Page 48 - Jourmal of World Association of Laparoscopic Surgeon

Medhat M Ibrahim

Table 2: The statistic result patients were discharged after the second postoperative day,
and there were no perioperative morbidities or operative
Age (months) 19 ± 12.40
Operative time (minutes) 55 ± 34.33 mortalities. There have been no recurrences reported in
Hospital stay (days) 5 ± 3.47 laparoscopic MH repairs, but long-term follow-up has not
been provided.
hernial contents was easy in 13 cases and difficult in two Transabdominal exploration and reduction of the hernial
cases. The diaphragmatic defect was closed directly by contents followed by suture closure of the hernial defect is
suturing the posterior diaphragmatic edge of the defect with commonly performed. However, laparoscopic repair, first
the intercostal muscles using Storz port closure needle in carried out by Kustar et al in 1992, since that, much
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all patients. The hernial sac was excised in three cases. The modification has been described to improve, ease the
procedure was completed easily and successfully in operative technique and the outcome. Improved video
14 (93.3%) patients. Elective conversion was required only technology, laparoscopic instruments, and surgical skills
in one (6.7%) patient, because the liver was preventing save have allowed surgeons to expand the repetition of minimally
needle manipulations to do suture in small abdominal cavity. invasive procedures.
A prosthetic patch was not required in any patient, as the In traditional laparoscopic approaches to a MH, a
defects were closed without tension. There was no blood 3-trocar technique is generally used with the umbilical site
loss. A chest drain was not inserted in all patients and there used for visualization (usually a 3 or 5 mm telescope) and
was not any complication from the nonexcised sac. All 2 upper abdominal working ports. Depending upon the
patients achieved full recovery without intra- or patient size, the working instruments may range in size from
postoperative complications. After the operation, a 2 to 5 mm. Triangulation of the access sites allows
conventional ventilator was required for two children. The intracorporeal sewing and tying with relative ease, in a sense,
mean postoperative ventilatory support was 1 day. mimicking the natural ergonomics of open surgery. 11,13
All patients started with paracetamol suppository 15 mg/ In this study, the facial needle was useful as it reduced
kg/dose, 10 patients needed second dose after 6 hours. the need for more than one port to perform the dissection of
Two patients needed fentanyl (0.5 μg/kg) plus midazolam the falciform ligament of the liver, help in the hernial content
(0.05-0.1 mg/kg). reduction and aid the facial needle thread holding
There was no morbidity, mortality or recurrence all over intracorporal.
the follow-up period. Chest X-ray and clinical examination In a MH the retrosternal rim of the diaphragm is
were normal in all patients at the 6th month postoperatively. frequently absent, and a simple suture technique is usually
Practically, no visible scars were reported at the 1 year not possible. Suturing of the diaphragmatic hernial margin
follow-up. to the peritoneum or periosteum behind the sternum is
difficult and not very solid, particularly with the
DISCUSSION laparoscopic approach. The defect itself may be closed
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The diagnosis of the MH may be difficult and patients often either by primary suture closure, primary placement of a
undergo extensive investigations. However, it may be mesh, or by a combination of both. 9,14 In this work,
discovered accidentally during routine investigations for I performed laparoscopic repair of MH using the full
other problems. The diagnosis is usually apparent on chest thickness of the anterior-abdominal wall to the posterior
radiograph and can be confirmed with computed diaphragmatic rim, with extracorporeal knot tying in the
tomography (CT) or magnetic resonance imaging (MRI). subcutaneous tissue without the need of a mesh in all cases.
Barium enema or meal is rarely required as the sensitivity Insertion of the needle from outside the thoracic cavity
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of CT and MRI approaches 100%. In this study CT was into the intercostal muscles was not difficult but the
100% sensitive, while the chest radiography was suspecting negotiation of the needle with the posterior diaphragmatic
a lesion in 11 (73.3%) cases and did not show any significant rim was the challenge and need for some aide by the grasper.
radiological signs in other four patients (26.6%). One barium The U sutures between the intercostal muscles and the free
enema was done to exclude colonic intestinal obstruction posterior diaphragmatic edge in the part of the defect were
in the hernia. effective. Extracorporeal ligation of the suture was ease.
Because MH is rare, comparing conventional open It abolishes the difficulty of intracorporeal suturing and knot
repairs with laparoscopic repairs have not been performed. tying. It does not need a long learning curve and is an
Patient demographics, hernia characteristics and effective rapid technique for closure of MH in children.
perioperative outcomes for the 15 cases of laparoscopic The repair described in this paper takes advantage of the
repair of MH are summarized in Tables 1 and 2. Only four fact that it incorporates the whole thickness of the intercostal
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