Laparoscopic repair of late presenting congenital diaphragmatic hernia

Late-Presenting Congenital Diaphragmatic Hernia: A Potentially Life Threatening Case

Congenital diaphragmatic hernia (CDH) generally presents with respiratory distress in the neonatal period. Late onset CDH is less common and is associated with a wide range of clinical symptoms. We report a case of a 4-year-old child presenting with sudden onset of dizziness, abdominal pain and vomiting after swimming. Radiological investigations showed a left CDH with mediastinal shift. She gradually developed respiratory distress after admission. Urgent operation showed that the contents of the hernia included stomach, spleen, small and large bowels. This case highlights the importance of suspicion of CDH, proper clinical examination and investigation of children with acute non-specific gastrointestinal complaints.

Complications in neonatal surgery

Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.

Laparoscopic Repair of a Chronic Iatrogenic Diaphragmatic Hernia

We report the diagnosis and repair of a chronic, iatrogenic diaphragmatic hernia using minimally-invasive techniques. A 69-year-old man presented with intermittent abdominal and shoulder pain. He had previously undergone laparoscopic Nissen fundoplication in which a grasper-induced puncture injury to the left hemidiaphragm was noted but not repaired. Radiographs and CT imaging diagnosed a left diaphragmatic hernia, with stomach herniated into the left thoracic cavity. This was repaired successfully via an intra-abdominal laparoscopic approach. This case represents the potential importance of repairing post-traumatic diaphragmatic hernia at the time that they occur, as well as a minimally invasive means for their repair.

Congenital diaphragmatic hernia in the adult

Bochdalek hernia is a rare surgical condition primarily diagnosed in infants. Morgagni hernia is more commonly identified in adults. A subset of patients with a Bochdalek hernia, especially those with a right-sided defect, may also be diagnosed during adulthood. Both adult forms of CDH may be discovered incidentally or diagnosed as part of the investigation of nonspecific gastrointestinal or respiratory symptoms. It is recommended that all adult CDH patients undergo surgical repair to prevent incarceration and strangulation of abdominal viscera. Currently, many reports have demonstrated the safety and efficacy of using open or minimally invasive repairtechniques, with or without mesh reinforcement. Regardless of the approach selected, surgical repair has been associated with low morbidity and mortality and excellent long-term outcomes with low rate of recurrence.

Robotic repair of congenital diaphragmatic anomalies

PURPOSE

Congenital diaphragm anomalies, including eventration, Morgagni diaphragmatic hernias (M-CDH), and Bochdalek diaphragmatic hernias (B-CDH), have been successfully repaired by using minimally invasive surgery (MIS). However, some reports have shown a high recurrence rate for some defects, potentially due to difficulty associated with the rigid instruments. Robotic surgery may help close diaphragmatic anomalies more effectively. In this paper, we present a series of 8 consecutive patients with diaphragmatic anomalies who underwent robotic repair.

METHODS

We retrospectively reviewed patients with diaphragmatic anomalies. There were 2 patients with eventration, 5 with B-CDH, and 1 with M-CDH. All procedures were performed by using the Standard Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm (5-mm two-dimensional scope) and two instrument arms (5 mm).

RESULTS

Average age was 3.9 months (4 days to 12 months). Average weight was 3.6 kg (range, 2.2-10.5). Four B-CDH patients were approached through the chest and 1 from the abdomen. The patient with M-CDH had an abdominal repair, and both eventrations were performed from the chest. One B-CDH and 1 eventration were converted to thoracoscopic procedures. Average operative time was 1 hour and 20 minutes. One recurrence developed in a relatively large B-CDH repair that was closed primarily. Average follow-up was 20 months.

CONCLUSIONS

Robotic surgery is safe and effective for repairing diaphragm anomalies in small children. Although we prefer the thoracic approach for repairing the B-CDH, occasionally smaller newborns-perhaps those less than 2.5 kg-may do better with the abdominal approach, since the articulating instruments requiring a significant length in order to maneuver.

Minimally invasive repair of a congenital right-sided diaphragmatic hernia in an adult

A 75-year-old woman who presented with a cough was found on investigation to have a large right-sided diaphragmatic hernia with intrathoracic herniation of the colon, small bowel, and right kidney. The patient denied any history of trauma and therefore the hernia was felt to be congenital in nature. The patient underwent a combined laparoscopic repair with polytetrafluoroethylene mesh and a thoracoscopic lysis of adhesions of the posterior right-sided diaphragmatic hernia. To our knowledge, this is the first reported case of a combined laparoscopic and thoracoscopic repair of a congential diahphragmatic hernia. Although successful repair can be accomplished laparoscopically, the addition of a thoracoscopic lysis of adhesions facilitated the early reexpansion of our patient's chronically scarred lung.