Two cases of traumatic diaphragmatic hernia with atypical medical history

We have recently experienced two cases of traumatic diaphragmatic hernia which has been repaired by surgery. The first case was a 58-year-old man who had suffered left upper abdominal injury with a branch in his childhood. Although he had never symptoms, chest X-ray showed abnormal shadow in the left lower lung field. Radiologic studies indicated that the great omentum was escaped into the thoracic cavity. On patient request, we performed primary repair of the diaphragmatic hernia on thoracotomy. The second case was a 56-year-old woman who had undergone a left nephrectomy for the left renal abscess. Seven months after the operation, she began to feel nausea and vomiting, and the symptom aggravated with time. Chest X-ray showed air bubbles in the left lower lung field. It proved to be a projection of the stomach into the thoracic cavity through the iatrogenic diaphragmatic injury. We successfully performed a repairment of the diaphragm with a mesh.     

Right delayed traumatic diaphragmatic hernia; report of a case

An 80-year-old woman was admitted to our hospital with abnormal shadow on chest X-ray 8 years after a chest trauma during which multiple ribs on the right side were fractured causing hemothorax. A diagnosis of right delayed traumatic diaphragmatic hernia was based on the findings on plain X-ray and multislice computed tomography. We performed surgery via thoracic approach with thoracoscopic assist. The transverse colon, liver, and omentum were dislocated into the right thoracic cavity and hardly adhered to the lung. We successfully repaired the ruptured diaphragm. The postoperative course was uneventful and the patient was discharged on the 33rd postoperative day.     

Left traumatic diaphragmatic hernia in the postoperative state of lung cancer: report of a case

We report a case of left traumatic diaphragmatic hernia in the postoperative state of the lung cancer. A 68-year-old man underwent video-assisted partial resection of the left lung for lung cancer. One year after the operation, he experienced an accident of falling from a tree. Chest radiograph and chest computed tomography revealed the stomach herniating into the left thoracic cavity. An emergent operation was performed by the abdominal approach. The stomach was returned into the abdominal cavity, and the hiatus in the central tendon of the left diaphragm was primarily sutured. The postoperative course was uneventful.     

Diaphragmatic Hernia Masquerading as a Pulmonary Metastasis

Iatrogenic injury accounts for the second most common cause of acquired diaphragmatic hernias after penetrating trauma. An increased incidence of these hernias has been observed with the widespread use of laparoscopic surgery. We present the case of a 65-year-old woman who initially underwent sigmoid resection for an adenocarcinoma and a subsequent liver resection for metastasis. She was noted to have a left lower lobe pulmonary nodule on surveillance computed tomography, for which she underwent a mini-thoracotomy for a planned resection. At the time of surgery, the pulmonary nodule was discovered to be a diaphragmatic hernia, most probably of iatrogenic origin. We discuss the difficulty in diagnosis given her history and the location of such a lesion.     

Diaphragmatic hernia following pneumonectomy; report of a case

We report a case of diaphragmatic hernia following left pleuropneumonectomy. A 70-year-old man was referred to our hospital after tube drainage for 3 months due to left pyothorax. He had a past history of left lung tuberculosis. Pleuropneumonectomy with partial resection of the muscle layer of the diaphragm was performed because adhesion of pleurae was severe. On the 19th postoperative day, he started to develop a slight fever. Chest X-ray and computed tomography (CT) demonstrated diaphragmatic hernia. On the 22nd postoperative day, we performed surgery because panperitonitis developed. At laparotomy, the transverse colon was pierced by the cut end of the rib. We successfully repaired the diaphragm and established transverse colostomy. The patient has been in good health for more than 10 years after the surgery.     

Anesthetic management of a 1.7-kg premature infant undergoing thoracoscopic thoracic duct ligation

We report successful anesthetic management of a 1.7-kg premature infant who underwent thoracoscopic thoracic duct ligation under general anesthesia. She was born at 30 weeks gestation with birth weight of 1,546 g and was suffering from respiratory distress due to persistent right chylothorax for two months after birth. Chest tube drainage, fasting and intrapleural fibrin glue did not reduce her right chylothorax. Thoracoscopic thoracic duct ligation was scheduled on her day 64 under general anesthesia. The tracheal tube end was placed in the midtrachea and carbon dioxide was insufflated into the operative side of the thorax. During thoracoscopy her left lung was ventilated with the right lung pressed with spatulaes, but her respiratory status did not deteriorate so much despite of unilateral ventilation. We speculate that, due to massive right chylothorax, her pulmonary blood flow had already shifted to the left lung, therefore intraoperative substantial left unilateral lung ventilation exerted minimal effect on her respiratory status. The operation was successful and she was weaned from the ventilator on the following day.     

Intrathoracic gastric volvulus complicating a robotic left upper lobectomy: A case report and review of literature

Unrecognized intrathoracic gastric volvulus can be a life-threatening condition, especially in elderly individuals undergoing major surgical procedures. We herein report the first case of a gastric volvulus after a robot-assisted left upper lobectomy for non-small-cell lung cancer in a patient with a known paraesophageal hernia. The operative procedure was performed by Dr Jacques Fontaine a senior thoracic surgeon at Moffitt Cancer Center in Tampa Florida a major academic institution. This operation was complicated by a large type-III hiatal hernia, with most of the stomach having herniated into the left pleural cavity and demonstrating organo-axial torsion one day after the indexed operation for the lung cancer. The patient required emergency surgery due to gastric ischemia. The patient underwent exploratory laparotomy with reduction of the volvulus and closure of the esophageal hiatus at that time. The patient was taken back to the operating room for a planned relook 24 h after the exploratory laparotomy to assess viability of the stomach. Unfortunately, the second look revealed necrotic areas of the stomach, which required to be resected. Given her age and poor nutritional status, we elected to place a feeding jejunostomy tube. Her postoperative course was marred by an abdominal wound infection treated with a wound vacuum-assisted closure device. Ultimately she was discharged home on POD#19 tolerating a regular diet. This case report highlights that in the elderly patients undergoing left lung resection with a known large hiatal hernia, the index of suspicion for herniation must be high and prompt recognition can avert mortality or morbidity.     

右侧肝膈疝合并肺内异位肝一例并文献复习

目的探讨肝膈疝合并肺内异位肝的诊疗方案。 方法回顾性分析1例右侧肝膈疝合并肺内异位肝患者的临床表现、影像学特征、手术治疗方案及病理，对异位肝进行相关的探讨及文献复习。 结果患者接受胸腔镜肺楔形切除术＋膈疝修补术，术中发现右肺下叶肿物，与疝入胸腔组织不连续。病理结果提示为异位肝组织。患者术后一年复查胸部CT未见异常，随访无特殊不适。 结论异位肝在临床上极为少见，病例结合相关文献复习，以提高对该病的认识，且腔镜微创手术不仅直观观察，也可直接切除明确诊断且治愈该病。     

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.     

Catamenial pneumothorax

We report 3 cases of catamenial pneumothorax, with review of the literatures. Case 1: A 38-year-old female had recurrent right-sided pneumothorax in February 2001. Videothoracoscopic visualization showed multiple small fenestrations in central tendon of diaphragm. A partial diaphragmatic resection including the lesions was performed. She received hormone therapy postoperatively. Case 2: A 40-year-old female with past history of ovarian endometriosis had recurrent right-sided pneumothorax in 1993. During the operation, multiple diaphragmatic fenestrations and bullae of right middle and lower lobes were identified. The lesions were resected and postoperative hormone therapy was performed for 6 months. In 1997, right-sided pneumothorax recurred. She underwent surgical procedure due to prolonged air leakage from the right lung. During the operation, a diaphragmatic fenestration and bulla of apex of right upper lobe of the lung were visualized. Diaphragm was reefed and bulla was resected. After that, she had no recurrence of pneumothorax. Case 3: A 39-year-old female had recurrent right-sided pneumothorax in 2003. Under video-assisted thoracoscopic surgery, multiple fenestrations of central tendinous diaphragm were identified. Diaphragmatic partial resection was performed. Postoperatively, she received hormone therapy for 6 months. After hormone therapy, she suffered from recurrent pneumothorax, and underwent an operation. During the operation, she had endometriosis of visceral pleura without diaphragmatic fenestration. Once again, she received postoperative hormone therapy. Catamenial pneumothorax is a rare disease, and the definite etiology has not been clarified. A combination of both surgical and hormone therapy is useful for treatment.     

Gastric incarceration and perforation following posttraumatic diaphragmatic hernia

We report the case of a 36-year-old male patient who developed gastric incarceration and perforation in a diaphragmatic hernia 8 months after an automobile accident. During emergency surgery, protrusion of the stomach into the thoracic cavity and perforation on the anterior aspect of the stomach were noted. The gastric perforation and the diaphragmatic defect were closed. During the postoperative course, the patient developed sepsis and coagulopathy that subsided following medical therapy. In order to prevent severe complications, surgery is indicated as soon as conclusive diagnosis is made.     

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.     

Pulmonary hernia secondary to limited access for mitral valve surgery and repaired by video thoracoscopic surgery

Iatrogenic pulmonary hernia is a rare condition. Repair is performed due to persistent symptoms and it is usually carried out by open surgery. We report a case of a 59-year-old woman who developed a lung hernia after small anterior thoracotomy that was performed for mitral valve surgery. The herniated lung is reduced with success by video thoracoscopic surgery and the chest wall defect is repaired by a polypropylene mesh fitted to the thoracic wall. At six-month follow-up, she was asymptomatic and without recurrence of hernia. Our experience suggests that video thoracoscopic surgery is a feasible surgical technique even for lung hernia secondary to mini-thoracotomy. However, before performing video thoracoscopic surgery, several factors preclusive to using this strategy must be considered, including the extensiveness of pleural adhesions due to the time interval between the previous operation and lung hernia, the site and the size of the hernia, and the insufficient experience in video thoracoscopic surgery.     

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.     

Thoracoscopic repair of traumatic diaphragmatic rupture

A 51-year-old man with a traumatic diaphragmatic rupture is presented. Preoperatively, diaphragmatic rupture and herniation of the stomach into the left thoracic cavity were suspected. Under thoracoscopic guidance, the stomach and omentum were repositioned in the abdominal cavity using Babcock forceps, and then the rupture site was closed using an endoscopic hernia stapler. The postoperative course was uneventful and the patient was discharged from our hospital with no symptoms.     

Hernia of the diaphragm with gastric ulcer and volvulus: an unusual complication after diaphragmatic resection by VATS

We present a 45-year-old female patient who developed diaphragmatic rupture and secondary hernia following a diaphragmatic resection for a diaphragmatic abnormality with spontaneous pneumothorax performed by endoscopic stapling in video-assisted thoracoscopic surgery (VATS). This complication can be avoided by careful direct repair of the diaphragmatic incision in addition to endoscopic stapling.     

Gastropleural fistula due to gastric perforation after lobectomy for lung cancer

We report a case of acute gastropleural fistula due to gastric perforation after a left lower lobectomy for lung cancer. A 76-year-old male, who received a left hemicolectomy 20 years previously, came to our hospital for surgical treatment of lung cancer, which was performed uneventfully as a left lower lobectomy with combined resection of the diaphragm. On the postoperative day 2, acute dilatation of the stomach followed by gradual cardiopulmonary collapse, and then gastric perforation into the thorax occurred. The perforated stomach wall and diaphragm became paper-thin and necrotic, though the abdominal cavity was free of contamination. This life-threatening condition was treated by an emergency thoracotomy and partial gastrectomy through the thorax, as the left hemidiaphragm was remarkably elevated. An oeganoaxial torsion gastric volvulus caused by anatomic rotation following the lobectomy was speculated as the disease process, with loss of suspended tissue of the gastro-colic ligament from the left hemicolectomy being a possible predisposing factor. Such an episode is rare, however, it should be looked for during perioperative care following a lobectomy.     

Laparoscopic repair of a chronic diaphragmatic hernia

Diaphragmatic injuries that remain undetected after an acute traumatic event may lead to the formation of a diaphragmatic hernia. Symptoms of a chronic diaphragmatic hernia are related to the incarceration of abdominal contents in the defect or to impingement of the lung, heart, or thoracic esophagus by abdominal viscera. A 49-year-old woman with a symptomatic chronic diaphragmatic hernia from an unrecognized iatrogenic injury to the left hemidiaphragm sought treatment. The diaphragmatic injury occurred 2 years earlier when a low, left-sided chest tube was placed for a persistent pleural effusion 2 weeks after a lower lobectomy for an aspergilloma. The patient's diaphragmatic hernia was diagnosed after an upper gastrointestinal series and an esophagogastroduodenoscopy. Approximately 75% of her stomach was incarcerated in the diaphragmatic defect. The diaphragmatic hernia was repaired laparoscopically using a 9 cm x 10-cm polytetrafluoroethylene patch sewn with nonabsorbable, interrupted, horizontal mattress sutures. Improvement of video technology, laparoscopic instruments, and surgical skills has allowed surgeons to expand the boundaries of advanced therapeutic laparoscopy. These factors facilitated the authors' standard tension-free prosthetic repair of a chronic diaphragmatic hernia using minimally invasive techniques.     

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: Report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.