Laparoscopic repair of traumatic diaphragmatic injuries

Background: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. Methods: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15–63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0–6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5–420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). Results: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5–12 cm). The mean operative time was 134.7 min (range, 55–200 min). The mean estimated blood loss was 108.5 ml (range, 30–500 ml), and the postoperative length of stay was 4.4 days (range, 1–12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6–14 days). Conclusions: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.     

Traumatic diaphragmatic hernia. Occult marker of serious injury.

OBJECTIVE: Recent experience with traumatic diaphragmatic hernias at the Massachusetts General Hospital was reviewed to identify pitfalls in the diagnosis and treatment of this injury. SUMMARY BACKGROUND DATA: Traumatic diaphragmatic disruption is a common injury and a marker of severe trauma. It occurs in 5% of hospitalized automobile accident victims and 10% of victims of penetrating chest trauma. Numerous reports describe splenic rupture in 25% of patients with blunt diaphragmatic rupture, liver lacerations in 25%, pelvic fracture in 40%, and thoracic aortic tears in 5%. Diaphragmatic rupture is a predictor of serious associated injuries which, unfortunately, is itself often occult. METHODS: A chart review of all patients admitted to the Trauma Service with traumatic diaphragmatic hernias was undertaken for the period of January 1982 to June 1992. RESULTS: Data on 68 patients sustaining blunt (n = 25) and penetrating (n = 43) diaphragmatic rupture or laceration were presented. The diagnosis was made preoperatively in only 21 (31%). Associated injuries were frequent in those injured by either blunt or penetrating trauma. Sixty-six patients underwent repair, 54 (82%) through a laparotomy alone and 12 (18%) with the addition of a thoracotomy. There were five (7.4%) deaths that were caused by coagulopathy, hemorrhagic shock, multisystem organ failure, and pulmonary embolism. Complications were twice as frequent in the blunt-trauma group and included abscess, pneumonia, and the sequelae of closed head injuries. CONCLUSIONS: The recognition of diaphragmatic rupture is important because of the frequency and severity of associated injuries. The difficulties in reaching the diagnosis require an aggressive search in patients at risk.     

What have we learned about traumatic diaphragmatic hernias in children?

BACKGROUND/PURPOSE: Diaphragmatic injuries have been reported to be a predictor of serious associated injuries in trauma and a marker of severity. The aim of this retrospective study was to identify pitfalls in the diagnosis and treatment of these injuries in children. METHODS: Data were collected from all patients admitted to the trauma service with traumatic diaphragmatic hernias for the period of January 1977 to August 1998. The authors evaluated 15 cases of traumatic diaphragmatic rupture (6 girls and 9 boys). RESULTS: Mean age was 7.5 years (range, 3 weeks to 15 years). Thirteen patients suffered from blunt trauma, and 2 patients suffered from penetrating trauma. The right and left hemidiaphragms were injured equally (7 patients each), with 1 additional patient suffering from bilateral injuries. All but 1 patient had laparotomies for trauma (n = 14). The diagnosis was made preoperatively in 8 patients (53%) with just a chest radiograph. Computed tomography (CT) scan, magnetic resonance imaging (MRI), and oral contrast studies were used as ancillary tests to diagnose traumatic diaphragmatic rupture. There were 3 missed injuries. Associated injuries included liver lacerations (47%), pelvic fractures (47%), major vessels tear (40%), bowel perforations (33%), long bone fractures (20%), renal lacerations (20%), splenic lacerations (13%), and closed head injuries (13%). The mean hospital stay was 20 days (range, 7 to 60 days). Complications were observed most commonly in those patients with multiple injuries and included postoperative ileus (40%), pneumonia (30%), pancreatitis (20%), wound infection (20%), intestinal obstruction (20%), cholestasis (10%), and renal failure (6%). Five deaths (33%) were caused by hemorrhagic shock, respiratory failure, coagulopathy, and refractory acidosis. CONCLUSIONS: Traumatic diaphragmatic hernias usually are associated with serious injuries in children. It is important to combine a high index of suspicion with radiological diagnostic tests in patients at risk. Palpation and/or visualization of both diaphragms at laparotomy is extremely important in detecting these injuries when they are not suspected preoperatively.     

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.     

Acute abdomen due to a right-sided strangulated traumatic diaphragmatic hernia. Case report

Traumatic rupture of diaphragm is sometimes diagnosed many years after the traumatic event. Due to the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. We describe a rare case of right diaphragmatic hernia, in which the diagnosis was made many years after the trauma. The incidence of right diaphragmatic hernia is about 11-14% of all diaphragmatic hernias. The patient showed acute hernia of the small intestine and was treated with resection of the intestinal loop and repair of breakthrough by suture. The diagnosis was made with a standard X-ray of thorax and abdomen. CT scan and NMR give more accurate information in these cases. The surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.     

Late-presenting congenital diaphragmatic hernia

Background

Late-presenting congenital diaphragmatic hernia (CDH) is a rare subset of CDH, most of the information derived from small series or case reports. The aim of this study was to document the clinical manifestations of late-presenting CDH using a large multicenter database.

Methods

Information about late-presenting CDH (diagnosed at later than 30 days of age) was identified from the database of the CDH Study Group (3098 cases collected during 1995-2004) and reviewed retrospectively.

Results

Seventy-nine cases (2.6%) from 30 centers met the inclusion criteria. Seven cases had a Morgagni hernia. There were 50 males (65%) and 27 females (35%). The mean age at diagnosis was 372 days (32 days to 15 years). Major associated anomalies (10 cardiac and 7 chromosomal abnormalities) were identified in 12 cases (15%). Presenting symptoms were respiratory in 20 (43%), gastrointestinal in 15 (33%), both in 6 (13%), and none (asymptomatic) in 5 (11%). The hernia was left-sided in 53 (69%), right-sided in 21 (27%), and central or bilateral in 3 (4%). Patients with gastrointestinal symptoms invariably had left-sided hernias (n = 19), whereas patients with respiratory symptoms (n = 24) seemed equally likely to have right- or left-sided lesions. A primary repair without patch was done in all cases with 100% survival.

Conclusions

Presenting symptoms of late-onset CDH can be respiratory or gastrointestinal, but presentation with gastrointestinal problems was more common in left-sided hernias, whereas respiratory symptoms predominated in right-sided lesions. The prognosis is excellent once the correct diagnosis is made.     

Prospective randomized single-center, single-blind Comparison of laparoscopic vs open repair of pediatric inguinal hernia

Background The repair of indirect inguinal hernia (IH) is one of the most common pediatric surgical procedures, and open surgery (OS) is the standard treatment. The aim of this study was to determine whether the recently developed laparoscopic repair (LR) of IH is superior to OS.Methods Between February 2003 and February 2004, we randomly assigned 97 consecutive IH patients at our institution into OS and LR groups. Fourteen pateints were excluded from the study for various reasons, leaving study population of 83 patients. After operation, multiple dressings were placed to blind observers to the operation type. Two pain scales, the children and Infants Postoperative Pain were used to assess postoperative pain. Acetaminophen (15 mg/kg/dose every 6 h) was given at a fixed pain score. Analgesic doses were compared. Parents also provided assessments of their children’s recovery and wound appearance.Results The amount of acetaminophen taken by the OS group (n = 42) was 1.05 ± 1.248 doses per patient, whereas the amount taken by the LR group (n = 41) was 0.54 ± 0.84 dose per patient (p = 0.032; 95% confidence interval 0.45–0.976). Laparoscopy detected 11 more bilateral hernias (p = 0.006). Although the operative times did not differ significantly for bilateral hernias (39.08 ± 13.37 min vs 34.0 ± 11.31 min, p = 0.623), it did differ for unilateral hernias (18.38 ± 5.71 vs 23.25 ± 6.26 min, p = 0.001). Five contralateral hernias were detected in the OS group on follow-up, but none were found in the LR group (p = 0.026). The scores given by parents for recovery and wound appearance were higher in the LR group (p = 0.05).Conclusions As compared with IH patients who undergo open surgery, those who have a laparoscopic repair suffer less pain, and their recovery and wound cosmesis are more satisfactory. With LR, contralateral hernias can be detected and repaired in a single operative procedure. This procedure takes slightly longer for unilateral than for bilateral hernias.     

Late-presenting congenital diaphragmatic hernia: diagnostic pitfalls and outcome

Purpose

We sought to review the presentation, diagnosis, and outcome of a series of children with late-presenting, congenital diaphragmatic hernias (CDH).

Methods

Bochdalek and Morgagni hernias that were diagnosed after 30?days of age, between January 1989 and December 2009, were reviewed retrospectively. A medical record review and telephone survey were conducted in 2010.

Results

Thirty-one subjects, diagnosed with CDH between 45?days and 13?years of age (mean, 16?months), were reviewed. Bochdalek hernias were present in 18 (58%) and Morgagni hernias in 13 (42%). There were twenty (64%) left-sided, eight (26%) right-sided, and three (10%) bilateral CDH. Five (16%) had other congenital anomalies. Eight (25.8%), including a subject with strangulated intestine that required resection, were initially misdiagnosed, due mostly to failure to obtain or correctly interpret a chest radiograph. Thirty (97%) were repaired by an abdominal approach, including seven laparoscopic closures. Follow-up ranged from 1 to 20?years (median, 7?years). All subjects survived without recurrence. Unlike neonatally diagnosed CDH, neither right-sided hernia, patch repair, nor associated esophageal atresia predicted morbidity.

Conclusion

Although diagnostic delays may lead to morbidity, if late-presenting CDH are expeditiously identified and repaired, their outcome is very good, in contrast to those that present in neonates.     

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.     

Repair of post–bariatric surgery,recurrent, and de novo hiatal hernias improves bloating,abdominal pain,regurgitation, and food intolerance

BackgroundPost–bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF).ObjectivesTo report the short-term outcomes of repairing post–bariatric surgery hiatal hernias in patients with BARF.SettingLarge, multispecialty group practice with university affiliation.MethodsWe reviewed the records of all consecutive patients who underwent repair of post–bariatric surgery hiatal hernias (2012–2020). Data are shown as means ± standard deviations.ResultsWe repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients.ConclusionsHiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post–bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients.     

Minimally invasive repair of traumatic right-sided diaphragmatic hernia with delayed diagnosis.

BACKGROUND: Traumatic diaphragmatic hernias are a diagnostic and therapeutic challenge due to variable presentations. Early repair is important because of risks of incarceration and strangulation of abdominal contents along with respiratory and cardiovascular compromise. Minimally invasive techniques have been useful for diagnosis and treatment of diaphragmatic hernias in both blunt and penetrating trauma. METHOD: We present the case of a 54-year-old victim of a motor vehicle crash who presented with a delayed diagnosis of a right-sided traumatic diaphragmatic hernia. By using a 4-port technique and intracorporeal suturing, the hernia was repaired. This case highlights the difficulties associated with diagnosing diaphragmatic hernias and the role of minimally invasive techniques to repair them. CONCLUSION: Minimally invasive surgical techniques are being increasingly used to both diagnose and repair traumatic diaphragmatic injuries with excellent results.     

Acute Thoracic Aortic Trauma: A Comparison of Endoluminal Stent Grafts with Open Repair and Nonoperative Management

The magnitude of injury necessary to cause a traumatic aortic tear often results in high mortality. Open surgery in these patients is often not well tolerated. The purpose of this study was to compare the outcomes of three different treatment options in patients with traumatic aortic injuries. This was a retrospective review of a prospectively maintained computer database. Over a period of 33 months, 27 patients were diagnosed with thoracic aortic tears on the basis of a computed tomogram or a diagnostic angiogram. All patients were initially seen by trauma surgery staff and managed nonoperatively (n = 12) if the predicted mortality due to associated injuries approached 100%. Thoracic surgery staff were consulted on all other patients, and open surgical repair was performed in 10 patients. Thoracic stent grafts were used in five patients because of inability to ventilate following an attempted thoracotomy (n = 2) or associated organ injury that prohibited anticoagulation (head ± liver injury, n = 3). Overall, patients in the endovascular group had a higher injury severity score than that of the open surgical group (42 ± 9 vs. 32 ± 11). However, mortality was lowest in the endovascular group (20%), higher in the open surgical group (50%), and highest in the nonoperative group (92%). No paraplegia was noted, and all surviving patients have been free of complications during the follow-up period. Due to the small number of patients in each treatment, no strong recommendations can be made. However, the results of thoracic stent grafts for patients with traumatic thoracic pseudoaneurysms may prove to be a safer and less invasive treatment option. Presented at the Thirteenth Annual Winter Meeting of the Peripheral Vascular Surgery Society, Snowmass, CO, January 31-February 2, 2003.     

The late-presenting pediatric Morgagni hernia: a benign condition

Data concerning 15 infants and children with late-presenting (more than 8 weeks) Morgagni hernias over the last 20 years (1966 to 1986) have been reviewed. Ten of the cases were clinically normal on presentation, and the most common symptoms and signs were gastrointestinal and respiratory. Only one child presented with acute symptoms. Five had previously normal chest x-rays, and two others had an incorrect initial radiologic assessment. Chest x-ray was the most common diagnostic test; preoperative barium studies were performed in three patients. Twelve patients had other major congenital abnormalities. Fourteen of the 15 had surgery, usually within days of presentation. At operation, 10 of the 14 hernias contained a hollow viscus, nine had a sac, and four had abnormal bowel fixation. Postoperatively, two children had radiologic evidence of impaired diaphragmatic motility. There was no mortality in this series. Overall, late-presenting Morgagni hernias are relatively benign.     

Traumatic flank hernias: acute and chronic management

BACKGROUND: Traumatic flank hernias are increasingly recognized as occurring after severe blunt injury. To clarify the role and timing of operative therapy, we review here our recent experience. METHODS: A prospectively maintained database at Oklahoma's only level I trauma center was reviewed to identify all patients presenting with traumatic flank hernias. RESULTS: During the period from July 2001 through February 2007, 25 patients (.2% of all blunt trauma patients) had traumatic flank hernias. The average age was 36.4 years (range 13 to 66), and all cases but 1 were related to motor vehicle crashes. All patients had at least 1 associated injury. Repairs were done by standardized approach. Eleven patients underwent immediate surgery; 8 underwent delayed repair; and 3 underwent late repair (range 4.5 to 10 years after injury). The other 3 patients were managed expectantly. There was 1 mortality and 3 recurrences. Length of stay for acute trauma ranged from 5 to 49 days and was dependent on the severity of associated injuries. Follow-up of 21 patients ranged from 7 to 710 days. CONCLUSIONS: Traumatic flank hernias are rare but more common than previously recognized. Prompt recognition, proper timing, and technique are key to successful outcomes.     

Morbidity associated with laparoscopic repair of suprapubic hernias

Background

Laparoscopic suprapubic hernia repair (LSHR) is frequently a technically difficult procedure. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, and adequate mesh coverage with transfascial suture fixation. The aim of the current study was to document the complications and morbidity associated with the repair of suprapubic hernias.

Methods

A retrospective review of patients with complex suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. The operative techniques were similar and included dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper's ligaments, and extensive transfascial suture fixation of the mesh.

Results

A total of 47 patients were reviewed, 29 women and 18 men, with a mean age of 54 years. Patients averaged 3.5 previous abdominal surgeries (SD ±2.3) and had a mean body mass index (BMI) of 35.1 (SD ±7.5). Previous ventral hernia repairs had been performed in 57% of patients. Average defect size was 139.8 cm² (SD ±126) and average mesh size was 453.8 (SD ±329.0), with an average hernia-to-mesh ratio of 3.2. Median length of stay was 3 days with a mean follow-up of 2.6 months (SD ±3.1). There were 18 complications (38%): symptomatic seroma (n = 4), prolonged ileus (n = 2), chronic pain (n = 2), postoperative urinary retention (n = 2), enterotomy (n = 1), intraoperative bladder injury (n = 1), postoperative urinary tract infection (n = 1), mesh infection (n = 1), rapid ventricular rate (n = 1), small bowel obstruction (n = 1), pulmonary embolism (n = 1), and pneumonia (n = 1). One patient required conversion to open ventral hernia repair, no injury was identified. Recurrence occurred in 3 patients (6.3%). The mechanisms of recurrence included reherniation at the level of the pubic tubercle, a lateral mesh recurrence in a patient with a high BMI and small abdominal excursion, and in a pregnant patient who developed a fixation suture hernia.

Conclusions

Laparoscopic suprapubic hernia repair is safe and effective with a relatively low recurrence rate, considering the complexity of the repair.     

Traumatic diaphragmatic rupture: look to see

OBJECTIVE: Traumatic diaphragmatic rupture (TDR) is a rare but potentially life threatening clinical entity with a high incidence of associated injuries. In this article, our experience with this challenging diagnosis is presented. METHODS: In this study, a total of 68 patients with TDR, were operated in our center between July 1994 and September 2005. Study group was analyzed retrospectively. The etiological factors, management and outcomes were discussed. RESULTS: The mean age was 32.9 years with a female to male ratio of 9/59. TDR was right-sided in 16.2% (n=11) and left-sided in 83.8% (n=57). The cause of the rupture was penetrating trauma in 51 (75%), and blunt trauma in 17 (25%). Only three patients (4.4%) had late diagnosis. Associated injuries were seen in 91% (n=62) of the patients. The most common used incision was a laparotomy incision (89.6%). Morbidity and mortality were encountered in 13.1% (n=9) and 16.2% (n=11) patients, respectively. CONCLUSIONS: Although rare, diaphragmatic rupture must be suspected in any patient with thoracoabdominal injury. Early diagnosis of TDR is sometimes difficult and depends on a high index of suspicion. Surgical repair is necessary even for small tears. The most common approach is the transabdominal approach, which allows a complete exploration of the abdominal organs for associated injuries. The transthoracic approach might be used in most cases with latent diaphragmatic rupture.     

Traumatic diaphragmatic hernia: a continuing challenge

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. From 1957 to 1982, we treated 41 patients with traumatic diaphragmatic hernias. In 39 patients (95%), diaphragmatic hernia followed blunt trauma. The herniation occurred on the right side in 14 patients and on the left side in 29; it was bilateral in 2. Twenty-four patients had diagnostic chest radiographs, and an additional 11 had abnormal but nondiagnostic studies. Peritoneal lavage was of little value in making the preoperative diagnosis. Twenty-three patients underwent laparotomy only, 13 required thoracotomy alone, and 5 had combined laparotomy and thoracotomy. There were 7 deaths (17%) from associated injuries. Only one missed injury was encountered; a second delayed hernia, initially treated elsewhere, was repaired 45 years after the original trauma. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. Right-sided injuries occur more commonly than previously thought and often require dual incisions (laparotomy and thoracotomy) for diagnosis and treatment. The organization of emergency care for such patients is critical in avoiding the potential of long-term sequelae.     

Management of blunt thoracic aortic injuries: endovascular stents versus open repair

BACKGROUND: Endovascular stent graft (EV) technology has been successfully adapted to the repair of blunt traumatic aortic injuries. The purpose of this study was to compare the outcomes of patients treated with EV repair and open repair after blunt thoracic aortic trauma. METHODS: A review of a tertiary trauma center's prospective trauma registry identified all patients who suffered a blunt traumatic thoracic aortic injury over an 11-year period (1991-2002). Operative interventions and outcomes were then compared. RESULTS: Over an 11-year period, 18 patients underwent repair of a blunt thoracic aortic injury (EV, 6; open, 12). There were no significant differences in demographics, injury, or crash statistics between groups. The open group had a 17% early mortality rate (n = 2), a paraplegia rate of 16% (n = 2), and an 8.3% incidence of recurrent laryngeal nerve injury (n = 1). This is in contrast to a 0% rate of mortality, paraplegia, and recurrent laryngeal nerve injury in the EV group. A definite trend toward decreased morbidity, mortality, intensive care unit length of stay, and number of ventilator-dependent days was seen with EV repair. CONCLUSION: We observed a clear trend toward improved outcomes after EV repair of thoracic aortic injuries compared with standard open repair. EV repair is emerging as the preferred method of repairing blunt thoracic aortic injuries in trauma patients with multiple injuries.     

Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice

Background: Although the laparoscopic totally extraperitoneal (TEP) approach to hernia repair has been associated with less pain and a faster postoperative recovery than traditional open repair, many practicing surgeons have been reluctant to adopt this technique because of the lengthy operative times and the learning curve for this procedure. Methods: Data from all patients undergoing TEP repair since 1997 and open mesh repair (OPEN) since 1999 were collected prospectively. Selection of surgical approach was based on local hernia factors, anesthetic risk, previous abdominal surgery, and patient preference. Statistical analyses were performed using unpaired t-tests and chi-squared tests. Data are mean ± SD. Results: TEP repairs were performed in 147 patients and open repairs in 198 patients. Patients in the OPEN group were significantly older (59 ± 19 years OPEN vs 51 ± 13 years TEP) and had a higher ASA (1.9 ± 0.7 OPEN vs 1.5 ± 0.6 TEP; p < 0.01). TEP repairs were more likely to be carried out for bilateral (33% TEP, 5% OPEN) or recurrent hernias (31% TEP, 11% OPEN) than were open repairs (p < 0.01). Concurrent procedures accompanied 31% of TEP and 12% of OPEN repairs (p < 0.01). Operative times (min) were significantly shorter in the TEP group for both unilateral (63 ± 22 TEP, 70 ± 20 OPEN; p = 0.02) and bilateral (78 ± 27 TEP, 102 ± 27 OPEN; p = 0.01) repairs. Mean operative times decreased over time in the TEP group for both unilateral and bilateral repairs (p < 0.01). Patients undergoing TEP were more likely (p < 0.01) to develop urinary retention (7.9% TEP, 1.1% OPEN), but were less likely (p < 0.01) to have skin numbness (2.8% TEP, 35.8% OPEN) or prolonged groin discomfort (1.4% TEP, 5.3% OPEN). Conclusions: Despite a higher proportion of patients undergoing bilateral repairs, recurrent hernia repair, and concurrent procedures, operative times are shorter for laparoscopic TEP repair than for open mesh repair. TEP repairs can be performed efficiently and without major complications, even when the learning curve is included. Presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, March 2003, Los Angeles, CA, USA     

A combined laparoscopic and endoscopic approach to acute gastric volvulus associated with traumatic diaphragmatic hernia

PURPOSE: The purpose of the article was to describe a comprehensive approach to laparoscopic repair of acute intrathoracic gastric volvulus in acquired diaphragmatic hernia. BACKGROUND: Traumatic diaphragmatic hernias are observed in 10% of diaphragmatic injuries, which include blunt trauma, penetrating trauma, and iatrogenic injuries. It is of utmost importance because of its high morbidity and mortality. Minimally invasive approaches are considered to be safe and effective procedures. They also provide rapid recovery from the operation, avoid the morbidity of laparotomy, and allow rapid recovery of gastric function. METHOD: From June 2002 to June 2006, we encountered 4 cases of acquired diaphragmatic hernia with acute gastric volvulus, which were successfully treated with laparoscopic reduction, detorsion, repair of diaphragmatic hernial defect, and percutaneous endoscopic gastropexy. RESULTS: There were no operative complications. All 4 patients tolerated the procedure well and the patients were discharged 1 to 3 days after the operation. After 1 to 2 years of follow-up, there were no radiologic recurrences of the volvulus and all patients remained asymptomatic. CONCLUSIONS: Laparoscopic surgery represents a safe and acceptable approach in the treatment of acute gastric volvulus through the abdominal approach with minimal morbidity and good outcome.