A tale of two unconventional adult diaphragmatic hernias

Nontraumatic right diaphragmatic hernia with malrotated left liver lobe incarceration: An unusual case report with literature review

Diaphragmatic hernia is an unusual finding, especially in emergency settings and in the absence of trauma. Imaging plays a crucial role, with various CT signs of diaphragmatic rupture having been described, including the "dangling diaphragm," "absent diaphragm," "collar sign," "hump sign," "fascia sign," and "dependent viscera sign". We report an unusual case of a 53-year-old woman who presented with exertional dyspnea and asthenia. A CT scan was performed, revealing a large right diaphragmatic hernia involving an abnormally rotated liver and several other organs. The association between a malrotated liver and diaphragmatic hernia is extremely rare, with only a few cases previously reported in the literature. Surgery remains the definitive treatment, and the surgical approach depends on the size of the defect and the presence of significant complications.

Diaphragmatic Hernia Repair in Adult Patients: A Retrospective Institutional Experience

Objectives Diaphragmatic hernias (DHs) in adults are an uncommon condition in which general characteristics and treatment strategies are poorly described. The objective of this study was to describe our institutional experience in the surgical repair of DH in adult patients. Methods A cross-sectional review was conducted on adult patients with DH who were diagnosed and surgically treated between 2012 and 2023 at the Instituto Nacional de Enfermedades Respiratorias in Mexico City. Results A total of 24 patients were included in this study, with a predominance of females (65.2%). The mean age for our study was 50 years (±4). Bochdalek hernias were the most commonly encountered (50%), followed by Morgagni hernias (25%), traumatic hernias (17%), and type IV hiatal hernias (8%). Admission (programmed vs. emergency) between surgical techniques was statistically different (p= 0.032), in addition to the development of complications between surgical techniques (p= 0.037). The mean time patients were hospitalized was 20 days (±2), with no mortality nor readmission after discharge. Conclusion Considering the outcomes of our study, both open thoracic and abdominal approaches seem feasible for treating DH in adults.

Area of Focus in 3D Volumetry and Botulinum Toxin A Injection for Giant Diaphragmatic Hernia with Loss of Domain: A Case Report with Video Illustration

Background

Chronic giant diaphragmatic hernia is a severe disease with challenging diagnosis and treatment. Given the risk of loss of domain, the use of botulinum toxin A is an option but has been minimally studied in diaphragmatic hernia surgery.

Case Report

We present a case of a giant diaphragmatic hernia in a 66-years-old patient who showed a 12-year history of progressive chronic respiratory insufficiency. There were not notion of traumatic injuries. The CT-scan showed a giant diaphragmatic hernia with herniation of small bowel, right liver, omentum and transverse colon.

Method

We assessed the risk of loss of domain using a 3D volumetry based on the Sabbagh score and decided to use Botox injection before laparoscopic reduction of the hernia due to the high risk of complications related to the loss of domain. A computed tomography was performed 24 months after surgery and showed no evidence of recurrence. The patient presented an excellent functional result with a normal physical activity.

Conclusion

This report is among the first to highlight the utility of 3D reconstruction in assessing the risk associated with loss of domain and in preparing the abdominal wall with botulinum toxin A for diaphragmatic hernia repair.

Incidental finding and successful management of Larrey's hernia during laparoscopic cholecystectomy: Case report

INTRODUCTION

Larrey hernias (LH) are birth defects causing abdominal viscera to protrude into the thoracic cavity. With an incidence of 2-4 %, they are exceptional in adults.

CASE PRESENTATION

A 65-year-old female patient was admitted for an elective laparoscopic cholecystectomy. During history intake, besides biliary colic, no additional symptoms were reported. Physical examination yielded normal results. Chest-X ray did not reveal any anomalies. Intraoperatively, an inspection of the diaphragm revealed a 3 cm defect in the left-sided sternocostal triangle, with the omentum protruding through the thorax. After performing cholecystectomy, the content of the LH was cautiously reduced. The hernia sac was not resected, to prevent potential injury to the neighboring anatomical structures. The defect was closed using non-resorbable interrupted sutures. The postoperative course was uneventful. No recurrence was detected during follow-up.

CLINICAL DISCUSSION

LH diagnosis is challenging due to its unspecific symptoms. Only 10 % of patients are asymptomatic. CT imaging establishes a positive diagnosis and identifies acute complications requiring emergency management.

CONCLUSION

Asymptomatic LH cases mandate surgery. Laparoscopic management is safe and efficient. The trans-abdominal approach offers easier access to hernia content. Hernia sac resection is still debatable. The selection of defect closure technique hinges on the quality and elasticity of the tissue, as well as the size of the defect, all under the unwavering banner of the tension-free principle. Literature remains conflicting on mesh use.