不同通气模式对老年患者腹腔镜结直肠手术呼吸参数的影响

目的观察小潮气量容量控制通气(VCV)联合呼气末正压通气(PEEP)和压力控制通气(PCV)联合PEEP对老年患者呼吸参数的影响。方法选择行腹腔镜直肠、乙状结肠手术患者51例,男25例,女26例,年龄65~80岁,BMI 18~30kg/m2,ASAⅠ或Ⅱ级,随机分为两组:VP组(VCV+PEEP)和PP组(PCV+PEEP),每组25例。气腹期间VP组以VT6 ml/kg+5cmH2O PEEP模式通气,PP组将VT设为6 ml/kg通气3 min后切换为PCV并加用5cmH2O PEEP进行通气。记录气管插管VCV通气5min(T1)、建立人工气腹5 min(T2)、建立人工气腹35min(T3)、建立人工气腹65min(T4)、手术结束(T5)、拔管前(T6)时VT、动态肺顺应性(Cdyn)、RR、气道峰压(Ppeak)、气道平台压(Pplat)和PETCO2。记录T1、T3、T4和离开PACU(T7)时PaO2、PaCO2,并计算肺泡-动脉血氧分压差(PA-aDO2)、氧合指数(OI)、呼吸指数(RI);记录术后5d内肺部并发症(PPCs)情况。结果与VP组比较,T2-T4时PP组VT明显升高、Cdyn明显增大(P0.05),T3-T5时PP组RR明显减慢(P0.05),T2-T5时PP组Ppeak和Pplat明显降低(P0.05),T4时PP组PETCO2和PA-aDO2明显降低、PaO2明显升高、RI明显减小、OI明显增大(P0.05)。术后随访两组患者PPCs差异无统计学意义。结论PCV联合PEEP通气模式明显降低Ppeak和Pplat、增高VT和增大Cdyn,同时明显改善气腹65min时肺氧合功能,所以老年患者腹腔镜结直肠手术术中应优先考虑使用。     

非胸腹部手术拔管时右侧膈肌运动的超声评价

目的 探讨应用床旁超声测量非胸腹部手术全身麻醉术后达到临床拔管指征时右侧膈肌运动幅度的临床效果. 方法 采用随机数字表法选择接受非胸腹部手术全身麻醉患者110例,分为男性组(56例)和女性组(54例),术前使用M型超声记录患者平静呼吸时膈肌运动幅度.术中依据HR、BP等调整用药,维持麻醉深度,手术结束前30 min停止追加肌肉松弛药,手术结束后患者进入PACU,使用2～5 MHz超声探头,右锁骨中线肋缘下以肝为声窗,用M型超声记录达到临床拔管指征平静呼吸时的膈肌运动幅度,拔管后10、30 min平静呼吸时膈肌运动幅度,并记录拔管时间、拔管时Ramsay镇静评分,患者持续抬头5s时间. 结果 与麻醉前[男(16.8±2.6) mm,女(14.6±1.6) mm]比较,拔管时[男(13.1±1.4) mm,女(12.4±1.2)mm]两组膈肌运动幅度差异有统计学意义(P＜0.05),拔管后10 min[男(15.7±2.7) mm,女(13.9±2.1) mm]、30 min[男(16.1±2.6) mm,女(14.3±2.0) mm]两组膈肌运动幅度差异均无统计学意义(P＞0.05);与拔管时比较,拔管后10、30 min两组膈肌运动幅度差异有统计学意义(P＜0.05);拔管后10 min与拔管后30 min比较,两组膈肌运动幅度差异无统计学意义(P＞0.05).两组拔管时间、Ramsay镇静评分、持续抬头5s时间比较,差异无统计学意义(P＞0.05). 结论 超声测量右侧膈肌运动有较高的可操作性和可重复性,在PACU对于评价麻醉恢复期膈肌功能的恢复具有可行性.     

不同时间膈肌超声对急性肠梗阻术后膈肌功能恢复的评估价值

通过超声检查评估急性肠梗阻术后机械通气24 h和48 h的膈肌功能恢复情况。选取2019年9月—2020年9月郴州市第一人民医院南院收治的67例急性肠梗阻术后患者,根据机械通气后有无合并脓毒症分为脓毒症组和非脓毒症组。在机械通气24 h及48 h收集患者血气分析结果,并进行膈肌超声检查记录膈肌偏移度（DE）、膈肌增厚分数（DTF）。对比分析不同时间各组临床指标的变化情况。脓毒症组的住院时间和机械通气时间均较非脓毒症组显著延长（t=3.096、4.796,P<0.01）。机械通气24 h,脓毒症组的DTF低于非脓毒症组,差异有统计学意义（t=3.929,P<0.001）,两组间DE差异无统计学意义（P>0.05）。机械通气48 h后,脓毒症组的DTF和DE均较非脓毒症组显著降低,差异有统计学意义（t=4.852、2.897,P<0.01）;此外,两组DTF和DE也均较机械通气24 h降低（P<0.05）。DTF可作为评估急性肠梗阻患者术后膈肌功能恢复的参考指标。     

肝癌合并门脉高压症患者腹腔镜肝癌切除术术中通气模式的临床研究

目的研究容量控制通气(VCV)、压力控制通气(PCV)及压力控制容量保证通气(PCV-VG)对行腹腔镜肝癌切除术的肝癌合并门脉高压症(HCPH)患者术中血流动力学、呼吸力学、血气指标和术后并发症的影响。 方法前瞻性选择2017年1月至2019年6月行腹腔镜肝癌切除术的120例HCPH患者作为研究对象。采用随机数字表法将患者分为VCV组、PCV组及PCV-VG组,每组40例。采用SPSS20.0软件进行分析,并发症等计数资料使用卡方检验;患者围术期指标及各时间点[插管后气腹前10 min(T0)、气腹后30 min(T1)、气腹后1 h(T2)、气腹结束10 min(T3)]心率等用( ±s)表示,多组间采用重复方差法分析,P<0.05为差异有统计学意义。 结果与T0比较,T1～T2时三组患者术中平均动脉压(MAP)、气道平均压力(Pmean)、气道峰值压力(Ppeak)、动脉氧分压(PaO₂)、呼末二氧化碳分压(PETCO₂)、动脉二氧化碳分压(PaCO₂)显著升高(P<0.05),动态肺顺应性(Cdyn)明显降低(P<0.05)。PCV-VG组在T1～T2时间段Ppeak均低于VCV组和PCV组(P<0.05),在T1～T3时间段Pmean均低于VCV组(P<005)。PCV-VG组和PCV组在T1～T2时间段Cdyn均高于VCV组(P<0.05),PCV-VG组在T2刻高于PCV组(P<0.05)。术后第7天PCV-VG组与PCV组并发症总发生率显著低于VCV组(P<0.05);PCV-VG组肺不张发生率显著低于VCV组(P<0.05)。 结论对于行腹腔镜肝癌切除术的HCPH患者,PCV-VG模式可以降低气道压力,改善肺顺应性,术后肺部相关并发症发生率较低,安全性更高。     

压力控制通气模式在合并轻度阻塞性通气功能障碍老年患者腹腔镜胆囊手术中的通气效果

目的评价压力控制通气(PCV)模式用于合并轻度阻塞性通气功能障碍的老年患者行腹腔镜胆囊切除术中的通气效果。方法选择择期拟行腹腔镜胆囊切除术患者40例,男23例,女17例,年龄65~75岁,ASAⅡ或Ⅲ级,合并轻度阻塞性通气功能障碍,BMI 18.5~23.9kg/m~2,采用随机数字表法,均分为两组:容量控制通气(VCV)组(V组)和PCV组(P组)。新鲜气流量均为2L/min,FiO_260%,VT_8~12ml/kg(P组调整吸气压),I∶E 1∶2,RR 12~16次/分。调整通气参数维持PET_CO2 35~45mm Hg。直至手术结束后气管导管拔除期间两组均分别维持以上通气模式及呼吸参数。于气管插管后5min(气腹前)(T_1)、气腹开始后30min(T_2)、气腹结束后10min(T_3)时记录气道峰压(Ppeak)、气道平台压(Pplat)、吸气阻力(Raw)和动态肺顺应性(Cdyn),采集桡动脉和混合静脉血行血气分析,计算氧合指数(PaO_2/FiO_2)、呼吸指数(RI)、死腔通气率(VD/VT_)和肺内分流率(Qs/Qt)。记录拔管时间、复苏室停留时间和拔管后2h内高碳酸血症、低氧血症等不良反应的发生情况。结果与V组比较,T_1~T_3时P组Ppeak、Pplat和Raw明显降低,Cdyn、PaO_2/FiO_2明显升高,RI、VD/VT_、Qs/Qt和拔管后低氧血症发生率明显降低(P0.05)。两组拔管时间、复苏室停留时间及高碳酸血症发生率差异无统计学意义。结论 PCV模式可安全用于合并轻度阻塞性通气功能障碍的老年腹腔镜胆囊切除术患者,其通气效果好,低氧血症发生率降低。     

肥胖患者行腹腔镜手术3种通气模式的比较

目的观察肥胖患者行全麻腹腔镜手术时,不同的机械通气模式对病人氧合情况的影响。方法选择60例行腹部腹腔镜手术的肥胖患者,按手术日期分为3组:容量控制通气(volume control ventilation,VCV)组,压力控制通气(pressure control ventilation,PCV)组,压力控制通气联合呼气末正压通气(pressure control ventilation and positive end expiratorypressure,PCV+PEEP)组,每组20例。分别于手术开始气腹后30min(T1)、气腹后60min(T2)、手术结束后拔气管插管后30min(T3)、拔气管插管后60min(T4),采血测定pH、PCO2、氧合指数、肺内分流率。结果PCV+PEEP组T1时点氧合指数429.35±51.88显著高于VCV组346.15±54.48(q=6.771,P<0.05)和PCV组393.50±58.34(q=2.918,P<0.05),T4时点氧合指数231.87±20.47显著高于VCV组211.50±12.52(q=5.172,P<0.05)和PCV组220.12±18.84(q=2.983,P<0.05)。PCV+PEEP组T1、T2、T3、T4的肺内分流率分别为(10.94±1.40)%、(11.17±1.42)%、(10.24±1.22)%、(9.92±1.09)%显著低于VCV组(12.09±1.41)%、(12.67±1.76)%、(11.64±1.44)%、(11.34±1.38)%(q=3.771,P<0·05;q=4.772,P<0.05;q=4.872,P<0.05;q=4.772,P<0.05)。HR、MAP3组不同时点比较无明显差异(P>0·05)。结论行腹腔镜手术时,压力控制通气联合呼气末正压通气可以显著提高肥胖患者的氧合情况。     

不同浓度罗哌卡因对老年患者肌间沟臂丛神经阻滞后膈肌运动功能的影响

目的:比较相同容量不同浓度罗哌卡因对老年患者行肌间沟臂丛神经阻滞镇痛效果和膈肌运动功能的影响。方法:择期行肩关节镜手术患者46例,按随机数字表法分为0.5%罗哌卡因20 ml组(A组,24例)和0.3%罗哌卡因20 ml组(B组,22例),分别于全身麻醉诱导前行超声引导下肌间沟臂丛神经阻滞。记录不同时间点两组患者血流动力学、阻滞后VAS评分、膈肌运动情况及其他不良反应发生率。结果:阻滞30 min内两组患者血流动力学差异无统计学意义(P>0.05);阻滞后20 h内两组患者静息和运动VAS评分及其他不良反应发生率差异无统计学意义(P>0.05);A组患者阻滞后5 min、3 h、6 h、20 h平静呼吸位和最大呼吸位双侧膈肌移动度与阻滞前差异有统计学意义(P<0.05);B组患者阻滞后5 min、3 h、6h平静呼吸位和最大呼吸位双侧膈肌移动度与阻滞前差异有统计学意义(P<0.05);阻滞后3h、20hA组患者膈肌麻痹发生率高于B组(P<0.05);阻滞后5 min、3 h、6 h、20 h A组患者阻滞侧膈肌厚度分数低于阻滞前(P<0.05),阻滞后3、6、20 h对侧膈肌厚度分数高于阻滞前(P<0.05)。阻滞后5min、3h、6hB组患者阻滞侧膈肌厚度分数低于阻滞前(P<0.05),阻滞后3、6 h对侧膈肌厚度分数高于阻滞前(P<0.05)。结论:20 ml 0.5%和0.3%罗哌卡因对于老年患者肩关节镜手术后20 h内镇痛效果相似,但高浓度组患者膈神经麻痹发生率和发生时长显著增高。     

不同通气模式在腹腔镜妇科手术肥胖患者中的应用效果评价

目的探讨压力控制通气(Pressure-controlled ventilation,PCV)与容量控制通气(Volume-controlled ventilation,VCV)对腹腔镜妇科手术肥胖患者呼吸功能及血气分析相关指标的影响。方法选取本院2014年1月至2017年6月择期于腹腔镜下行妇科手术的肥胖患者共计80例。ASA分级Ⅰ~Ⅱ级,体重指数(Body Mass Index,BMI)30kg/m2。患者采用计算机随机软件分为PCV与VCV每组各40例。于气管插管后10分钟(T_0)、气腹后10分钟(T_1)、气腹后30分钟(T_2)、撤除气腹后10分钟(T_3)记录患者气道平台压(Pplat)、气道峰压(Ppeak)、平均气道压(Pmean)、动态肺顺应性(Cdyn)。于上述各时点抽取动脉血行血气分析并记录PaO_2、PaCO_2、PH值。观察术后24小时内气胸、皮下气肿、肺水肿发生情况。结果在T_1、T_2时点,PCV组患者Pplat、Ppeak、Pmean显著低于VCV组患者,PCV组患者Cdyn显著高于VCV组,差异有统计学意义(P0.05);PCV组患者PaO_2显著高于VCV组患者,PCV组患者PaCO_2显著低于VCV组,差异有统计学意义(P0.05)。两组患者PH值在各时点差异均无统计学意义(P0.05)。所有患者均未发生气胸、皮下气肿、肺水肿等并发症。结论对行妇科腹腔镜手术的肥胖患者而言,PCV能够在气腹期间维持较低的气道压力及较高的肺顺应性,同时还能维持较高的PaO_2及较低的PaCO_2,与VCV相比具有良好的安全性和有效性。     

婴幼儿腹腔镜手术不同方法肺复张效果的比较

目的比较婴幼儿腹腔镜手术不同方法肺复张的效果。方法选取2020年9月至2021年6月择期行腹腔镜手术的患儿70例, 年龄1～6岁, 体重10～24 kg, 性别不限, ASA分级Ⅰ或Ⅱ级, 预计手术时间≤2 h。采用随机数字表法分为2组(n=35):PEEP递增法肺复张组(PV组)和控制性肺膨胀法肺复张组(RM组)。患儿气管插管后行压力控制模式通气, 分别于气腹后20 min、气腹结束即刻和手术结束气管拔管前行肺复张。PV组逐渐递增PEEP, 气道压力上限35 mmHg, 增加5 cmH2O, 通气30 s, 再次增加至15 cmH2O, 通气30 s, 调整为原参数继续通气, 直至下次肺复张。RM组改为手控模式通气, 调节压力阀为30 cmH2O, 快速充氧将压力上升到最大, 手动挤压呼吸气囊使气道压力达到30～35 mmHg, 持续30 s后调整为原通气参数继续通气, 直至下次肺复张。于气管插管后5 min(T1)、气腹20 min(T2)、气腹结束即刻(T3)和手术结束气管拔管前(T4)记录气道峰压和平均气道压, 计算动态肺顺应性;于T2和T4时行血气分析, 记录PaO2和PaC...     

右美托咪定预防神经外科全麻术后躁动的临床观察

目的观察右美托咪定预防神经外科手术患者术后躁动的临床效果。方法选择神经外科全麻手术患者60例,随机均分为右美托咪定组(D组)和生理盐水组(C组)。患者手术结束前10min停用麻醉药,D组静脉泵注右美托咪定0.4μg/kg10min,C组静注等剂量的生理盐水。记录麻醉前、拔管即刻、拔管后5min血流动力学变化,并对拔管后5、30、60、120min躁动程度、镇静状态、躁动发生率进行评估。观察呼吸恢复时间、唤醒时间和拔管时间。结果与C组比较,D组拔管即刻及拔管后5min的MAP明显降低,HR明显减慢(P<0.05);与麻醉前比较,D组拔管后5min的MAP明显降低,HR明显减慢,C组拔管即刻及拔管后5min的MAP明显升高,HR明显增快(P<0.05)。D组麻醉苏醒期躁动发生率、躁动程度明显低于C组,D组VAS评分在拔管后5、30、60、120min均明显低于C组(P<0.05),Ramsay镇静评分拔管后5、30min明显高于C组(P<0.05)。结论静脉泵注0.4μg/kg右美托咪定能减轻拔管期应激反应,减少躁动,不延迟呼吸恢复时间、唤醒时间和拔管时间,可预防神经外科全麻术后躁动。     

The spectrum of diaphragmatic injury in a busy metropolitan surgical service

Introduction

The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component.

Methodology

A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study.

Results

A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy.

Conclusion

If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.     

Thoracoscopic plication for idiopathic eventration of the bilateral diaphragm: Report of a case

IntroductionDiaphragmatic eventration, defined as permanent elevation of the diaphragm without defects, is a rare anomaly in adults. Trauma, neoplasms, infection, and degenerative disease are the most common causes of this condition, whereas idiopathic eventration of the diaphragm is relatively infrequent.Presentation of caseWe herein present the rare case of an 85-year-old female with idiopathic eventration of the bilateral diaphragm. The patient demonstrated a rapidly progressive course with dyspnea; therefore, thoracoscopic surgery of the unilateral diaphragm was performed. She subsequently withdrew from home oxygen therapy, which had introduced preoperatively, and exhibited a significant improvement in her pulmonary function for one year after the operation.DiscussionVarious approaches for diaphragmatic plication have been reported, including open (transthoracic or transabdominal) and minimally invasive methods, such as thoracoscopic or laparoscopic plication. We consider thoracoscopic plication to be an effective minimally invasive method, although single-lung ventilation is required.ConclusionWe experienced a case in which thoracoscopic plication of the unilateral diaphragm resulted in adequate objective improvements in the pulmonary function in a patient with idiopathic eventration of the bilateral diaphragm.     

Laparoscopic repair of diaphragmatic defect by total intracorporeal suturing: clinical and technical considerations.

OBJECTIVE: The use of laparoscopy in urology is increasing. Tumor of the kidney or adrenal gland and, in some cases, metastatic disease can involve the diaphragm. We describe the application of laparoscopic suturing techniques in the case of diaphragmatic involvement with a renal tumor. METHODS: After resection of the tumor and a small area of the diaphragm, a chest tube was placed under laparoscopic guidance. The tube was kept clamped until the end of the procedure. Decreasing intraabdominal pneumoperitoneum pressure made suturing easier with less tension on the edges of the diaphragmatic incision. Nonabsorbable interrupted horizontal mattress sutures were placed to close the diaphragmatic defect. RESULTS: The repair was uneventful; no intraoperative complications occurred. Extubation was done at the end of the procedure in the operating room. The chest tube was removed on postoperative day 2, and the patient was discharged on postoperative day 3. CONCLUSIONS: Laparoscopic repair of the diaphragm should be commensurate with traditional open surgical principles. In this regard, it is essential that surgeons interested in performing "advanced" laparoscopic oncologic surgery become facile in laparoscopic suturing.     

胸腰椎骨折及截瘫合并膈疝

本文报告9例胸腰椎骨折及截瘫合并膈疝,除1例系高处坠落腰背部着地外,其它为重物压于腹背部或胸腹背部。骨折部位T_(12)～L_4,8例合并截瘫,9例均出现休克,膈疝全部发生在左侧。作者还对膈疝的形成机制、诊断及治疗问题作了讨论。     

脓毒症相关膈肌功能障碍的研究进展

背景 研究发现,脓毒症可以导致膈肌功能障碍,从而加重呼吸衰竭的发生,针对脓毒症相关膈肌功能障碍的临床治疗并未取得理想的效果. 目的 脓毒症相关膈肌功能障碍的病理生理过程复杂,发病机制尚未完全揭示.现对近年来相关研究作一综述,希望能够为临床应用提供参考. 内容 脓毒症导致的膈肌功能障碍的发病机制可能与膈肌的蛋白降解、氧化应激、细胞凋亡、促炎细胞因子有关. 趋向 随着脓毒症相关膈肌功能障碍发生机制研究的深入,有望为临床提供新的治疗思路.     

Enflurane impairs canine diaphragmatic contractilityin vivo

We examined the effect of enflurane on diaphragmatic contractility in six anesthetized mechanically ventilated dogs. The diaphragmatic force was assessed from transdiaphragmatic pressure (Pdi) developed at functional residual capacity against an occluded airway during cervical phrenic nerve stimulation. Pdi-stimulus frequency relationship was compared at three levels of anesthesia, namely 1, 1.5, and 2 MAC (minimum alveolar concentration) of enflurane. The sequence of changing anesthetic concentration was randomized between animals. Pdi at 50 and 100Hz stimulation was significantly decreased with increasing MAC while Pdi at 10Hz stimulation was not affected by the depth of anesthesia. Pdi of 20Hz stimulation was significantly decreased at 2 MAC as compared to those at 1 and 1.5 MAC. We conclude that enflurane decreases contractility of the diaphragm mainly through impairment of the neuromuscular transmission and/or membrane excitability. Part of its effects is, however, probably related to the impairment of excitation-contraction coupling, as suggested by the depression of Pdi at 2 MAC in response to 20Hz stimulation.(Kochi T, Ide T, Isono S et al.: Enflurane impairs canine diaphragmatic contractility in vivo. J Anesth 4: 226–231, 1990)     

Spontaneous diaphragmatic rupture related to local invasion by retroperitoneal liposarcoma

We report a case of the female patient who was admitted to the hospital because of syncope experienced while climbing stairs. Diagnostic workup raised the suspicion of a right diaphragmatic rupture that was eventually confirmed by surgery (right-sided thoracotomy). Surgery also revealed tissue protruding through the rupture site from within the retroperitoneum that was proven subsequently to be a dedifferentiated liposarcoma. Second surgery was performed to completely remove the liposarcoma tissue and repair a coincident old right lumbar region hernia. The patient recovered fully. Spontaneous rupture of the diaphragm is rare and this is especially true for the right hemidiaphragm. We report the first case of diaphragmatic rupture caused by local infiltration by a retroperitoneal liposarcoma. This and similar reports emphasise that in cases with high clinical suspicion of diaphragmatic rupture, diagnosis should be pursued even in the absence of a preceding traumatic event.     

Injury to the diaphragm and its repair during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has now become the gold standard for the treatment of gallstone disease. Parallel with the conversion from the open to the laparoscopic technique, some complications peculiar to the laparoscopic approach have been experienced. Such a technique-related complication, resulting in an injury to the diaphragm and its repair during laparoscopic cholecystectomy is presented.     

Thoracoscopic diaphragmatic eventration repair in children: about 10 cases

Background and Aim

Recent reports in literature have emphasized the clinical perception of reduced pain, postoperative morbidity, and dysfunction associated with thoracoscopic approach compared with standard thoracotomy.The authors describe a thoracoscopic approach and technical details for diaphragmatic eventration repair in children.

Patients and Methods

Ten patients, 4 girls and 6 boys, 1 teenager (14 years old) and 9 children (age range, 6-41 months; average, 17 months), were operated for a diaphragmatic eventration in 3 different pediatric surgery teams, according to the same technique. Symptoms were recurrent infection (7 cases), dyspnea on exertion (2 cases), and a rib deformity (1 case). An elective thoracoscopy was performed, patient in a lateral decubitus. A low carbon dioxide insufflation allowed a lung collapse. Reduction of the eventration was made progressively when folding and plicating the diaphragm. Plication of the diaphragm was done with an interrupted suture (6 cases) or a running suture (4 cases). The procedure finished either with an exsufflation (4 cases) or a drain (6 cases).

Results

A conversion was necessary in 2 cases: 1 insufflation was not tolerated and 1 diaphragm, higher than the fifth space, reduced too much the operative field. Patients recovered between 2 and 4 days. Dyspnea disappeared immediately. Mean follow-up of 16 months could assess the clinical improvement in every patient.

Discussion

Thoracoscopic conditions are quite different between a diaphragmatic hernia repair previously reported and an eventration. Concerning diaphragmatic hernias, reduction is easy, giving a large operative space for suturing the diaphragm. Concerning diaphragmatic eventrations, the lack of space remains important at the beginning of the procedure despite the insufflation into the pleural cavity. The operative ports must be high enough in the chest to allow a good mobility of the instruments. Chest drainage seems to be unnecessary.

Conclusion

Diaphragmatic eventration repair by thoracoscopy is feasible, safe, and efficient in children. Above all, it avoids a thoracotomy. It improves the immediate postoperative results with a good respiratory function.     

Symptomatic Bochdalek Hernia in an Adult

Background and Objectives:

Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Symptomatic Bochdalek hernias in adults are infrequent and may lead to gastrointestinal dysfunction or severe pulmonary disease. We describe our experience with this rare entity.

Methods:

A retrospective chart review was performed on a single patient for data collection purposes.

Results:

The patient is a morbidly obese 53-year-old female who presented with epigastric pain and diffuse abdominal tenderness. Computed tomography scans of the chest and abdomen revealed a small posterior diaphragmatic defect containing gastric fundal diverticulum. Laboratory work and imaging revealed no other findings. Laparoscopic repair of the Bochdalek hernia was done via an abdominal approach and utilized primary closure with an AlloDerm patch apposed to the defect. The patient has had significant clinical improvement and continues to do well at 9 months postoperatively.

Conclusion:

Laparoscopic repair of symptomatic adult Bochdalek hernias can be performed successfully and may result in significant clinical improvement.