Page 48 - World Journal of Laparoscopic Surgery

CASE REPORT
Laparoscopic Diaphragmatic Repair: A Single-center

Experience

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Eppa Vimalakar Reddy , Gourang Shroff , Vemula Bala Reddy , Dinesh Reddy Kaipu , Raju Musham 5
AbstrAct
Background: With the ongoing advances in the field of laparoscopy, more and more of diaphragmatic repairs are being performed
laparoscopically. All forms of diaphragmatic pathologies, such as congenital diaphragmatic hernia (CDH) including diaphragmatic eventration,
hiatus hernia as well as traumatic diaphragmatic rupture, can be well performed through laparoscopy. Laparoscopic repair along with the
advantage of improved vision and accessibility can also avoid large incisions, thereby reducing morbidity and long hospital stay, due to pain
and lung complications, with early return to work.
Materials and methods: A total of five cases underwent laparoscopic diaphragmatic repair at our center in 1 year duration. All cases were
followed up with immediate postoperative and quarterly chest X-rays.
Results: None required conversion to open. Diaphragm was reconstructed and reinforced with mesh. None had any postoperative complications.
Follow-up postoperative chest X-rays were unremarkable.
Conclusion: Laparoscopic diaphragmatic hernia repair is a feasible, acceptable, affordable, superior, and safe alternative to open repair with
better short-term postoperative outcomes and a recurrence rate similar to the open approach.
Keywords: Congenital diaphragmatic hernia, Diaphragmatic eventration, Laparoscopy, Mesh repair, Minimal invasive, Traumatic diaphragmatic
rupture.
World Journal of Laparoscopic Surgery (2020): 10.5005/jp-journals-10033-1391

IntroductIon 1–5 Department of Surgical Gastroenterology, Sunshine Hospitals,
Among the various organs of the torso, diaphragm is a relatively Hyderabad, Telangana, India
rarely encountered surgical organ. Most common pathologies Corresponding Author: Eppa Vimalakar Reddy, Department of
involving the diaphragm include congenital or acquired Surgical Gastroenterology, Sunshine Hospitals, Hyderabad, Telangana,
diaphragmatic hernias, diaphragmatic eventrations, hiatus hernia, India, Phone: +91 9573201103, e-mail: vimalakarreddy@gmail.com
and traumatic diaphragmatic rupture. How to cite this article: Reddy EV, Shroff G, Reddy VB, et al. Laparoscopic
The congenital diaphragmatic hernias (CDHs) are usually Diaphragmatic Repair: A Single-center Experience. World J Lap Surg
reported in pediatric age-group with pulmonary complications. 2020;13(1):46–50.
Asymptomatic neglected CDH is also in later age-group. In adults, Source of support: Nil

traumatic rupture and eventration are relatively more common. Conflict of interest: None
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Sudden elevation in the pleuroperitoneal pressure gradient results
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in traumatic diaphragmatic rupture. Due to protective effect of liver,
underdiagnosis on the right side, and weak left hemidiaphragm at the remnant sac is present, most surgeons prefer to leave the sac
embryonic fusion points of pleuroperitoneal canals, 1,3,4 it is more behind, due to the chances of pleural injury. A study of the 30-day
common on the left side. Chronic, undiagnosed, or ignored rupture postoperative CT scan showed complete disappearance of sac
develops dense adhesions between the abdominal organs, sac, and by 30th day. No studies had proven superiority of interruption
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pleura predisposing to incarceration as well as damage to contents over continuous sutures or permanent over absorbable sutures.
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during reduction. 5 Defects larger than 20 to 30 cm should be reinforced with
The average age of presentation in adults is 36 years, with a appropriate mesh. 11,15
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male preponderance (11:2). It is more common on the left side
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(85%). Most patients present with shortness of breath (SOB) on
exertion, atypical chest pain, abdomen pain, or recurrent lung MAterIAls And Methods
infections. Rarely may present with obstruction. Sometimes may be A total of five cases underwent laparoscopic diaphragmatic repair
asymptomatic and incidentally detected or present with a history at our center in 1 year duration. Two were for left diaphragmatic
of blunt trauma. The contrast-enhanced computed tomography eventration (Fig. 1), one for right Morgagni, one for left Bochdalek
(CECT) abdomen is the most acceptable diagnostic tool. (Fig. 2), and one for left traumatic rupture (Fig. 3).
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Surgery is indicated for symptomatic as well as asymptomatic All cases were evaluated with preoperative chest X-ray and
patients who are fit for surgery. 9–11 Laparoscopy has superseded CECT abdomen.
open repair as a standard of care.
Controversies in diaphragmatic hernia management include Operative Procedure
(1) management of hernia sac, (2) to close the defect or not, and Under general anesthesia, with single lung ventilation, patients
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(3) the choice of mesh. Although the risk of seroma formation in were kept in supine, leg split position with reverse Trendelenburg
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