Laparoscopic diaphragm rupture repair

Thoracic trauma: principles of early management

Thoracic trauma remains an important cause of early and late mortality in the injured patient. This review provides an overview of the emergency room management of thoracic trauma, amplifying the approach and principles of Advanced Trauma Life Support. The presentation, pathophysiology, diagnosis and treatment of the 12 most significant thoracic injuries are described. Focusing on emergency room management, and using the concept of the ‘lethal six’ and ‘hidden six,’ appropriate management strategies are detailed.

Single-Incision Laparoscopic Nontraumatic Left Lateral Diaphragmatic Hernia Repair

Diaphragmatic hernia is a quite uncommon disease, being congenital or posttraumatic. Its diagnosis is frequently accidental. Surgical treatment can be performed through the abdomen as well as through the chest. Laparoscopy and thoracoscopy offer a surgical benefit because of reduced wall trauma and added advantages of minimally invasive surgery. Besides the improved cosmetic result, transumbilical single-incision laparoscopy can add other advantages to minimally invasive surgery like reduced postoperative pain, shorter hospital stay, and improved patient's comfort. The authors describe the technique of transumbilical single-incision laparoscopic suture and mesh reinforcement for a nontraumatic left lateral diaphragmatic hernia, discovered accidentally in a 45-year-old male.

Lung resection using transumbilical incision: an animal survival study

INTRODUCTION

Transumbilical single-port surgery is a potentially less invasive approach to many types of abdominal surgeries and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. It avoids the complication of intercostal neuralgia and may reduce the risk of pulmonary complications after video-assisted thoracic surgery. This study evaluated the feasibility of transumbilical lung wedge resection.

METHODS

Lung resection was performed in 11 beagle dogs weighing 5.9 to 8.5 kg. A 3-cm umbilical incision and one diaphragmatic incision were made, and an endoscopic stapler was used. The diaphragmatic incisions were repaired under video guidance using a V-Loc knotless suturing device (Covidien, Mansfield, Massachusetts). Animals were monitored daily for signs of postoperative infection. White blood cell count, C-reactive protein level, and IL-6 level were measured in all animals. Animals were euthanized 14 days after surgery and underwent necropsy evaluation.

RESULTS

Accurate lung resection was achieved in 10 of 11 animals during a median operative time of 98 minutes (range 60-165). In 1 animal, transumbilical lung resection was not possible and was converted to thoracotomy. All animals survived without major postoperative complications. At necropsy, evidence of uneventful healing of the stapled resection margin and diaphragmatic wound were found. There was no evidence of vital organ injury or intrathoracic infection.

CONCLUSION

A transumbilical approach to thoracic cavity exploration and stapled lung resection is technically feasible. Primary suturing of the diaphragmatic incision is a simple and effective means of diaphragmatic wound closure. This may be an alternative to video-assisted thoracic surgery for the management of simple thoracic disease.

Late-onset congenital diaphragmatic hernia: A case report

INTRODUCTION

A Bochdalek hernia is a posterior congenital defect of the diaphragm, usually on the left hemidiafragm, caused by a lack of closure of the pleuroperitoneal canal between the eighth and tenth week of fetal life during the embryonic development. It typically presents in the neonatal period with severe respiratory failure.

PRESENTATION OF CASE

In this paper we present a 35 year old man with a 5-year history of episodes of severe dyspnea who arrived to the emergency room, during his medical work-up we incidentally found an intrathoracic gastric bubble, a laparoscopy was performed, founding a necrotic stomach and for defect correction.

DISCUSSION

This pathology is infrequent in adults, among this age group, there are two different clinical presentations: asymptomatic patients who are diagnosed incidentally when abdominal organs are found in the thorax in a chest X-ray, and symptomatic patients due to side effects of incarceration, strangulation, hemorrhage and visceral perforation in the chest cavity.

CONCLUSION

Diaphragmatic hernias are rare among adult population, and they are usually asymptomatic, in this case we presented a symptomatic patient, diagnosed with a chest X-ray and treated surgically. The surgical approach for the resolution of this pathology is variable and it depends on the presence and severity of visceral complications.

Innovations in the surgical management of congenital diaphragmatic hernia

Surgical management of congenital diaphragmatic hernia (CDH) remains a challenge for all clinicians. While the treatment strategies for CDH have evolved from emergent surgical intervention to initial hemodynamic stabilization with delayed surgical repair, surgical innovations have remained limited in the last 20 years. Advances in surgical approaches, such as minimally invasive surgery and alternatives to diaphragmatic replacement, have focused on improvements in surgical morbidity.

Minimally invasive repair of congenital diaphragmatic hernia

PURPOSE

Operative approach, including minimally invasive surgery (MIS) in the repair of congenital diaphragmatic hernia (CDH), is variable among institutions. The short-term recurrent hernia rate is not well described. We evaluated the in-hospital recurrence rate of MIS repairs of infants with CDH from the Congenital Diaphragmatic Hernia Registry.

METHODS

Prospectively collected data from infants with CDH were analyzed from the Congenital Diaphragmatic Hernia Registry from January 1995 to January 2010. Recurrent hernia was defined as reoperations during initial hospitalization. Operative approaches included abdominal, thoracic, laparoscopic, and thoracoscopic techniques.

RESULTS

Five thousand four hundred eighty infants with CDH were identified, of which 4516 (82.4%) were repaired. Operative data were available in 4390 infants. One hundred fifty-one infants (3.4%) underwent MIS repairs with 12 reported recurrences (7.9%) compared with 114 for open techniques (2.7%, P < .05). Minimally invasive surgery demonstrated a significant increased odds for recurrence (odds ratio, 3.59; 95% confidence interval, 1.92-6.71) after adjusting for gestational age, birth weight, patch repair, and extracorporeal membrane oxygenation.

CONCLUSION

Minimally invasive techniques appear to have a significant higher recurrent hernia rate, with thoracoscopy being the highest. Although adjusted for patch repair, other factors with regard to disease severity may contribute to differences in outcomes among centers. This study is limited to short-term recurrence during initial hospitalization.

Laparoscopic splenectomy and diaphragmatic rupture repair in a 27-week pregnant trauma patient

Report of a 27-week pregnant woman having diaphragmatic rupture and intrathoracic ruptured spleen is presented. She was managed by laparoscopic reduction of the intrathoracic viscus, with repair of the defect and splenectomy.

Pediatric laparoscopy

Significant developments in minimally invasive surgery (MIS) for the adult population have led to increased application of MIS techniques for pediatric patients. Laparoscopy is the most common MIS procedure used in pediatrics. Traditional surgical procedures that are now being performed laparoscopically include gastrostomy, pyloromyotomy, and repair of congenital diaphragmatic hernia and imperforate anus. All perioperative team members must be prepared to provide appropriately sized instruments and equipment to facilitate use of MIS techniques in the pediatric population and must ensure safe patient care to achieve optimal patient outcomes.

Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia

Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.

Thoracoscopic repair for congenital diaphragmatic hernia: lessons from 45 cases

PURPOSE

To describe the surgical technique, initial results, and overview indications of thoracoscopic repair of congenital diaphragmatic hernia (CDH).

MATERIALS AND METHODS

A retrospective review was undertaken of patients with CDH who underwent thoracoscopic repair by the same surgeon from January 2001 to January 2005. Patients underwent surgery under general anesthesia. Reduction of the hernia contents was carried out using 1 optical trocar and 2 operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots.

RESULTS

There were 45 patients, including 29 boys and 16 girls. Among 19 newborn patients, there were 13 patients younger than 7 days. The other 26 patients were infants and elders. The hernia was located in the left side in 37 patients and in the right side in 8 patients. The mean operative time was 54 minutes. Conversion was required in 4 patients. There were no complications. However, there were 2 postoperative deaths.

CONCLUSIONS

Thoracoscopic repair is feasible and safe for children with CDH, including selective newborn. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.

Thoracoscopic Repair of a Right-Sided Congenital Diaphragmatic Hernia

The presentation of a congenital diaphragmatic hernia (CDH) beyond infancy is rare, as it is a common cause for severe respiratory distress in the newborn. In contrast to the newborn period, delayed diagnosis of right-sided congenital diaphragmatic hernia (RCDH) is known as it causes less severe symptoms than left-sided CDH. A case of an 8-month-old girl is reported. Chest x-ray and ultrasound examination of the diaphragm for symptoms of pneumonia revealed an RCDH. Thoracoscopic repair could be performed. The further course was uneventful. Thoracoscopic repair of a RCDH proved in this case to be feasible and safe beyond the newborn period. It avoided the morbidity of a major thoracotomy or laparotomy and provided an excellent cosmetic result. To our knowledge, this is the first report of thoracoscopic repair of RCDH.

Intestinal Obstruction Caused by a Strangulated Morgagni Hernia in an Adult Patient

A Morgagni hernia is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The reported incidence of congenital diaphragmatic hernias is estimated to be 1 in between 2000 to 5000 births. Morgagni hernias comprise 2% of diaphragmatic hernias. Most Morgagni hernias are found and repaired in children, but 5% are found in adults. They are usually asymptomatic and often found incidentally on chest radiography. Symptoms of these hernias are attributable to the herniated viscera. Morgagni hernias containing bowel may require repair on presentation because of the risk of incarceration. We present a case of an incarcerated and strangulated Morgagni hernia in a 71-year-old woman admitted to our clinic for abdominal pain and symptoms of intestinal obstruction. The diagnosis was made preoperatively by chest radiography, sonography, and computed tomography. Emergent laparotomy was performed, with the herniated transverse colon and omentum reduced into the abdomen. The diaphragmatic defect was repaired, followed by resection of the strangulated omentum. In conclusion, a Morgagni hernia may cause intestinal obstruction. Routine radiographic studies are usually sufficient to arrive at the diagnosis, but a CT scan and sonography may be necessary. Laparotomy is appropriate for the management of symptomatic adult patients with Morgagni hernias, particularly those with findings of intestinal strangulation, with laparoscopic treatment an alternative approach in selected cases.

[Diaphragmatic hernia of Morgagni-Larrey in adults: analysis of 10 cases]

Congenital diaphragmatic hernia of Morgagni-Larrey is a rare entity that usually presents on the right side. These hernias, occurring in the anterior midline through the sternocostal hiatus of the diaphragm, are usually discovered incidentally when the patient has reached adulthood, or when they become symptomatic due to intestinal involvement (occlusive symptoms) or when respiratory dysfunction occurs. We present 10 patients (mean age: 69 years) with symptomatic sternocostal hernia and intestinal occlusion. In 7 patients, the hernia was located on the right (Morgagni's hernia) and in three it was located on the left (Larrey's hernia). Most of the patients presented important associated comorbidity, mainly cardiovascular and neoplastic. Surgical treatment consisted of reduction of the contents of the herniated sac and hernia repair through simple suture with or without mesh for reinforcement, mainly through the abdominal approach. Mortality in this series was nil. The infrequency of this entity and its diagnosis mainly in adults, with a high prevalence of circumstances favoring abdominal hernias, suggest that an embryological defect of the sternocostal foramina of Morgagni or Larrey are an essential element in the physiopathology of these processes.

Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned

BACKGROUND

Minimally invasive surgery (MIS) for the repair of congenital diaphragmatic hernias (CDH) had been described. This report reviews the authors' experience with MIS repairs of CDH and discusses the technical development of this approach.

METHODS

From 1999 until now, the authors collected data on children who underwent an MIS approach for CDH repair.

RESULTS

Seventeen children (11 Morgagni and 7 Bochdalek) had undergone an attempt at MIS repair. All Morgagni defects were treated successfully using laparoscopy (mean age, 28 +/- 31 months). Mean follow-up was 22 +/- 9 months. There was 1 recurrence. Four children with Bochdalek CDH were treated as newborns (range, 3 to 21 days), and 3 had operations later (4, 11, and 32 months). The first repair was attempted initially transabdominally and was converted to a thoracoscopic approach. The rest of the Bochdalek repairs were performed thoracoscopically. Bochdalek repairs via MIS were successful in 3 children (2 older children and 1 neonate). No child had pulmonary hypertension. Two of the 3 Bochdalek patients did well postoperatively (follow-up, 18 +/- 7 months); the last patient experienced recurrence 11 months after repair.

CONCLUSIONS

MIS for CDH is ideal for Morgagni defects. It should be considered for nonnewborns with a Bochdalek CDH. The MIS approach for a newborn with a CDH cannot be recommended because of the high failure rate and frequent rise in PCO2 levels.

Thoracoscopic Surgery for Congenital Diaphragmatic Hernia: A Report of Nine Cases

PURPOSE

To describe the surgical technique and early results of thoracoscopic repair of congenital diaphragmatic hernia (CDH) in children.

MATERIALS AND METHODS

A retrospective review was undertaken of patients with CDH who underwent thoracoscopic surgery in our institution over a period of 15 months. There were nine patients, five boys and four girls, ranging in age from 7 days to 8 years. All nine patients underwent surgery under general anaesthesia. Reduction of the hernia contents was carried out using one optical trocar and two operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mmHg. The hernia defect was repaired using non-absorbable interrupted sutures.

RESULTS

The hernia was located on the left side in seven patients and on the right side in two. The mean operative time was 80 minutes. In all patients, the chest tube was removed on the first postoperative day. All patients were discharged on the fifth postoperative day. Chest X-ray and clinical examination 3 months after surgery were normal in all patients.

CONCLUSION

The thoracoscopic approach for the repair of CDH in children, including small infants and newborns, is feasible and safe. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery.

Combination of paraesophageal hernia and Morgagni hernia in an old patient

Paraesophageal hiatal hernia is an uncommon condition that requires urgent correction to prevent life-threatening complications. It is present in 14% of all hiatal hernias. The incidence of Morgagni hernia among all diaphragmatic defects is 3-4% and about 90% of the hernias occur on the right, 8% are bilateral and 2% are on the left. The combination of a Morgagni hernia and paraesophageal hernia is very rare and only four cases have been reported in the literature. All of them occurred in the right. This report describes an old case admitted to our clinic with dyspnea, chest pain and chronic gastrointestinal symptoms, found to have combined left Morgagni and paraesophageal hernia. Surgical repair was performed via transabdominal approach. This unusual case and surgical approaches are discussed in light of the data presented in the literature.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a lethal human birth defect. Hypoplastic lung development is the leading contributor to its 30-50% mortality rate. Efforts to improve survival have focused on fetal surgery, advances in intensive care and elective delivery at specialist centres following in utero diagnosis. The impact of abnormal lung development on affected infants has stimulated research into the developmental biology of CDH. Traditionally lung hypoplasia has been viewed as a secondary consequence of in utero compression of the fetal lung. Experimental evidence is emerging for a primary defect in lung development in CDH. Culture systems are providing research tools for the study of lung hypoplasia and the investigation of the role of growth factors and signalling pathways. Similarities between the lungs of premature newborns and infants with CDH may indicate a role for antenatal corticosteroids. Further advances in postnatal therapy including permissive hypercapnia and liquid ventilation hold promise. Improvements in our basic scientific understanding of lung development may hold the key to future developments in CDH care.