Huge Chronic Trauma Rupture of the Left Diaphragm Complicated with Massive Visceral Herniation and Colon Obstruction: Laparoscopic Primary Suture Repair, Sparing the Chest Tube

Abstract

Introduction: In the early post-traumatic period, diaphragmatic hernias may be missed and complicated at a later time by intestinal obstruction and strangulation. In most cases, open thoracic or abdominal approach is performed. While laparoscopic approach has been established as the method of choice for hiatal hernioplasty, it can well be considered as an alternative approach to post-traumatic diaphragmatic hernias, independently of the defect size. Our case was a chronic (happened 6 months before), left diaphragmatic trauma-rupture, starting anterior to the esophageal hiatus and transversely extending for more than 10 cm along the left tendonous part of the diaphragm that was managed with total laparoscopic approach. In addition, the remnant pneumothorax was fully eliminated intraoperatively, sparing chest tube. Methods: A 50-year-old man was admitted to hospital complaining of colicky epigastric pain, shortness of breath and constipation. After a chest X-Ray and a double-contrast CT-scan, he was diagnosed with massive visceral herniation, subsequent left diaphragmatic rupture complicated with colon obstruction, left lung collapse and atelectasis. No other injury was administered. Laparoscopic management was promptly decided for the repair of the diaphragmatic rupture. The operation started with the restoration of viscera into the abdominal cavity, giving view to the collapsed left lung. Extensive adhesiolysis and meticulous dissection were performed due to chronic dense adhesions, especially between the stomach fundus and the posterior flap of the diaphragm. The left triangular liver ligament was divided in order to create adequate space for suture repair. The extended dissection and preparation of the diaphragm allowed for a tension-free, primary suture repair of the defect, using a nonabsorbable Ethibond (No. 2-0) running suture. The anesthetist recruited Valsalva maneuver with Positive End Expiratory Pressure (PEEP), aiding the elimination of remnant pneumothorax, while the surgeon was aspirating the remained air from the thoracic cavity, using a suction device, through a small diaphragmatic opening that was left unsutured for that purpose. Once the pneumothorax was fully aspirated, the opening was also sutured, sealing-up the diaphragm. Results: Despite hernia's size and chronicity, the patient was successfully managed laparoscopically with primary intracorporeal suture repair of the rupture. Operation time was 120 minutes. The pneumothorax was completely eliminated intraoperatively with the aid of the anesthetist. The lung was immediately expanded; thus, no chest tube was needed. No intraoperative complication occurred. The patient was uneventfully discharged home 2 days later. Conclusions: Laparoscopic approach to traumatic diaphragmatic hernias is feasible and safe. Beyond its well-known advantages to open surgery, its efficiency depends on the surgeon's experience in advanced laparoscopic surgery with intracorporeal suturing skills. Intraoperative elimination of remnant pneumothorax can result in reduced morbidity and hospital stay. The authors have nothing to disclose. Run time of video: 7 mins 50 secs