|Year : 2022 | Volume
| Issue : 2 | Page : 89-90
Diaphragmatic hernia repair using uniportal video-assisted thoracoscopic surgery: A case report
Bhavik Patel1, Sylvio E Provenzano2
1 Division of Trauma, Gold Coast University Hospital, Southport, Australia
2 Division of Cardiothoracic Surgery, Gold Coast University Hospital, Southport, Australia
|Date of Submission||21-Jun-2021|
|Date of Decision||26-Jul-2021|
|Date of Acceptance||20-Aug-2021|
|Date of Web Publication||19-May-2022|
Dr. Bhavik Patel
Division of Trauma, Gold Coast University Hospital, 1, Hospital Boulevard, Southport 4215
Source of Support: None, Conflict of Interest: None
The objective of this case study is the management of small necked diaphragmatic hernia in a patient with hostile abdomen. Case study describes the technique of uniportal video-assisted thoracoscopic surgery (U-VATS) for management of diaphragmatic hernia. This is a novel case for the management of diaphragmatic hernia using a patch utilizing minimally invasive cardiac surgical instrumentation via U-VATS approach. U-VATS is a feasible option for the management of diaphragmatic hernia in a patient with hostile abdomen.
Keywords: Cor-Knot, diaphragmatic hernia, patch graft, uniportal video-assisted thoracoscopic surgery
|How to cite this article:|
Patel B, Provenzano SE. Diaphragmatic hernia repair using uniportal video-assisted thoracoscopic surgery: A case report. Int J Abdom Wall Hernia Surg 2022;5:89-90
| Introduction|| |
A 66-year-old woman presented to the emergency department with a history of fall down a steep driveway face first under the influence of alcohol. The history included an orthotopic liver transplant for alcoholic liver disease and was currently on tacrolimus. On clinical examination, she was maintaining her own airway with no hemodynamic compromise. Because of the mechanism of injury and immunocompromised status trauma series computed tomography (CT) was carried out [Figure 1].
|Figure 1: Portal venous phase CT scan suggestive of narrow neck (1.5 cm) diaphragmatic hernia|
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This demonstrated nasal bone fractures and an incidental finding of the small neck (1.5 cm), moderate size (10 cm × 5 cm), right-sided diaphragmatic hernia with omentum as content. The radiological findings were discussed with the original transplant surgeon who did concur that the hernia has increased in size. In view of the small neck, increasing content within the sac, immunocompromised status, and previous major abdominal surgery, we decided to offer uniportal video-assisted thoracoscopy (U-VATS) procedure.
| Procedure|| |
The procedure was conducted under anesthesia via a double lumen tube with the patient in the lateral position. The thoracic cavity was entered via a muscle-sparing 3-cm incision at the mid-axillary line on the fifth intercostal space. [Figure 2] demonstrates the moderate-size hernia with a narrow neck. The sac was opened, viable omentum as content was confirmed, and both were simply reduced.
|Figure 2: Intraoperative picture of hernia with narrow neck (1.5 cm) and moderate size (10 × 5 cm) with omentum as content|
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Hernial defect was closed using a 2.0 braided polyester suture (Ti-Cron, Medtronic, Minneapolis, MN), with a 3-cm circular patch of expanded polytetrafluoroethylene (ePTFE, Gore-Tex patch, original size: 150 mm × 200 mm × 2 mm, W. L. Gore and Associates, Inc., Flagstaff, AZ), and Cor-Knot mini device kit. The patch was used to overlap the edges, and a topic hemostatic agent (FLOSEAL, U.S. Baxter International Inc., Deerfield, IL) was applied [Figure 3]. A paravertebral catheter was inserted for pain relief, and an intercostal catheter was temporarily used to evacuate the thoracic cavity being removed on the beginning of port site closure. The Patient was extubated on a table, spend 24 h in the High Dependency Unit, and was discharged on day 4 following surgery.
| Discussion|| |
Diaphragmatic hernias are well reported after liver transplantation in pediatric population. Case reports of adult diaphragmatic hernia following transplantation managed with thoracotomy are well published. This is, however, the first case to our knowledge in the management of diaphragmatic hernia in a liver transplant patient using the U-VATS approach. The rationale behind the operation was to avoid an emergency thoracotomy for torsion of omental content in a narrow neck hernia.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wang K, Gao W, Ma N, Meng X-C, Zhang W, Sun C, et al
. Acquired diaphragmatic hernia in pediatrics after living donor liver transplantation: Three cases report and review of literature. Medicine (Baltimore) 2018;97:e0346.
Steinbrück K, Fernandes R, Enne M Diaphragmatic hernia after adult orthotopic liver transplantation: A rare surgical complication associated to immunosuppression? J Clin Case Rep 2015;5:11.
[Figure 1], [Figure 2], [Figure 3]