Intentional resection of the diaphragm during cytoreductive laparoscopic radical nephrectomy.

PURPOSE: Laparoscopic radical nephrectomy is being performed more commonly. To our knowledge intentional resection of the diaphragm during laparoscopic radical nephrectomy for large renal tumors has not yet been described. We detail the laparoscopic management of diaphragmatic resection. MATERIALS AND METHODS: From March 1996 to February 2001, 36 patients underwent cytoreductive laparoscopic radical nephrectomy at our institution in preparation for systemic immunotherapy. Charts and operative tapes were reviewed and cases were identified in which diaphragmatic resection was performed for locally invasive tumors. RESULTS: In 3 patients a portion of the diaphragm was dissected via laparoscopy during debulking nephrectomy. All patients had renal cell carcinoma with documented metastatic disease. The diaphragm was repaired laparoscopically using intracorporeal suturing techniques in 2 of the 3 patients and a chest tube was placed in all 3. Transient systolic hypotension and hypercarbia in 1 case resolved with manual ventilation. The chest tube was removed on postoperative days 2 to 4. There were no complications and no ipsilateral pleural metastasis was identified at an average of 6 weeks (range 2 to 23) of followup. CONCLUSIONS: A portion of the diaphragm may be intentionally resected during laparoscopic radical nephrectomy. This maneuver may be successfully managed without conversion to an open procedure. In cases of a large diaphragmatic defect or the potential for coagulopathy postoperatively a chest tube should be inserted. Potential invasion of the diaphragm by large tumors should not be considered a contraindication to cytoreductive laparoscopic radical nephrectomy.     

Repair of a diaphragmatic injury during hand assisted laparoscopic nephrectomy using an onlay patch of polypropylene and polyglactin mesh

PURPOSE: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. MATERIALS AND METHODS: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. RESULTS: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. CONCLUSIONS: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.     

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.     

Laparoscopic resection of an intradiaphragmatic bronchogenic cyst

BACKGROUND: A 43-year-old woman with recurrent hiccup and discomfort in the right upper abdomen was diagnosed by computed tomographic (CT) scan with a cystic tumor in the right liver. Echinococcus serology was negative. METHODS: A laparoscopic procedure was chosen as standard therapy for symptomatic cystic liver tumors. The presumed tumor turned out to be a diaphragmatic cyst 8 cm in diameter at the center of the right hemi-diaphragm. By using the ultrasonic device, the cystic tumor was completely and safely removed from the diaphragm. The defect was closed by using nonabsorbable sutures. A chest drain was inserted for 1 day. RESULTS: The postoperative course was uneventful, and the patient was discharged on day 4. The histopathological examination revealed a bronchogenic cyst. No recurrence was noted by CT-scan after 12 and 24 months. CONCLUSIONS: Due to this rare diagnosis, the intradiaphragmatic location of a bronchogenic cyst is difficult to identify with radiological methods. Complete surgical excision is the treatment of choice. The conventional surgical approach is a posterolateral thoracotomy. In the literature, video-assisted thoracoscopic surgery (VATS) has been described as a safe and effective procedure. In our case, we could demonstrate that the laparoscopic excision of a cyst including partial diaphragmatic resection can be done safely in a diaphragmatic location with all the advantages of minimally invasive surgery.     

Symptomatic Right-Sided Diaphragmatic Hernia in the Third Trimester of Pregnancy

Background:

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach.

Methods:

Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation.

Results:

Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy.

Conclusion:

Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.     

Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients

Background Up to 50% of the patients in the intensive care unit (ICU) require mechanical ventilation, with 20% requiring the use of a ventilator for more than 7 days. More than 40% of this time is spent weaning the patient from mechanical ventilation. Failure to wean from mechanical ventilation can in part be attributable to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics, which are normally improved by maintaining a more natural negative chest pressure. The authors have previously shown that laparoscopic implantation of a diaphragm pacing system benefits selected patients. They now propose that an acute ventilator assist with interventional neurostimulation of the diaphragm in the ICU is feasible and could facilitate the weaning of ICU patients from mechanical ventilation. Natural orifice transluminal endoscopic surgery (NOTES) has the potential to expand the benefits of the diaphragm pacing system to this acute patient population by allowing it to be performed at the bedside similarly to insertion of the common gastrostomy tube. This study evaluates the feasibility of this approach in a porcine model. Methods Pigs were anesthetized, and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilation. The diaphragm was mapped using a novel endoscopic electrostimulation catheter to locate the motor point (where stimulation provides complete contraction of the diaphragm). An intramuscular electrode then was placed at the motor point with a percutaneous needle. The gastrotomy was managed with a gastrostomy tube. Results Four pigs were studied, and the endoscopic mapping instrument was able to map the diaphragm to identify the motor point. In one animal, a percutaneous electrode was placed into the motor point under transgastric endoscopic visualization, and the diaphragm could be paced in conjunction with mechanical ventilation. Conclusions These animal studies demonstrate the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation. Presented at the 2006 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) April 2006, Dallas, TX, USA     

Thoracoscopic treatment for delayed presentation of congenital diaphragmatic hernia in the infant

Background: Delayed presentations of congenital hernia occurring outside of the neonatal period have been reported for all ages. Classically, repair of the hernia defect involves a transverse subcostal laparotomy in the pediatric age group and usually a thoracotomy in the adult. The first report describing a laparoscopic repair of a congenital diaphragmatic hernia in a 6-month-old infant was published in 1995. During the past 25 years, 17 patients with delayed presentation of congenital diaphragmatic hernias have been managed by our pediatric surgery team. The last three patients underwent surgery thoracoscopically. Patients and Methods: This study involved two boys (ages, 8.3 and 19 months, respectively) and one girl (age, 9 months) weighing 8 to 13 kg. All three infants underwent surgery using a thoracoscopic approach with general anesthesia. A thoracic epidural catheter was placed systematically for postoperative analgesia during the first 24 hours. Reduction of the hernia contents using one optical trocar and two operating trocars was difficult in the case without any hernia sac. In the cases with a hernia sac, reduction was easily and quickly obtained with a pleural insufflation of carbon dioxide (~8 mmHg). The hernia defect was repaired using interrupted sutures of 2/0 Ethibond. For two of the three patients, this repair was reinforced with staples in the one case and a nonresorbable mesh in the other case. Results: The mean operative time was 78 min. The chest tube was removed on the first or second postoperative day and the patients were discharged on the fourth or fifth postoperative day. At the 19-month follow-up assessment in one case, the chest x-ray was perfectly normal and diaphragmatic motion also was confirmed to be normal by ultrasonography. Conclusions: The thoracoscopic approach for the repair of delayed-presentation congenital diaphragmatic hernia is feasible. Our results demonstrate the safety and efficiency of this surgery, as well as a remarkable functional and cosmetic result and a very quick recovery.>     

Dual-scope guided (simultaneous thoraco-laparoscopic) transthoracic transdiaphragmatic intraoperative radiofrequency ablation for hepatocellular carcinoma located beneath the diaphragm

Background Among treatment modalities for unresectable hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) is getting popular due to low morbidity and its effectiveness. However, when the tumor is located just under the diaphragm, a percutaneous approach for RFA is often impossible because of the difficulty in visualizing the tumor with conventional ultrasonographic examination. Method Simultaneous thoraco-laparoscopic transthoracic transdiaphragmatic intraoperative RFA was performed on a 55 year-old male with HCC just beneath the diaphragm as well as laparoscopic RFA for dysplastic nodule near the gallbladder. Most of all, the patient wanted to undergo liver transplantation for the HCC and underlying liver cirrhosis. Therefore we chose to provide this procedure as a bridge to the liver transplantation. A total of four trocars (12 mm, 10 mm, 5 mm trocars for laparoscopy, and one 5 mm trocar for thoracoscopy), a 10 mm flexible laparoscope, a 5 mm thoracoscpe, and a laparoscopic ultrasound were used for this surgical procedure. After finishing laparoscopic RFA for dysplastic nodule near the gallbladder, the patient was placed into the left lateral decubitus for dual-scope guided transthoracic transdiaphragmatic intraoperative RFA. Complete separation of the diaphragm from the hepatic dome and good visualization of the subdiaphragmatic vessels provided a safe procedure without any injury to the diaphragm and other vessels. Results The operative time was 240 minutes and the blood loss was zero. The postoperative course was uneventful. The diet was started on the operative day. A chest tube and an abdominal drain was removed on first day after surgery. The patient discharged on the second day after surgery. The patient has been followed up for three months after the dual-scope guided intraoperative RFA without any evidence of tumor recurrence. He is now actively being evaluated for liver transplantation. Conclusion Dual-scope guided (simultaneous thoraco-laparoscopic) transthoracic transdiaphragmatic intraoperative RFA is an easy, safe, and effective minimal invasive modality for treatment of the selective patient with HCC, with liver cirrhosis, which is located immediately under the diaphragm. Further experiences and a long term follow up is mandatory. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Healing of traumatic diaphragm injuries: comparison of laparoscopic versus open techniques in an animal model

BACKGROUND: Minimally invasive surgical techniques have become routinely applied to the evaluation and treatment of patients with isolated diaphragmatic injuries due to penetrating trauma. The objective of the study was to compare the healing of diaphragm injuries as determined by macroscopic inspection, histologic appearance, and tensile strength following repair by open suturing, laparoscopic suturing, and laparoscopic stapling techniques in an animal model. METHODS: Using a pig model, three injuries were created and repaired in each hemidiaphragm of five animals, for a total of 30 lacerations. These injuries were repaired using single-layer open repair, single-layer laparoscopic repair, or laparoscopic stapling. After a 6-week healing period the animals were sacrificed. The gross integrity, histologic appearance using H+E and trichrome satins, and tensile strength of each repair were assessed. RESULTS: All injuries were grossly intact without dehiscence or herniation. Histologic examination revealed no difference in the collagen deposition between the three groups. The tensile strengths of each type of repair were similar. CONCLUSION: Laparoscopic techniques used to repair diaphragmatic injuries allow for adequate healing equivalent to open sutured repairs. Simple approximation of the peritoneum with laparoscopic staples allows full-thickness healing of these injuries.     

Perforation of the stomach due to chest tube complication in a patient with iatrogenic diaphragmatic rupture

Diagnosis of diaphragmatic injury is difficult. A case of iatrogenic diaphragmatic rupture is reported in which perforation of a herniated stomach occurred following left lobectomy and partial resection of the diaphragm for lung cancer. On the second postoperative day, bile-stained fluid coming out from the chest tube revealed gastrointestinal leakage. This rare complication of chest tube insertion, early diagnosis and treatment are emphasized.     

Perforation of the Stomach Due to Chest Tube Complication in a Patient with Iatrogenic Diaphragmatic Rupture

Diagnosis of diaphragmatic injury is difficult. A case of iatrogenic diaphragmatic rupture is reported in which perforation of a herniated stomach occurred following left lobectomy and partial resection of the diaphragm for lung cancer. On the second postoperative day, bile-stained fluid coming out from the chest tube revealed gastrointestinal leakage. This rare complication of chest tube insertion, early diagnosis and treatment are emphasized.     

Indications,techniques and results of laparoscopic surgery for diaphragmatic diseases

Eleven patients with congenital, traumatic and functional extrahiatal diaphragmatic lesions are reported. Since 1991 two patients with acute, two patients with old ruptures of the diaphragm and one patient with a Morgagni-Larrey-hernia were successfully treated by laparoscopic direct suturing. In two other patients with Morgagni hernias we used a polypropylene mesh for closure of the defect. One procedure was performed in a patient with symptomatic congenital dysplasia of the diaphragm with aplasia of the pericard. Laparoscopic plication of the diaphragm was performed in three symptomatic patients with phrenic nerve palsy after cardiac surgery. The intra- and postoperative course was uneventful in all cases. During a median follow-up of 60 months there was no recurrence. Therefore the laparoscopic technique is an effective and attractive alternative for treatment of these diseases.     

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.     

A case of diaphragmatic paralysis in a patient with diabetes mellitus after surgery in prolonged prone position

A 56-year-old woman with diabetes mellitus was scheduled for bilateral kidney lithotomy. She was in the prone position for about seven hours during operation. At the end of operation, arterial blood gas analysis showed PaO2 64 mmHg and PaCO2 44 mmHg under 100% oxygen inhalation through a face mask, and the chest x-rays showed elevation of the right diaphragm. Her trachea was intubated again. The right diaphragm returned to the preoperative level by positive pressure ventilation on supine position. Hypoxemia disappeared when the patient was placed in the sitting position, and the trachea was extubated. The right diaphragm returned to the normal level on the 1st postoperative day, but hypoxia continued until the 6th postoperative day with the patient on supine position. We speculate that the diaphragmatic paralysis was caused by over-extension of the neck for a prolonged period, and that the patient might have been susceptible to nerve injury due to underlying diabetes mellitus.     

Laparoscopic repair of congenital diaphragmatic hernia with prosthesis: a case report

We report here our experience in the treatment of a large congenital diaphragmatic hernia, an uncommon pathology, approachable by laparoscopy. The patient was a 33-year-old woman with trisomy 21 syndrome, who only complained of colicky abdominal pain and a cough for 7 months before the hospitalization. Thoracic and abdominal CT scans showed a large anteromedial diaphragmatic hernia with slippage of the colon into the mediastinum and posterior displacement of the cardiovascular structures. The patient underwent laparoscopic repair of the hernia. The colon was put back in the abdomen; the defect (8×4 cm) was repaired by a Composix mesh (PTFE-polypropylene), fixed to the diaphragm by nonabsorbable stitches and staples. The patient was discharged on the third postoperative day. The postoperative course was uneventful. Follow-up at 18 months didn't show any complications or recurrence. We believe laparoscopic repair of diaphragmatic hernia to be the elective surgical choice, because of its technical feasibility and certain intra- and postoperative advantages. Electronic Publication     

Use of gelatin matrix to rapidly repair diaphragmatic injury during laparoscopy

Iatrogenic diaphragmatic injury during laparoscopy has necessitated intracorporeal suturing and occasionally thoracostomy tube placement. We describe a technique to repair the diaphragm quickly using a novel gelatin thrombin matrix. The matrix can be administered through a trocar or hand-assist device and can rapidly seal small injuries, obviating the need for formal suture repair. The presented case and technique should be considered in selected small diaphragmatic injuries.     

Laparoscopic surgery—anesthetic implications

Laparoscopic cholecystectomy is a relatively new surgical procedure which is enjoying everincreasing popularity and presenting new anesthetic challenges. The advantages of shorter hospital stay and more rapid return to normal activities are combined with less pain associated with the small limited incisions and less postoperative ileus compared with the traditional open cholecystectomy. The efficacy of laparoscopic appendectomy and hemicolectomy has been recently evaluated. However, there have been no prospective randomized studies to date comparing laparoscopic with traditional laparotomy techniques. The physiological effects of prolonged pneumoperitoneum and the longer duration of surgery with the laparoscopic techniques are of concern. The application of laparoscopic inguinal hernia repair may be limited because, unlike traditional surgical hepair, general anesthesia is required and concerns have been expressed about the duration of surgery and the possibility of hernia recurrence. Notwithstanding case reports and series describing successful diaphragmatic and hiatus hernia repair using a laparoscopic surgical technique, the frequently encountered complications of cervical surgical emphysema, pneumothorax, and pneumomediastinum, attributed to passage of insufflating gas through weak points or defects in the diaphragm, must be of major concern. Anesthesiologists must maintain a high index of suspicion for these potential complication and must undertake appropriate monitoring. If there is clinical evidence of a tension pneumothorax, immediate chest tube decompression is indicated.Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiological changes associated with patient positioning and pneumoperitoneum creation. The choice of anesthetic technique for upper abdominal laparoscopic procedures is most frequently limited to general anesthesia. Controlled ventilation avoids hypercarbia, and an anesthetic technique incorporating antiemetics and nonsteroidal anti-inflammatory agents has reduced postoperative nausea and vomiting following laparoscopic cholecystectomy. The use of nitrous oxide during laparoscopic procedures remains controversial.Laparoscopic cholecystectomy is a major advance in the management of patients with symptomatic gallbladder disease. However, in the present era of cost containment, older and sicker patients may present for this procedure on the day of surgery without adequate preoperative evaluation. Anesthesiologists should thus be prepared to recommend deflation of the pneumoperitoneum and possibly conversion to an open procedure if hemodynamic, oxygenation, or ventilation difficulties arise during the procedure.     

A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair.

HYPOTHESIS: The technique used for repair of the esophageal hiatus during laparoscopic Nissen fundoplication can influence the likelihood of postoperative dysphagia. DESIGN: A prospective double-blind randomized control trial. SETTING: A university teaching hospital. PARTICIPANTS: A total of 102 patients with proven gastroesophageal reflux disease, undergoing a laparoscopic Nissen fundoplication were randomized to undergo fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Patients were excluded for the following reasons: they had esophageal motility disorders, required a concurrent abdominal procedure, had undergone previous antireflux surgery, or had very large hiatus hernias. INTERVENTIONS: Laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. MAIN OUTCOME MEASURES: Independent assessment of dysphagia, heartburn, patient satisfaction, and other symptoms 1, 3, and 6 months following surgery, using multiple standardized clinical grading systems. Objective measurement of lower esophageal sphincter pressure, esophageal emptying time, distal esophageal acid exposure, and endoscopic assessment of postoperative anatomy and esophageal mucosa. RESULTS: Symptoms of postoperative dysphagia, relief of heartburn, and overall satisfaction 6 months after surgery were not influenced by the hiatal repair technique. However, to achieve a similar incidence of dysphagia, more patients who initially underwent posterior hiatal repair required a second surgical procedure (6 vs 0 patients). The hiatal repair technique did not affect the likelihood of early postoperative paraesophageal herniation. CONCLUSION: Anterior suturing of the hiatus appears to be at least as good in the short-term as posterior suturing as a method of narrowing the hiatus during laparoscopic Nissen fundoplication.     

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.     

A minimally invasive technique for stabilizing the diaphragm on the thoracic wall after blunt chest trauma: the “lifting-up method”

Most traumatic diaphragmatic tears are located centrally or radially and may be amenable to repair by direct suturing or suturing with a surgical patch. However, diaphragmatic tears, such as those immediately adjacent to the costal margin, are uncommon. We describe how we repaired this type of tear using a needle loop retractor to pass a 2-0 braided suture through the chest wall on both sides of the rib to suture the torn diaphragm to the chest wall. Our technique is more physiologically and anatomically consistent than previously reported techniques. We have termed this technique the “lifting-up method”, which we believe to be an easy and useful technique for repairing traumatic diaphragmatic injuries with no seam allowance.