.

Keywords

laparoscopy, treatment of diaphragmatic hernia

Media type

Duration

05'05''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2426.htm

Laparoscopic treatment of a non-congenital diaphragmatic hernia

1. Clinical case presentation 00'12''

This is the case of a 43-year-old man with a previous surgical history of Nissen fundoplication operated on in 1996. The patient was referred to our unit with repeated episodes of colicky abdominal pain with no associated respiratory distress.

2. CT-scan examination 00'29''

A CT-scan was performed and showed a diaphragmatic hernia with migration of the colon in the left pleural space. The patient is placed supine in reverse Trendeleburg with arms and legs apart. Tilting the table at a 30 degree angle facilitates gravitation of abdominal viscera out of the thorax.

3. Diagnostic laparoscopy and hernia defect identification 00'52''

A diagnostic laparoscopy is performed to visualize the hernia defect and any associated pathology. The exploratory laparoscopy shows a normal looking Nissen fundoplication placed in an intra-abdominal position surrounded by a few adhesions. The diaphragmatic defect is identified at about 15cm from the hiatus in the left hemi-diaphragm.

4. Hernia reduction 01'16''

The intervention begins with reduction of the hernia into the abdominal cavity. The content of the hernia is progressively reduced using atraumatic bowel graspers on the mesentery. Adhesions are taken down using sharp dissection by means of the Ligasure device and cold endoscopic scissors. A relaxing lateral incision on the neck of the hernia defect is required to facilitate the reduction of its contents and to avoid bowel injury. The whole colon together with its meso is herniated above the diaphragm. Four trocar are used: a 12mm trocar for a 0 degree scope is placed 5cm above the umbilicus, and 3 additional 5mm trocars are then introduced, the first 4cm above the optical trocar at the midline, then on the left mid-clavicular and left axillary line. Exploration of the left pleural cavity shows the left lung pushed all the way up to the apex without any visible injury. Once the edges of the defect are defined and freed, the defect itself measured about 5cm in diameter. The spleen and the transverse colon now back into a normal intra-abdominal position, they are carefully inspected for any inadvertent injuries. Now to the closure.

5. Hernia defect closure 03'45''

The defect is closed by 4 U-stitches of non-absorbable 2/0 Ethibond sutures. Although no tension is encountered when approximating the margin of the orifice, a suitable-sized 15 by 15cm Prolene (polypropylene) mesh is chosen to reinforce the closure and is secured above the hernia defect with a few intracorporeal stitches. No thoracic drain is left in place. The postoperative course was uneventful. In the immediate postoperative period, the patient was thoroughly monitored for any signs of symptoms of chest trauma. A chest X-ray performed on postoperative day 1 was negative with no apparent pneumothorax and correct lung expansion.

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