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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 31-34

The laparoscopic repair of giant diaphragmatic hernia with synthetic mesh: A report of three cases


Department of Hernia and Abdominal Wall Surgery, Beijing Chaoyang Hospital, Capital Medical University, Shijingshan District, Beijing, China

Date of Submission27-Aug-2020
Date of Decision01-Oct-2020
Date of Acceptance29-Oct-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Prof. Huiqi Yang
Jingyuan Road No. 5, Shijingshan District, Beijing 100040
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_37_20

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  Abstract 


Three cases of giant diaphragmatic hernia were reported in our study. Computed tomography (CT) scan showed multiple organ migration into the chest. The clinical presentation included bowel obstruction, dyspnea, or chest pain. The operations were performed initially by laparoscopy to reduce the hernia content. The defect was closed with a nonabsorbable suture and was reinforced with a synthetic mesh. All patients recovered well without any serious complications. The symptom improved significantly after surgery. Postoperative CT scan showed normal anatomy. There was no evidence of recurrence within 6 months after the operation.

Keywords: Diaphragmatic hernia, laparoscopy, mesh repair


How to cite this article:
Yuan X, Yang H, Nie Y, Guan L, Chen J. The laparoscopic repair of giant diaphragmatic hernia with synthetic mesh: A report of three cases. Int J Abdom Wall Hernia Surg 2021;4:31-4

How to cite this URL:
Yuan X, Yang H, Nie Y, Guan L, Chen J. The laparoscopic repair of giant diaphragmatic hernia with synthetic mesh: A report of three cases. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Mar 7];4:31-4. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/1/31/309980




  Introduction Top


Traumatic diaphragmatic hernia is a rare disease, encountered in 0.8%–2.1% of blunt trauma.[1],[2] Herniation of abdominal organs might cause gastrointestinal and cardiopulmonary symptoms or even no symptom for years after the trauma.[3] Operation is the standard treatment, and should be performed as soon as diagnosed. Traumatic diaphragmatic injury is often a hidden evidence of serious injury to the thoracic or abdominal viscera, causing some cases missed. Years after trauma, the defect enlarges and adhesion between the chest and abdominal contents forms gradually, adding difficulty to the surgery and risk of complications. In this study, our experience on the repair of giant diaphragmatic hernia with a synthetic mesh was reported.


  Case Reports Top


Case 1

A 68-year-old female, with a body mass index (BMI) of 22.8 kg/m2, was referred to our hospital for progressive abdominal pain and vomiting within the last month. She had a history of rib fracture at a car accident 2 years ago. On physical examination, she had a distended abdomen and bowel sound was heard at the right lower chest. Computed tomography (CT) scan showed a significant right diaphragmatic defect, with the liver, colon, and small intestine herniated into the right thoracic cavity [Figure 1]a and [Figure 1]b. Blood gas test showed a Type I respiratory failure. During the exploration,the herniated organs were confirmed tobe omentum, stomach, small intestine,transverse colon, and liver [Figure 1]c. The hernia defect (6 cm × 7 cm) was closed by a V-Loc™ suture, and was reinforced with a composite anti-adhesion mesh (Parietex Composite, PCO1510, Covidien, New Haven, USA).We fixed the mesh with an absorbable suture and medical glue (COMPONT Medical Adhesive, 1.0 ml/tube; Beijing COMPONT Medical Devices Co. Ltd., Beijing, China). The operation time was 180 min. The patient was transferred to the intensive care unit for hypoxemia. She was transferred back to the ward after being medically stable. She experienced a transient respiratory stress at the ward with a descending oxygen saturation, and improved with the support of noninvasive ventilation. The patient was discharged after a nonsignificant CT scan [Figure 1]d. The length of hospital stay was 8 days.
Figure 1: (a and b) Preoperative computed tomography showing the intestine herniated into the right thoracic cavity. (c) Right liver lobe, intestine, and omentum herniated through the defect. (d) Postoperative computed tomography showing pleural effusion

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Case 2

A 30-year-old male patient, with a BMI of 28.4 kg/m2, suffered chest blunt injury 1 year ago with multiple rib fracture. For the last 6 months, he suffered aggravating dyspnea without abdominal pain or vomiting. CT scan showed a defect in the left diaphragm with stomach, spleen, and colon herniation into the chest [Figure 2]a. Laparoscopic exploration was performed. The herniated organ was reduced with an atraumatic grasper after dividing the surrounding adhesion with a harmonic scalpel. The defect was about 6 cm × 8 cm and was closed with a V-Loc suture. A piece of synthetic mesh (Parietex Composite, PCO1510, Covidien, New Haven, USA) was fixed with a suture and medical glue (COMPONT Medical Adhesive, 1.5 ml/tube; Beijing COMPONT Medical Devices Co. Ltd., Beijing, China) [Figure 2]b and [Figure 2]c. The operation time was 160 min, and the patient tolerated well. The symptoms improved significantly after the procedure. Postoperative CT scan showed small amount of pleural effusion [Figure 2]d. The length of hospital stay was 5 days.
Figure 2: (a) Preoperative computed tomography showing the stomach, spleen, and colon herniated into the left thoracic cavity. (b) Operation findings: the large hernia defect on the left diaphragm, and hernia content including the omentum, spleen, and stomach. (c) A piece of synthetic mesh (PCO, Covidien, USA, 10 cm × 15 cm) was fixed with a suture and medical glue for reinforcement. (d) Postoperative computed tomography showing the reduced hernia content and small amount of pleural effusion

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Case 3

A 63-year-old male patient with a BMI of 26.6 kg/m2 presented with a history of thoracic-abdominal aneurysmal resection 11 months ago. The incision was 40 cm from the left chest to the lateral abdominal wall. He presented initially for large incisional hernia, and his main presentation was intermittent intestinal obstruction and dyspnea. The preoperative CT scan confirmed large incisional hernia and found diaphragmatic hernia with spleen and colon herniation [Figure 3]a and [Figure 3]b. Respiratory function test revealed severe ventilation disorder. For safety concerns, a two-stage procedure was planned, and the diaphragmatic hernia was repaired first as the incisional hernia was completely reducible. The operation time was 140 min, and the hernia content including spleen and colon was reduced with an atraumatic grasper. The hernia defect was about 8 cm × 6 cm, and was closed with a V-Loc suture. A piece of synthetic mesh (PCO, 15 cm × 10 cm, Covidien, USA) was fixed to reinforce the defect with a suture and medical glue (COMPONT Medical Adhesive, 1.0 ml/tube; Beijing COMPONT Medical Devices Co. Ltd., Beijing, China). After the operation, the dyspnea had improved significantly and CT scan showed lung re-expansion [Figure 3]c.
Figure 3: (a and b) Preoperative computed tomography showing the giant diaphragmatic hernia. (c) Postoperative computed tomography showing the reduced hernia content

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Six months after discharge, the three patients were followed up in the outpatient department. The patients did not complain any special discomfort. CT scan showed a normal lung and no recurrence of diaphragmatic hernia.


  Discussion Top


Diaphragmatic hernia is classified as congenital and traumatic. Traumatic diaphragmatic hernia is a complication of closed or penetrating trauma to the thoraco-abdominal transition area on either side. Patients with blunt trauma to the lower chest are prone to suffer traumatic diaphragmatic hernia.[4] The hernia on the left diaphragm would appear more often than that on the right side, and this is due to the protection of liver on the right.[5] Nonspecific symptoms add difficulties to early diagnosis. Over time, the defect enlarges and adhesion between the chest and herniated organ forms gradually, and this brings significant difficulty to surgery and therefore increases the risk of complications. In our study, the operation of case one was difficult because of severe adhesion between the liver and diaphragm. The patient of case two had a relatively shorter history, and the procedure was performed more smoothly under laparoscopy. The last case suffered a more complicated condition with both diaphragmatic and incisional hernia, and the laparoscopic repair of diaphragmatic hernia was performed first. Tales et al. reported open surgery with two incisions: an anterolateral left thoracic incision at the intercostal space, and a midline abdominal supraumbilical incision. The defect of the diaphragm was closed in two layers with dual-mesh (polypropylene/polyethylene) reinforcement at the thoracic interface.[6] Some sporadic cases of diaphragmatic hernia by laparoscopic approach have been reported in recent years, showing fewer postoperative complications and quicker recovery.[7],[8],[9],[10] A meta-analysis showed that the preferred approach is related to the phase of the disease.[11] However, it still lacks studies about the giant diaphragmatic hernia with multiple organ herniation. In the present study, based on the condition of the patients, the individualized treatment was suggested. In our three cases, laparoscopic operation was performed with an encouraging outcome, and of course the possibility of conversion needs to be explained to the patients.

Mesh fixation in diaphragmatic hernia repair is technically challenging, and proper mesh fixation is the key for the efficiency and the safety of the repair. Tacks is widely used now to fix the mesh in incisional hernia repair, but some serious complications of tacks in the diaphragm such as cardiac tamponade have been reported.[12] The thickness of central tendon of the diaphragm is 2.9 mm to 3.0 mm on an average, while the penetrating depth of tacks ranges from 3.7 mm to 5.9 mm.[13] As a result, the tacks fixation was strongly opposed by quite a few surgeons.[12] Furthermore, extreme care should be taken as well when using suture fixation, and an extreme superficial bite was suggested when suturing mesh on the diaphragm.[14] Fibrin glue has been recommended to be a safe option for mesh fixation to the diaphragm.[15] In our reported three cases, we fixed the mesh with a combination of medical glue and suture, and this combination provided solid and reliable fixation.

In conclusion, laparoscopy is the preferred approach for the management of diaphragmatic hernia. On the other hand, the likelihood of conversion to open needs to be estimated especially for patients with a long history or with multiple organ herniation. Furthermore, we suggest the combination of suture and glue for mesh fixation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A comparison of right and left blunt traumatic diaphragmatic rupture. J Trauma 1993;35:255-60.  Back to cited text no. 1
    
2.
Rubikas R. Diaphragmatic injuries. Eur J Cardio-thora 2001;20:53-7.  Back to cited text no. 2
    
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Fiscon V, Portale G, Migliorini G, Frigo F. Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm. Surg Endosc 2011;25:3423-5.  Back to cited text no. 3
    
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Meyers BF, McCabe CJ. Traumatic diaphragmatic hernia. Occult marker of serious injury. Ann Surg 1993;218:783-90.  Back to cited text no. 4
    
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Matsevych OY. Blunt diaphragmatic rupture: Four year's experience. Hernia 2007;12:73-8.  Back to cited text no. 5
    
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de Nadai TR, Lopes JC, Inaco Cirino CC, Godinho M, Rodrigues AJ, Scarpelini S. Diaphragmatic hernia repair more than four years after severe trauma: Four case reports. Int J Surg Case Rep 2015;14:72-6.  Back to cited text no. 6
    
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Kulendran K, Keogh C, Chiam HC. Laparoscopic repair of a right diaphragmatic hernia in a post-partum lady. J Surg Case Rep 2017;10:1-3.  Back to cited text no. 7
    
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Zanotti D, Fiorani C, Botha A. Beyond Belsey: Complex laparoscopic hiatus and diaphragmatic hernia repair. Ann R Coll Surg Engl 2019;101:162-7.  Back to cited text no. 8
    
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Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, et al. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 2003;17:254-8.  Back to cited text no. 9
    
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Macfie R, Orenstein S, Tse D. Laparoscopic transabdominal Morgagni hernia repair. Int J Abdom Wall Hernia Surg 2018;1:66-8.  Back to cited text no. 10
  [Full text]  
11.
Silva GP, Cataneo DC, Cataneo AJM. Thoracotomy compared to laparotomy in the traumatic diaphragmatic hernia. Systematic review and proportional meta-analysis. Acta Cir Bras 2018;33:49-66.  Back to cited text no. 11
    
12.
Köckerling F, Schug-Pass C, Bittner R. A word of caution: Never use tacks for mesh fixation to the diaphragm! Surg Endosc 2018;32:3295-302.  Back to cited text no. 12
    
13.
Frantzides CT, Welle SN. Cardiac tamponade as a lifethreatening complication in hernia repair. Surgery 2012;152:133-5.  Back to cited text no. 13
    
14.
Rodriguez HA, Oelschlager BK. Secrets for successful laparoscopic antireflux surgery: Mesh hiatoplasty. Ann Laparosc Endosc Surg 2017;2:50.  Back to cited text no. 14
    
15.
von Rahden B, Spor L, Germer CT, Dietz UA. Three-component intraperitoneal mesh fixation for laparoscopic repair of anterior parasternal costo diaphragmatic hernias. J Am Coll Surg 2012;214:e1-6.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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