Commentary: Robotic repair of diaphragmatic hernia.

Abstract

Listen

Translate article

Central MessageRobotic transthoracic repair of diaphragmatic hernias is an option in the face of a hostile abdomen.See Article page 578. Robotic transthoracic repair of diaphragmatic hernias is an option in the face of a hostile abdomen. See Article page 578. Repair of traumatic diaphragmatic hernias can be complex.1Blitz M. Louie B.E. Chronic traumatic diaphragmatic hernia.Thorac Surg Clin. 2009; 19: 491-500Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Traditionally, surgeons fixed these hernias either through an open thoracotomy or via the abdomen with laparoscopy. Often, intrathoracic adhesions make the repair from the abdomen difficult. Very large diaphragmatic hernias occupying most of the chest can also make a transabdominal repair difficult. Finally, reentering the abdominal cavity to repair the hernia in patients with a hostile abdomen may increase the risk of complication and is often avoided. In the current issue of the JTCVS Techniques, Sideris and Molena2Sideris A.C. Molena D. Robotic transthoracic diaphragmatic hernia repair.J Thorac Cardiovasc Surg Tech. 2021; 10: 578-580Scopus (2) Google Scholar report a case of a patient with a diaphragmatic hernia after debulking for ovarian cancer. Debulking included disease on both hemi-diaphragms. In the late postoperative period (6 months), she was found to have a large hernia through the left hemidiaphragm containing stomach. The authors used the DaVinci robot to repair the diaphragm. The authors used primary repair reinforced with absorbable mesh, in a “sandwich” fashion, with mesh on both the thoracic and abdominal side of the diaphragm after taking down adhesions in the abdominal side. I would encourage the reader to watch the excellent video submitted with the manuscript, in which the authors demonstrate their technique. The patient did well and was discharged home on postoperative day 1. The surgical robot is a versatile tool that can facilitate some complex procedures. The mobility inside a tight cavity and wrist articulation makes suturing relatively easy. The ease of suturing facilitates the repair of a diaphragmatic hernia. I like the authors' option for a transthoracic approach. With a hostile abdomen, just the laparoscopic entry may induce serious complications. Many will question the use of absorbable mesh on both sides of the diaphragm, and others may question the use of mesh altogether. However, there are no clear guidelines on the use of mesh in this patient population. If one borrows from other types of chronic hernias, such as ventral hernias, the use of mesh was shown to be beneficial in decreasing recurrences.3Holihan J.L. Hannon C. Goodenough C. Flores-Gonzalez J.R. Itani K.M. Olavarria O. et al.Ventral hernia repair: a meta-analysis of randomized controlled trials.Surg Infect (Larchmt). 2017; 18: 647-658Crossref PubMed Scopus (49) Google Scholar Although I do not use mesh routinely, the case presented by Sideris and Molena may be a time in which I would consider using an absorbable mesh to make up for the previous debulking and stripping. With a lack of Level I evidence, we must use our clinical judgment in this type of situation. Robotic transthoracic diaphragmatic hernia repairJTCVS TechniquesVol. 10PreviewDiaphragmatic hernias are rare entities that can be congenital, traumatic, or iatrogenic.1 Transthoracic hernia repairs are most often performed via open thoracotomy, with few reports of robotic-assisted approaches.1-3 We report a case that illustrates our technique of transthoracic diaphragmatic hernia repair with mesh using the da Vinci Xi robotic platform in the presence of an extremely hostile abdomen. The Memorial Sloan Kettering Cancer Center institutional review board approved the submission, as this does not constitute human subjects research and the project does not involve identifiable patient information (#16-1631, October 27, 2020). Full-Text PDF Open Access