Laparoscopic repair of congenital diaphragmatic hernias

Bochdalek and Morgagni hernias are the least common congenital diaphragmatic hernias, with the prevalence of Bochdalek hernia being 1/2200 births and the prevalence of Morgagni hernia being 1/1 million births. Although they are usually asymptomatic, congenital diaphragmatic hernias, especially Bochdalek and Morgagni hernias, are diagnosed in early childhood. In adulthood, they are diagnosed incidentally or when they become symptomatic. The repair of congenital diaphragmatic hernia is indicated in all children and symptomatic adults. We present three cases of congenital diaphragmatic hernia, two Morgagni and one Bochdalek hernias, repaired laparoscopically. We describe the operational methods. The results of the operations were satisfactory, with cure defined with radiological images after 1 month. We propose the use of laparoscopy in the repair procedure because it is a safe and effective method. Benefits include that it provides an excellent view of the surgical field, ease of execution, minimal surgical trauma, excellent cosmetic results, rapid recovery, and shorter hospitalization stay.     

Laparoscopic repair of congenital diaphragmatic hernias

Most Morgagni and Bochdalek hernias are found and repaired in children, but 5% are found in adults. Symptoms of these hernias are attributable to the involved viscera. Both hernias require repair on presentation because of the risk of incarceration. We describe a laparoscopic method of repairing these hernias that allows shorter recovery than open surgery.     

Laparoscopic repair of congenital diaphragmatic hernias

Diaphragm rupture is an infrequently encountered but well-documented injury in the multiply injured patient. Only a few cases in which minimally invasive techniques were used for repair have been reported thus far. Herein we describe the repair of a diaphragm rupture in a 36-year-old man who was injured in a motor vehicle accident. In a 10-year review of the literature, we were able to locate seven journal articles reporting 10 patients. We conclude that in appropriate stable patients with diaphragm rupture, minimally invasive techniques offer a reasonable alternative to open laparotomy or thoracotomy.     

Laparoscopic repair of traumatic diaphragmatic hernias

BACKGROUND: Traumatic diaphragmatic hernias are serious complications of blunt abdominal or thoracic trauma. In the early posttraumatic period, they are often missed, and they may be followed by a variety of subacute or chronic symptoms due to pulmonary or intestinal obstruction. METHODS: We present three cases of traumatic diaphragmatic hernias. Two of them were successfully treated by laparoscopy and direct suturing during the early posttraumatic period; the other was treated 10 years after the trauma. RESULTS: We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but for treatment as well. The postoperative course was uneventful in all cases. All patients remained asymptomatic during long-term follow-up (42-60 months). These results are promising. We expect the same good long-term results after laparoscopic repair as after open conventional surgery. CONCLUSION: We recommend that surgeons with sufficient experience in laparoscopy use a minimally invasive approach to treat chronic as well as acute traumatic diaphragmatic hernias in hemodynamically stable patients.     

Laparoscopic patch repair of diaphragmatic hernias with Surgisis

Background

Laparoscopic repair of congenital diaphragmatic hernias has been sparsely reported. Moreover, each report has primarily been a single operative case. In most of the reports, prosthetic mesh has not been used, and when used, it has been nonabsorbable in nature. Most of these case reports have documented only a few months of clinical follow-up.

Methods

After institutional review board approval (No. 01-12-115X), the clinical course and outcome of 3 patients undergoing laparoscopic repair of foramen of Morgagni and Bochdalek hernias using 4-ply Surgisis soft tissue graft (Cook Inc, Bloomington, Ind) were reviewed to determine if this approach is appropriate.

Results

In 2001, 2 patients, ages 9 months and 14 years, underwent laparoscopic foramen of Morgagni repair and one 5-day-old underwent laparoscopic foramen of Bochdalek repair using Surgisis soft tissue graft as a patch to close the diaphragmatic defects because there was too much tension with primary repair. In each case, the prosthesis was secured to the rim of the defect using interrupted silk sutures tied intracorporally. The mean operative time for repair of the Morgagni defects was 230 minutes with a postoperative discharge of 1 and 2 days. For the foramen of Bochdalek repair, the operative time was 204 minutes, and the patient was discharged at 3 weeks. No complications have occurred during or after any of the procedures, but the oldest patient underwent diagnostic laparoscopy 3 months postoperatively for a radiographic finding of suspected recurrence. At laparoscopy, the patch was intact, and no diaphragmatic hernia was noted.

Conclusions

Laparoscopic repair of congenital diaphragmatic defects using prosthetic material is possible although the operative time required is around 3.5 hours. Because of the brief postoperative course, the laparoscopic approach appears justified in the nonneonatal patients. Whether this approach is appropriate for repair of neonatal Bochdalek hernias remains unclear.     

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.     

Laparoscopic repair of post-esophagectomy diaphragmatic hernias using human acellular dermal matrix

Diaphragmatic hernias occur in up to 2% of patients after esophagectomy with gastric pull-up, and the surgical repair in the setting of a previous esophagectomy is a challenge with high complication rates, in particular with regards to the gastric conduit and its critical vascular supply. We describe two cases and the technique of minimally invasive, laparoscopic repair of diaphragmatic defects with organ herniation after esophagectomy using absorbable human acellular dermal matrix.     

Thoracolaparoscopic repair of diaphragmatic hernias

Complex long-standing diaphragmatic hernia presenting in adults is often managed through an open approach. Minimal invasive approach by either laparoscopy or thoracoscopy is limited by its ability to tackle these complex hernias with large defects and thoraco-mediastinal adhesions. Thus, standard laparoscopic or thoracoscopic approach is associated with high conversion to open approach. We herein describe a novel combined thoraco-laparoscopic approach to repair complex diaphragmatic hernias in a series of three adults.     

Laparoscopic repair of an iatrogenic intrapericardial diaphragmatic hernia using the falciform ligament flap

Iatrogenic intrapericardial diaphragmatic hernia after creation of a pericardial-peritoneal window is a very rare entity. We present the clinical case of an acute intestinal bowel obstruction due to herniation of small bowel into the pericardial sac. After laparoscopic reduction of the herniated small bowel, the diaphragmatic defect was successfully repaired using the hepatic falciform ligament.     

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy

Background: Although the recurrence rate for endoscopic herniorraphy is low (0–3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy. Received: 7 September 1998/Accepted: 13 October 1998     

Laparoscopic repair of recurrent hernias

The purpose of this study was to evaluate the results of a laparoscopic approach to recurrent inguinal hernia repair which dissected the entire inguinal floor and repaired all potential areas of recurrence without producing tension. Both a transabdominal preperitoneal and a totally extraperitoneal laparoscopic approach were utilized. Ninety recurrent hernias were repaired in 81 patients. The patients had 26 indirect, 36 direct, and 26 pantaloon recurrent hernias of which eight had a femoral component. In all but one patient the primary operations were open anterior repairs. The median follow-up was 14 months, ranging from 1 to 28 months. Patients returned to normal activities in an average of 1 week. The only recurrence observed was in the one patient whose primary repair was laparoscopic. When the entire inguinal floor of the recurrent hernia was redissected and buttressed with mesh, early recurrence was eliminated and recovery was shortened.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Laparoscopic repair of strangulated hernias

Background Although laparoscopic transabdominal preperitoneal polypropylene (TAPP) hernia repair is now a recognized procedure for groin hernia repair in patients undergoing elective surgery, there is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. Methods Unless contraindicated, the authors’ department considers laparoscopic TAPP repair the procedure of choice for all strangulated hernias. A prospective database of 1,532 consecutive hernia repairs performed between May 1998 and April 2004 was reviewed. Results A total of 28 irreducible strangulated hernias were observed and repaired through laparoscopic TAPP. There were three conversions (10.7%): one because of extensive adhesions and two because of bowel distention. Resection became necessary in 9 (36%) of the 25 cases involving effective TAPP repair of strangulated hernias. The mean operation time, with and without resection, was 103 and 55 min, respectively. The rate of postoperative morbidity was 4% because of one inguinal hematoma case. During a mean follow-up period of 340 days, there were no recurrences after TAPP repair. Conclusions For selected patients, the TAPP approach appears to be a good therapeutic option for strangulated hernias.     

Laparoscopic repair of incisional hernias

Laparoscopic repair of incisional hernia has been shown safe and efficacious, with low rates of conversion to open, short hospital stay, moderate complication rate, and low recurrence. Using the benefits of open retromuscular, sublay repair, the laparoscopic approach provides adequate mesh overlap and allows for identification of the entire abdominal wall fascia at risk for hernia formation. Fixation of the prosthesis to the abdominal wall is best provided by transabdominal to secure the mesh during the initial phase of incorporation. Long-term follow-up data support the durability of laparoscopic repair of ventral hernias with reduced rate of recurrence, low risk of infection, and applicability to difficult patient populations, such as the morbidly obese and those with prior failed attempts.     

Laparoscopic repair of recurrent hernias

BACKGROUND: Recurrence after primary conventional inguinal herniorrhaphy occurs in approximately 10% of patients depending on the type of repair and expertise of the surgeon. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The failure rate of these repairs using an open anterior approach may reach as high as 36%. Because of such a high failure rate, a number of investigators have focused on repairing these difficult recurrent hernias laparoscopically using a tension-free approach. Some of the earlier reports suggested a low recurrence rate of 0.5% to 5% when a laparoscopic approach was used to repair these hernias. The purpose of this study was to evaluate the efficacy of laparoscopic treatment for recurrent hernias in our institutions. METHODS: Between February 1991 and February 1995, 96 recurrent hernias were repaired in 85 patients (78 men and 7 women). There were 48 right, 26 left, and 11 bilateral hernias. The mean age of the patients was 59 years (range, 18-86 years); the mean height was 69 in. (range, 54-77 in.); and the mean weight was 176 pounds (range, 109-280 pounds). A total of 68 herniorrhaphies were performed using the transabdominal preperitoneal (TAPP) method: 19 using intraperitoneal on-lay mesh (IPOM) repair and 8 using the total extraperitoneal (TEP) method. The method of repair in one patient was not recorded. The mean operating time was 76 min (range, 47-172 min). Thirteen patients underwent additional procedures. RESULTS: Long-term follow-up was performed by questionnaire, examination, or both in 76 patients (85 hernias). Median follow-up time was 27 months (range, 2-56 months). There were four recurrences (2 in IPOM and 2 in TAPP). Three of these were repaired laparoscopically and one conventionally. There were 20 minor and 14 major complications and no mortality. One conversion occurred in the TAPP group. Mean postoperative stay was 1.4 days (range, 0-4 days). It was felt by 92% of the patients that their symptoms were completely relieved, whereas 4% of the patients continued to exhibit symptoms for which their hernia was repaired, and 3.6% failed to answer. As reported, 86% of the patients preferred their laparoscopic repair; 1% preferred the conventional repair; and 13% failed to reply. Afterward, 77% of the patients returned to normal activity, and 35% returned to vigorous activity within 4 weeks of surgery. Satisfaction with laparoscopic repair was expressed by 92% of the patients, whereas 8% either were dissatisfied or did not answer. In the end, 95% of the patients stated that they would recommend laparoscopic hernia surgery to their family and friends. CONCLUSIONS: These preliminary data show that laparoscopic repair of recurrent inguinal hernia is a safe alternative procedure with acceptable rates of recurrence and complications.     

Laparoscopic repair of inguinal hernias

For patients with recurrent inguinal hernia, or bilateral inguinal hernia, or for women, laparoscopic repair offers significant advantages over open techniques with regard to recurrence risk, pain, and recovery. For unilateral first-time hernias, either laparoscopic or open repair with mesh can offer excellent results. The major drawback of laparoscopy is that the technique requires a significant number of cases to master. For surgeons in group practice, it makes sense to have one surgeon in the group perform laparoscopic repairs so that experience can be concentrated. For others, the best technique remains the approach that the surgeon is most comfortable and experienced performing.     

Laparoscopic diaphragmatic hernia repair

Background: Adult-congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias are uncommon entities that are often technically challenging to repair. There is growing experience with a minimal access approach to these defects. Methods: We reviewed the English-language literature using a MEDLINE search for "diaphragmatic hernia" and "laparoscopy." Results: We found 19 case reports of laparoscopic adult-congenital diaphragmatic hernia repair. Reported complications included two enterotomies, one of which required conversion to laparotomy. We also found 11 case reports of laparoscopic chronic traumatic diaphragmatic hernia repair, with no reported complications or recurrences. Average operative time was 98 min, and average length of stay was 4.5 days. All reports claimed that there was less postoperative pain and an earlier return to full activity with the laparoscopic approach. Herein we discuss anatomy, pathophysiology, diagnosis, method of repair, and recurrence. Conclusion: Adult-congenital diaphragmatic hernia and chronic traumatic diaphragmatic hernia are amenable to laparoscopic repair. Although experience is still limited, laparoscopic repair appears safe and is associated with a shorter hospital stay.     

腹腔镜腹股沟疝修补术（TAPP）

此病例为女性斜疝患者,应用腹腔镜经腹腹膜前疝修补术（TAPP）治疗。腹腔镜治疗女性腹股沟疝有其特殊性,原因是女性患者的子宫圆韧带与腹膜非常致密,不象男性患者的精索那样可以轻易的做到“腹壁化（Parietalization）”,因此补片往往无法覆盖在子宫圆韧带和腹膜之间。该手术有两个不同于男性患者的操作步骤：（1）游离疝囊至内环口水平即可,不强调子宫圆韧带的“腹壁化”。（2）补片剪一开口,绕过子宫圆韧带覆盖在其后方,而不是平铺在其前方。补片开口处可用缝合或医用胶等方法关闭,相当于进行内环口整形。