Laparoscopic repair of diaphragmatic hernias: experience of six cases

OBJECTIVE: Laparoscopic diaphragmatic hernia repair is increasingly performed in adults for congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias. This study reviewed our experience with laparoscopic diaphragmatic hernia repair to evaluate its safety, efficacy and outcomes. METHODS: Between January 1999 and December 2002, four male and two female patients presented to us with diaphragmatic hernias, three with traumatic and three with congenital hernias. The mean age of patients was 58.6 years (range, 42-83 years). Five patients presented with main complaints of postprandial retrosternal/chest discomfort and one patient had an acute gastric outlet obstruction. Dissection was performed laparoscopically to reduce the contents of the sac and the hernial defect was repaired using prolene sutures and a polypropylene mesh. RESULTS: Laparoscopic repair of diaphragmatic hernias was completed successfully in all patients. The mean size of the defect was 6.8 cm (range, 3-12 cm) and the mean operative time was 100 minutes (range, 60-150 minutes). There were no major intraoperative complications. One patient required placement of a chest tube due to inadvertent opening of the pleura with the hernial sac and one patient had prolonged postoperative gastric ileus. The mean hospital stay was 2.3 days (range, 1-4 days) and the mean pain score was 4 (range, 2-6). All patients remained asymptomatic over a mean follow-up of 2.9 years. CONCLUSION: Adult congenital and chronic traumatic diaphragmatic hernias are amenable to laparoscopic repair. Laparoscopic repair is safe and feasible and confers all the advantages of minimal access surgery.     

Thoracoscopic surgery for congenital diaphragmatic hernia: a report of nine cases

PURPOSE: To describe the surgical technique and early results of thoracoscopic repair of congenital diaphragmatic hernia (CDH) in children. MATERIALS AND METHODS: A retrospective review was undertaken of patients with CDH who underwent thoracoscopic surgery in our institution over a period of 15 months. There were nine patients, five boys and four girls, ranging in age from 7 days to 8 years. All nine patients underwent surgery under general anaesthesia. Reduction of the hernia contents was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mmHg. The hernia defect was repaired using non-absorbable interrupted sutures. RESULTS: The hernia was located on the left side in seven patients and on the right side in two. The mean operative time was 80 minutes. In all patients, the chest tube was removed on the first postoperative day. All patients were discharged on the fifth postoperative day. Chest X-ray and clinical examination 3 months after surgery were normal in all patients. CONCLUSION: The thoracoscopic approach for the repair of CDH in children, including small infants and newborns, is feasible and safe. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.     

Thoracoscopic repair for right congenital diaphragmatic hernia

PURPOSE: The aim of this study is to describe the surgical technique and initial results of thoracoscopic repair for the right congenital diaphragmatic hernia (CDH). METHODS: Patients underwent surgery under conventional general anesthesia. The operation was carried out by using one optical and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-4 mm Hg. The hernia defect was repaired by using nonabsorbable interrupted sutures with extracorporeal knots. RESULTS: There were 16 patients, including 13 boys and 3 girls. Six patients were newborns and the other 10 patients were infants or elders. The mean operative time was 82 minutes. Conversion was required in 1 patient. There were no operative or postoperative complications. However, there was one postoperative death. There was one recurrence on postoperative day 39. Follow-up ranged from 2 to 77 months. A normal chest X-ray was shown in all patients. CONCLUSION: Thoracoscopic repair is feasible and safe for children with a right CDH, including selected newborns.     

Thoracoscopic patch repair of a right-sided congenital diaphragmatic hernia in a neonate

Purpose  Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate operative technique for the management of congenital diaphragmatic hernias in neonates [1–3]. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in a 3-day-old male. Methods  Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient’s remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD), and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed with a thoracoscopic repair of the CDH. Results  The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully repaired thoracoscopically using a 5 × 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and division at 1 month of age. There has been no evidence of CDH recurrence in follow-up. Conclusions  As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in a neonate with significant congenital cardiac anomalies. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Laparoscopic repair of Morgagni hernia

BACKGROUND: Morgagni hernia is a rare type of diaphragmatic hernia which represents less than 5% of all congenital diaphragmatic hernias. Patients are generally asymptomatic and are diagnosed incidentally. When symptomatic, it generates symptoms due to the compression of thoracic organs or compression of herniated intraabdominal organs. Once diagnosed, the condition requires prompt surgical correction. The defect is repaired either by primary suture or by the use of a prosthetic mesh. In adults, prosthetic mesh repair is preferred. Recently, laparoscopic repair of Morgagni hernia has been introduced and gained wide acceptance. MATERIALS AND METHODS: Between 2002 and 2004, 5 patients with Morgagni hernia were treated laparoscopically at our department. Female/male ratio was 3/2. Mean age was 56 years (range 41 to 69 y). Diagnosis were made by chest x-ray and CT scan. Herniation was on the left in 2 patients, and on the right in 3. The content of hernial sac was transverse colon and stomach. There were 2 separate defects in a patient with left-sided hernia. All cases were laparoscopically treated using prosthetic material. RESULTS: All operations were completed laparoscopically. The postoperative hospital stay was 3 to 5 days with a mean of 4 days. None of the patients developed any complication in the early postoperative period. The mean follow-up period is 7 months (range 3 to 24 mo). All patients are actually in good health and without recurrence. CONCLUSION: Laparoscopic repair of Morgagni hernia is a safe, simple, and reliable procedure which presents all the advantages of the minimally invasive surgery.     

Hand-assisted thoracoscopic repair of a Bochdalek hernia in an adult

BACKGROUND: Bochdalek hernias are congenital diaphragmatic hernias that are generally asymptomatic and often discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by open abdominal or thoracic approaches. MATERIALS AND METHODS: A healthy 24-year-old male presented with an 8-month history of shortness of breath. The patient was noted to have a postero-lateral diaphragmatic hernia, with a 4 cm defect in the left hemidiaphragm seen with computed tomography scan. He underwent hand-assisted video-assisted thoracoscopic surgery, in which the herniated omentum was reduced and the defect was repaired primarily and reinforced with Marlex mesh. The patient recovered uneventfully and was discharged home after a short hospitalization. CONCLUSION: Video-assisted thoracoscopic surgery for repair of Bochdalek hernias offers diagnostic as well as therapeutic advantages as it provides an excellent view of the surgical field, is easily executed, results in minimal surgical trauma, and has excellent cosmetic results and rapid recovery. We report a hand-assisted intracorporeal thoracoscopic repair to be a secure and satisfactory adjuvant to achieve the repair and conclude that thoracoscopic repair of the rare Bochdalek hernia is feasible.     

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey–Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.     

Laparoscopic repair of congenital bilateral Morgagni hernia

Morgagni hernia is a rare type of congenital diaphragmatic hernia found in the anterior aspect of the diaphragm. It typically presents in the pediatric population and rarely is diagnosed in adults. Only 3% of diaphragmatic hernias are the Morgagni type, and only 4% of these are found to present bilaterally. Surgical repair of Morgagni hernia has been performed through various approaches including open, laparoscopic, thoracotomy, and video-assisted thoracoscopic surgery (VATS), all with and without mesh. The optimal method of surgical repair is not known due to the rarity of this condition and the limitations of setting up a prospective, randomized trial to evaluate the different methods. Laparoscopic repair with mesh has been described with good short-term results. Few case reports exist in the world literature describing laparoscopic repair of a bilateral Morgagni hernia with mesh. At the University of Washington, the authors present a video showing their technique for laparoscopic repair of a congenital, bilateral Morgagni type hernia with mesh.     

Video. Laparoscopic repair of congenital bilateral Morgagni hernia

Morgagni hernia is a rare type of congenital diaphragmatic hernia found in the anterior aspect of the diaphragm. It typically presents in the pediatric population and rarely is diagnosed in adults. Only 3% of diaphragmatic hernias are the Morgagni type, and only 4% of these are found to present bilaterally. Surgical repair of Morgagni hernia has been performed through various approaches including open, laparoscopic, thoracotomy, and video-assisted thoracoscopic surgery (VATS), all with and without mesh. The optimal method of surgical repair is not known due to the rarity of this condition and the limitations of setting up a prospective, randomized trial to evaluate the different methods. Laparoscopic repair with mesh has been described with good short-term results. Few case reports exist in the world literature describing laparoscopic repair of a bilateral Morgagni hernia with mesh. At the University of Washington, the authors present a video showing their technique for laparoscopic repair of a congenital, bilateral Morgagni type hernia with mesh.     

Laparoscopic repair of a Morgagni-Larrey hernia

Morgagni-Larrey hernia is a congenital type of diaphragmatic hernia. It is quite uncommon, particularly when it occurs on the left side of the diaphragm. This is a report of a case of a large left-side diaphragmatic hernia through the foramen of Morgagni treated by laparoscopy. The hernia was repaired by incorporating and fixing a polypropylene double-filament mesh into the defect, leaving the sac in mediastinum. The patient recovered promptly after the hernia repair, and there was no recurrence or complaints 30 months after surgery. Our conclusion is that laparoscopically repairs of Morgagni hernias with a prosthetic material are a safe and effective treatment. A literature review also shows that laparoscopic techniques are the gold standard in diaphragmatic hernias repairs.     

Congenital massive hiatus hernia type IV; initial experience with laparoscopic repair in young infant

Congenital massive hiatus hernia (CMHH) is an uncommon disorder during childhood. It can be associated with grave complications especially if presented in the highest grade; type IV, when the hernia contains other intra-peritoneal organ beside the stomach through a large hiatus defect. The insidious form of clinical presentation can be deceptive in diagnosis and may mimic congenital diaphragmatic hernia or other chest pathologies. The basic principle of surgical repair is to reduce the herniated organs, excise the hernia sac, and repair the crural defect and to add anti-reflux procedure with or without gastropexy. Traditionally, this has been done by open approach. Nowadays, the minimally invasive approach is the preferred method of treatment. A sixteen-month-old boy with history of recurrent respiratory symptoms was diagnosed with CMHH type IV for which laparoscopic repair was performed. Few reports in using minimally invasive technique in the management of CMHH in the pediatric age group are present in the literature, to the best of our knowledge type IV had never been described in young infants. We present a new case repaired by laparoscope in a young infant with CMHH type IV from the Middle East.     

Pericardiodiaphragmatic hernia

Twenty-seven reported cases of pericardial diaphragmatic hernia are reviewed and another case is added. This entity may be congenital or traumatic in origin, the latter being more frequent at a ratio of 2:1. All patients except one were male and the mean age at diagnosis was 40 years. The patients were usually symptomatic, the most frequent complaints being of cardiac or respiratory origin. Pneumoperitoneum may be diagnostic although chest roentgenograms and contrast studies may suggest the diagnosis. Computed axial tomography and echocardiography may prove useful in the future. We believe the anterior abdominal approach is preferable to the transthoracic approach in reducing the hernia and repairing the defect because it affords better exposure and easier accessibility to other intraabdominal disease and can easily be converted into a median sternotomy if needed. The stomach and transverse colon became herniated most frequently and in only three cases was a sac found. The defect involves the central leaflet of the diaphragm and primary repair generally results in a good prognosis.     

Laparoscopic repair of Morgagni diaphragmatic hernia

Background: Morgagni diaphragmatic hernia is a rare congenital hernia that lies retrosternal through a congenital defect between the sternal and costal portions of the diaphragm. Surgical repair of Morgagni hernia is recommended because incarceration or strangulation of bowel within the thoracic cavity may occur. Methods: A case of Morgagni diaphragmatic hernia is presented and laparoscopic repair using Gore‐Tex DualMesh is described. Results: There was complete resolution of the patient’s symptoms including her dyspnoea. There were no postoperative complications. Conclusion: Laparoscopic repair of Morgagni diaphragmatic hernia is a safe and effective method for treating this rare surgical condition. The use of dual‐layer mesh allows tension‐free repair without the risk of intra‐abdominal adhesions forming between bowel and mesh.     

Bochdalek diaphragmatic hernia in the elderly: a case report]

We successfully treated surgically an elderly patient, a 80-year-old woman, with Bochdalek diaphragmatic hernia. She had intermittent episodes of intestinal obstruction. A preoperative chest roentgenograph revealed a loop of gas-filled bowel in the left chest and elevation of the left diaphragm. CT scanning of the thorax revealed the bowels filled with gastrografin in the left thoracic cavity. She was treated surgically, through transabdominal and then transthoracic approaches. The herniated large bowel was reduced from the thoracic cavity and the hernial sac was excised. The posterolateral defect of the diaphragm, 5 x 6 cm in size was closed with interrupted mattress sutures. The patient has been well without any symptoms 6 months after the surgery. Bochdalek diaphragmatic hernia is the most common problem in infants with risky respiratory distress and high mortality, however it is preferable to carry out surgical treatment for adult patients because of good postoperative results. As a surgical route in the management of Bochdalek diaphragmatic hernia in adults, a transthoracic approach is preferable since it provides easy separation and reduction of herniated bowels from the thoracic cavity and easy closure of the diaphragmatic defect, furthermore there are no other serious gastrointestinal complications which are required specific repair.     

Bilateral congenital posterolateral diaphragmatic hernia

The 11th recorded case of bilateral congenital posterolateral diaphragmatic hernia is here presented. Left-sided diaphragmatic hernia was corrected surgically, while the baby expired because of respiratory failure on the 31st operated day. Autopsy revealed that the baby had right posterolateral diaphragmatic defect with sac. From this experience, it might be said that at surgery for left-sided hernia, right diaphragm should be examined carefully.     

Congenital diaphragmatic hernia repair--impact of delayed surgery and epidural analgesia

This study was undertaken to assess the impact on mortality and the need for postoperative ventilation of intra- and postoperative epidural analgesia and delayed surgery in neonates with congenital diaphragmatic hernia. The study was a retrospective chart review of 35 neonates with congenital diaphragmatic hernia treated in Durban between 1988 and 1993. The mortality rate was 30%, with too few patients having delayed surgery to demonstrate a benefit from this policy. Mortality and the requirement for postoperative ventilation were reduced in the epidural group. However, the patients with the worst prognosis all received general anaesthesia. The benefit of delaying surgery for congenital diaphragmatic hernia repair could not be demonstrated because of small numbers. Epidural analgesia appears to be a useful technique to reduce the need for postoperative ventilation following repair in lower-risk patients.     

Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: a retrospective study

Background  Diaphragmatic hernias may be congenital or acquired (traumatic). Some patients present in adulthood with a congenital hernia undetected during childhood or due to trauma, known as the adult-onset type. The authors present their series of adult-onset type diaphragmatic hernias managed successfully by laparoscopy. Methods  This study retrospectively investigated 21 adult patients between 1995 and 2007 who underwent laparoscopic repair at the authors’ institution, 15 of whom were symptomatic. Laparoscopic repair was performed with mesh for 18 patients and without mesh for three patients who had Morgagni hernia. Results  In this series, Bochdalek hernia (n = 12), Morgagni hernia (n = 3), eventration (n = 3), and chronic traumatic hernia (n = 3) were treated. Intercostal drainage was required for 14 patients, whereas in three cases the hypoplastic lung never reinflated even after surgery. The time of discharge was in the range of postoperative days 4 to 9. The complication rate was 19%, and mortality rate was 4.5%. One case of recurrence was noted after 10 months. Conclusion  The controversies involved are the surgical approach, management of the hernial sac, whether or not to suture the defect, and choice of prosthesis. Although laparoscopic and thoracoscopic approaches are comparable, the laparoscopic approach seems to have certain distinct advantages. The authors prefer not to excise the hernial sac and favor suturing the defects before mesh reinforcement. Regarding the type of mesh used, composite, expanded polytetrafluoroethylene (ePTFE), or polypropylene are the available options. Laparoscopic repair is feasible, effective, and reliable. It could become the gold standard in the near future.     

Recurrent paraesophageal hernia due to diaphragm rupture: a case report

A 58-year-old male patient was operated for complaints of dysphagia, anemia and retrosternal discomfort due to a type II hiatal hernia. A complete hernia sac excision and posterior crural repair was performed laparoscopically with support of the da Vinci™ robotic system. An antireflux procedure was not performed because of the absence of gastroesophageal reflux disease. Nine months after surgery the patient presented with recurrent complaints of dysphagia and retrosternal pain. Barium esophagram series revealed a recurrent paraesophageal hernia which was confirmed on esophagogastroscopy. A robot-assisted re-laparoscopy was performed. Left to the still intact hiatoplasty of the original operation a tear in the diaphragm, through which part of the stomach covered with peritoneum had herniated, was encountered. The hernia sac was excised, the diaphragmatic defect closed and reinforced with an expanded polytetrafluoroethylene strip of 5×8 cm. After surgery the patient recovered quickly, oral intake was resumed on the first postoperative day and the hospital stay was 3 days. The use of prosthetic mesh to reinforce the hiatoplasty and the addition of an antireflux procedure after hiatal hernia repair are ongoing controversial aspects of hiatal hernia repair. Reports on laparoscopic redo surgery for recurrent diaphragmatic hernia are limited and will be addressed in this case report, in perspective of the aforementioned controversial components.     

Impact of concomitant thoracic interventions on feasibility of Nuss procedure

Background

This study aimed to analyze the feasibility of subsequent minimally invasive pectus repair, particularly modified Nuss procedure, combined with simultaneous thoracic procedures for different underlying intrathoracic diseases and conditions.

Methods

A total of 110 patients, who underwent minimally invasive pectus repair in Nuss technique over a 5-year period, were retrospectively analyzed concerning complications, cosmetic results, and satisfaction. Six patients (5%) underwent the Nuss procedure with concomitant thoracic interventions. Patients with prior cardiac surgery or planned redo pectus repair were not examined and were excluded. The mean age of 6 patients (3 male and 3 female) was 11 years (range, 5.5-17.2). Two patients with former left-sided transabdominal diaphragmatic hernia repair and 1 with former lobectomy of the left lower lobe underwent thoracoscopic adhesiolysis. Two underwent thoracotomy: one for closure of a recurrent left-sided diaphragmatic hernia with fundoplication owing to a large hiatal hernia, another for lobectomy of the right middle lobe owing to recurrent infections and bronchodysplasia. One patient presented with anterior mediastinal mass, which was suspected to be benign, and underwent thoracoscopic complete resection. All patients underwent a 1-stage procedure with subsequent simultaneous Nuss procedure.

Results

Simultaneous Nuss procedure was feasible without intraoperative complications in all patients (100%). Thoracoscopic adhesiolysis did not affect the feasibility of the Nuss procedure in 3 patients with former diaphragmatic hernia repair, particularly former lobectomy in one. Thoracotomy with middle-lobe lobectomy, as well as repair of recurrent diaphragmatic hernia and fundoplication in 2, did not affect modified Nuss technique and dispensed thoracoscopic guidance. Histopathologic analysis in one patient with a removed anterior mediastinal mass revealed Hodgkin lymphoma (stage IA), and the patient received multiagent chemotherapy. The postoperative course was uneventful in 5 of 6 patients. One patient required intermittent drainage of pleural effusion after simultaneous lobectomy. At follow-up (6 months-5 years), 6 patients had excellent cosmetic results and good quality of life confirmed by a questionnaire. There was no evidence of recurrent malignancy in one patient after 6 months.

Conclusions

Thoracic surgery and subsequent Nuss procedure can be performed simultaneously. Underlying conditions, such as prior repair of congenital diaphragmatic hernia or diaphragmatic eventration, as well as former lobectomy, had no impact on feasibility. Open thoracotomy can be combined with Nuss procedure dispensing thoracoscopy.     

Congenital posterolateral diaphragmatic hernia past infancy

Twenty-seven cases of congenital posterolateral diaphragmatic hernia past infancy are reviewed in tabular form and discussed as to presenting symptoms, physical and radiographic findings, operative treatment, and final outcome. A ten year old male treated by us is presented as a detailed case report.A great contrast is noted between the acute respiratory symptoms which threaten life in the infant hernia compared with the more chronic and recurrent gastrointestinal and respiratory symptoms in patients past infancy. Onset of symptoms did not correlate with age or sex. Chest x-ray films and gastrointestinal contrast studies were most helpful in diagnosis. Abdominal and thoracic approaches were equally effective in reducing the herniated viscera and closing the diaphragmatic defect.We believe that long-term survival of patients with congenital posterolateral diaphragmatic hernia may be due to persistence of a confining pleuroperitoneal sac. Rupture of this sac in later life may coincide with onset of the characteristic symptoms which in turn prompt diagnostic studies. Congenital diaphragmatic hernia must be considered in the differential diagnosis of patients with both recurrent gastrointestinal and respiratory complaints. Plain radiographs of the chest and contrast studies of the gastrointestinal tract are necessary to confirm diagnosis preoperatively.