Diaphragmatic Hernia After Living Donor Right Hepatectomy: Proposal for a Screening Protocol

Abstract

BackgroundLiving donor hepatectomy (LDH) is increasingly being used to improve access to liver transplantation for those with end-stage liver disease. Although recipient outcomes are equivalent, donor complication rates range from 10% to 41%. A rare, but potentially serious complication is occurrence of a diaphragmatic hernia (DH), of which 9 cases have been reported so far in the literature. The purpose of this work was to review the clinical impact of DH post-LDH, including risk factors (RF) in hope of mitigating impact.MethodsA literature review was performed identifying all previous reports of post-operative DH in living liver donors. Demographic and outcome data were gathered to help identify RF. We also report 2 cases from our own institution.ResultsReported incidences range from 0.6% to 2.3%, of which the majority are delayed (≥19 months). Obstruction or intestinal strangulation was present in 45%, 60% of whom required an intestinal resection. The most common RF was right lobe donation.ConclusionsPostoperative DH is a rare but serious complication of LDH. The major RFs are right lobe donation and potentially conditions resulting in increased intraabdominal pressure. Diaphragmatic hernia frequently lead to intestinal obstruction and strangulation and should be repaired when identified. The implementation of a screening protocol for early identification could lead to repair before the development of complications. We propose the addition of screening chest x-ray to follow-up protocols to aid in the identification and subsequent repair of postoperative DH. Such a practice could hopefully reduce the clinical impact of this complication.

Diaphragmatic hernia following liver resection: case series and review of the literature

“…The selected studies included 6 case reports, 6 9 11 14 16 17 4 retrospective case series, 4 7 8 12 2 letters to the editor, 10 15 and 2 original articles 13 18 ( Table 2 ). 4 6 7 8 9 10 11 12 13 14 15 16 17 18 Overall, 28 cases of DH after LR have been described (excluding our 3 cases). The most common indication of LR were as follows: living donor liver procurement in 11 cases (39.4%), liver metastases in 6 cases (21.4%), HCC in 2 cases (7.1%), adenoma in 2 cases (7.1%), focal nodular hyperplasia in one case (3.6%), and others in 6 cases (21.4%).…”

“…In our experience, this complication was not associated with mortality. However, in the literature review ( Table 1 ), 4 6 7 8 9 10 11 12 13 14 15 16 17 18 one patient died 3 months after hepatectomy, secondary to sepsis from a segment of small bowel that perforated into the DH. 13 This suggests that even though this complication is rare, it should be repaired surgically, even for asymptomatic patients.…”

“…The literature review revealed 18 cases and 10 cases of DH following LR, for liver tumors and in the setting of living liver donor, respectively. 4 6 7 8 9 10 11 12 13 14 15 16 17 18 …”

Laparoscopic repair of an incarcerated diaphragmatic hernia after right hepatectomy for hepatic injury: a case report

“…The defect may enlarge progressively, resulting from the constant diaphragmatic motion or the adhesions that form after surgery, with the inflamed postoperative scar tissue exerting traction on the diaphragm [ 6 ]. In addition, Scott et al reported right hepatectomy for liver transplantation to carry the greatest risk for DH because of the right diaphragmatic attachments to the liver, which cover a relatively large surface area and are substantially more adherent than on the left side of the diaphragm and, therefore, increase the risk of inadvertent injury during liver mobilization [ 7 ]. The patient in our case report had undergone hepatectomy with a diaphragm incision and intra-operative direct repair, and then the defect of the DH was observed to be clearly separated from the suture area during the first laparotomy performed.…”

Incidence, Diagnosis and Repair of a Diaphragmatic Hernia Following Hepatic Surgery: A Single Center Analysis of 3107 Consecutive Liver Resections

“…As CT scan is a part of most cancer follow-up examinations and at the same time the most effective procedure, it should take center stage in routine diagnostics, while sonography, being even easier to perform, could be used as first-line in an emergency situation or in outpatient clinic consultations by experienced examiners [ 23 ]. Although in synopsis of the studies it is shown that the sensitivity of chest X-ray (CXR) for diaphragmatic injuries varies between 40% and 81%, with some studies also speaking of an error rate of 40%, in our opinion, CXR is not a meaningful method, while ultrasound is superior, being proven in several studies as a reliable method of diagnosing diaphragmatic hernias [ 24 , 25 , 26 , 27 , 28 , 29 , 30 ].…”