Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia

Background:The descriptive clinical study was conducted to analyse the clinical profile as well as the outcome of congenital right diaphragmatic defects among children including neonates in a tertiary care referral neonatal and paediatric centre in southern Karnataka, India.Materials and Methods:This retrospective and prospective observational clinical study was conducted from January 2005 to August 2019, over a period of 14.7 years in a tertiary care referral neonatal and paediatric centre. Clinical characteristics and risk factors of 33 children including neonates admitted and diagnosed with congenital right diaphragmatic defects were assessed both pre- and postoperatively. Neonates and children with acquired right diaphragmatic hernia defects and the left-sided diaphragmatic defects were not included in this clinical study.Results:For statistical as well as clinical analysis, 33 study subjects were grouped into four groups, depending on the pre-operative and intraoperative findings as well as on their final diagnosis. Group I comprised right congenital diaphragmatic hernia (RCDH) (n = 18), Group II comprised RCDH with sac (n = 6), the babies with diagnosis of right diaphragmatic eventration were included in Group III (n = 7), whereas babies with other right-sided diaphragmatic hernia defects diagnosis were included in Group IV (n = 2).Conclusion:Right-sided congenital diaphragmatic defects, though rare, do carry excellent survival if referred early and managed in a tertiary care neonatal and paediatric centre as that of left diaphragmatic defects.

Diaphragmatic rupture is an uncommon injury after blunt abdominal trauma. The diaphragmatic defect may not be obvious in imaging studies immediately after the initial injury. Patients may have delayed presentation when the diaphragmatic defect enlarges and allows abdominal content to herniate into the thoracic cavity. Here, we present the case of a 30-year-old man who presented with the emergency department complaining of shortness of breath at rest for two days duration. He reported having shortness of breath for the last five years, but he attributed it to his smoking. The shortness of breath was associated with cough productive and vague abdominal pain. The patient had an unremarkable relevant medical history. He reported having a motor vehicle accident five years ago that was severe but he did not sustain any significant injuries or fractures. Upon examination, the patient appeared in respiratory distress. Respiratory examination revealed diminished air entry on the left hemithorax and the abdominal examination revealed increased generalized tenderness with increased bowel sounds. The patient underwent a thoracic computed tomography scan, which unexpectedly demonstrated a huge left-sided diaphragmatic defect with bowel loops observed to occupy the left hemithorax completely. The patient was stabilized and shifted to emergency laparotomy during which the hernia content was reduced and the defect was closed with a mesh. The patient reported the resolution of his symptoms after the surgery. Intensive chest physiotherapy exercises were performed. After six months of follow-up, the patient remained asymptomatic with no active complaints. The diaphragmatic hernia may have delayed presentations after several years of blunt abdominal trauma. The case highlighted the importance of initial imaging studies after blunt trauma may not identify the diaphragmatic defect.

Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate operative technique for the management of congenital diaphragmatic hernias in neonates. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in a 3-day-old male. Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient's remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD), and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed with a thoracoscopic repair of the CDH. The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully repaired thoracoscopically using a 5 x 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and division at 1 month of age. There has been no evidence of CDH recurrence in follow-up. As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in a neonate with significant congenital cardiac anomalies.

Diaphragmatic hernias (DH) occurring after pediatric liver transplantation (LT) are rare. However, such complications have been previously reported in the literature and treatment has always been surgical repair via laparotomy. We report our experience of minimally invasive thoracoscopic approach for repair of DH occurring after LT in pediatric recipients.From April 2010 to December 2014, 7 cases of DH were identified in pediatric LT recipient in Samsung Medical Center. Thoracoscopic repair was attempted in 3 patients. Patients’ medical records were retrospectively reviewed.Case 1 was a 12-month-old boy, having received deceased donor LT for biliary atresia (BA) 5 months ago. He presented with dyspnea and left-sided DH was detected. Thoracoscopic repair was successfully done and the boy was discharged at postoperative day 7. Case 2 was a 13-month-old boy, having received deceased donor LT for BA 2 months ago. He presented with vomiting and right-sided DH was detected. Thoracoscopic repair was done along with primary repair of herniated small bowel that was perforated while attempting reduction into the peritoneal cavity. The boy recovered from the surgery without complications and was discharged on the 10th postoperative day. Case 3 was a 43-month-old girl, having received deceased donor LT for Alagille syndrome 28 months ago. She was diagnosed with right-sided DH during steroid pulse therapy for acute rejection. Thoracoscopic repair was attempted but a segment of necrotic bowel was noticed along with bile colored pleural effusion and severe adhesion in the thoracic cavity. She received DH repair with small bowel resection and anastomosis via laparotomy.Thoracoscopic repair was attempted in 3 cases of DH occurring after LT in pediatric recipients. With experience and expertise in pediatric minimally invasive surgery, thoracoscopic approach is feasible in this rare population of patients.

Treatment of a case with right-sided diaphragmatic hernia associated with an abnormal vessel communication between a herniated liver and the right lung

Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report

Herniation of abdominal contents through the diaphragm into the thoracic cavity can occur after blunt abdominal injury, resulting in a permanently acquired diaphragmatic hernia. Their clinical presentation is varied and non-specific, which can go unnoticed for a long duration.A 27-year-old male presented with right upper quadrant pain and right-sided pleuritic chest pain for the past 20 days. His past medical history included high-impact blunt trauma a few years back. His workup revealed a right-sided diaphragmatic hernia through which the gallbladder had herniated into the thoracic cavity, along with liver and hepatic flexure of the colon. The gallbladder contained gallstones which were the cause of his symptoms. The patient was managed successfully with a laparotomy and repair of the diaphragmatic hernia and cholecystectomy.After blunt abdominal trauma, right-sided diaphragmatic injury is less common because most of the trauma is absorbed by the liver, providing a protective effect. The sign and symptoms of acquired diaphragmatic hernia lack sensitivity and specificity, due to which many cases remain undiagnosed and are incidentally picked up on chest auscultation where bowel sounds are audible in the chest, and breath sounds on the affected side are absent, whereas patients have complaints of respiratory difficulty and recurrent pneumonia. Chest and abdominal imagining in the form of chest X-rays and abdominal ultrasound can help diagnose.The case we present was a unique presentation of acquired right-sided diaphragmatic hernia resulting in herniation of the gallbladder in the right-sided chest and leading to acute cholecystitis. The treatment modality is surgical repair of the diaphragm. Any patient presenting with unusual symptoms of pneumonia or abdominal pain should be investigated, especially patients with a history of blunt abdominal trauma.

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach. Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation. Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy. Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.

Post-traumatic diaphragmatic hernias (PTDH) are rare but potentially life-threatening complications of thoraco-abdominal trauma, often underdiagnosed due to their subtle and delayed presentation. This case report describes a 55-year-old female who presented with acute onset of chronic right upper quadrant pain and exertional dyspnea two weeks after sustaining severe blunt thoraco-abdominal trauma in a road traffic accident. Initial evaluation at the time of the trauma revealed no immediate signs of significant injury, and she was discharged without further investigations. On admission, physical examination revealed dullness to percussion and absent breath sounds over the right lower thorax. A thoraco-abdominal CT scan confirmed the diagnosis of a right diaphragmatic hernia, with herniation of the liver into the thoracic cavity through an 8 cm diaphragmatic defect, causing displacement of thoracic structures and compression of the right lung. The patient underwent surgical repair via a midline laparotomy, with reduction of the herniated liver, diaphragmatic defect closure using interrupted non-absorbable sutures, and thoracic drainage. The postoperative course was uneventful, and the patient was discharged on postoperative day 5 with favorable clinical and radiological outcomes at six-month follow-up. This case underscores the diagnostic challenges associated with PTDH, particularly in delayed presentations, and highlights the importance of a high index of suspicion in patients with a history of thoraco-abdominal trauma. Advanced imaging, particularly CT scans, plays a crucial role in diagnosis, while timely surgical intervention is essential for optimal outcomes. The rarity of liver herniation in PTDH further emphasizes the need for increased awareness among clinicians to prevent missed or delayed diagnoses. This report aims to reinforce the importance of thorough clinical evaluation, appropriate imaging, and long-term follow-up in patients with a history of trauma to identify and manage such rare but serious complications.

Pleuroperitoneal hernia is the most frequent diaphragmatic congenital hernia, appearing in 1 in 3,000 births. This diaphragmatic defect is located on the left side in 80% to 90% of cases. Pleuroperitoneal hernia is usually diagnosed in the first 8 weeks of life due to respiratory compromise caused by the herniation of abdominal organs into the thoracic cavity; therefore, adult presentation is a rare condition. We present a case of a 55-year-old man with a history of long-term cigarette smoking who arrived at the emergency department with a chronic cough. Initially, the patient was misdiagnosed as exacerbated chronic obstructive pulmonary disease, for which a contrast chest computed tomography was performed showing a left posterior pleuroperitoneal hernia that contained the upper pole of the ipsilateral kidney and adrenal fatty tissue. The surgical approach chosen in this case was through laparoscopy, resulting in an appropriate postsurgical evolution, for which the patient was discharged with a general surgery control appointment. The patient was evaluated 1 week and 1 month after surgery, showing a normal physical examination and resolution of the respiratory symptoms. Pleuroperitoneal hernia symptoms in adults most commonly affect the gastrointestinal and the respiratory tract. The diagnosis is performed by computed tomography or magnetic resonance imaging, in which a diaphragmatic defect can be seen. Pleuroperitoneal hernia complications must always be discarded by computed tomography and transthoracic echocardiogram. The treatment is based on surgical repair of the diaphragmatic defect. The surgical approach chosen may vary according to the surgeon's expertise.

Right-sided diaphragmatic hernia with hepatic herniation after blunt trauma: Report of two cases of early diagnosis and treatment

Congenital bronchobiliary fistula in association with right-sided congenital diaphragmatic hernia

Laparoscopic Morgagni hernia repair on an infant using percutaneous suturing technique

A 41-year-old man developed phrenic nerve palsy after the resection of anterior mediastinal tumor, who underwent diaphragmatic resection with an endostapler. After the surgery, the surgical stump ruptured, resulting in a large diaphragmatic defect with the liver prolapsing into the thoracic cavity. Then, the diaphragmatic defect was closed with a polytetrafluoroethylene (PTFE) patch. The diaphragm was reconstructed using a second PTFE patch overlaying the diaphragmatic defect that had been closed by the first PTFE patch, because solely patching the diaphragmatic defect had a risk of recurrence of diaphragmatic elevation due to remaining original diaphragm and the presence of phrenic nerve palsy. The second PTFE patch was fixed to the lower ribs by non-absorbable suture. The postoperative course was favorable. After 3 months, his symptoms and pulmonary function improved. We underwent double PTFE patch repair in a patient with both huge diaphragmatic defect and phrenic nerve palsy.

Using an Affymetrix GeneChip(R) Human Mapping 100K Set to study a patient with a late-presenting, right-sided diaphragmatic hernia and microphthalmia, we found a maternally inherited deletion that was 2.7 Mb in size at chromosome 18q22.1. Mapping of this deletion using fluorescence in situ hybridization revealed three deleted genes-CDH19, DSEL, and TXNDC10, and one gene that contained the deletion breakpoint, CCDC102B. We selected DSEL for further study in 125 patients with diaphragmatic hernias, as it is involved in the synthesis of decorin, a protein that is required for normal collagen formation and that is upregulated during myogenesis. We found p.Met14Ile in an unrelated patient with a late-presenting, anterior diaphragmatic hernia. In the murine diaphragm, Dsel was only weakly expressed at the time of diaphragm closure and its expression in C2C12 myoblast cells did not change significantly during myoblast differentiation, thus reducing the likelihood that the gene is involved in myogenesis of the diaphragm. Although it is possible that the 18q22.1 deletion and haploinsufficiency for DSEL contributed to the diaphragmatic defect in the patient, a definite role for DSEL and decorin in the formation of the collagen-containing, central tendon of the diaphragm has not yet been established.