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

Abstract

BackgroundDiaphragmatic hernias (DH) are generally classified as either congenital or acquired. Acquired DH are generally of traumatic cause, being a rare complication after hepatectomy. Although repair of a DH can be performed via laparotomy, laparoscopy, or thoracoscopy, the use of laparoscopy is rare after hepatectomy owing to the formation of scar tissue. In this case, we describe our successful attempt at laparoscopic repair of a recurrent DH after hepatectomy.Case presentationA 30-year-old man underwent right hepatectomy for trauma and thoracotomy via the eighth intercostal space, with direct closure of the diaphragm by suturing. The patient subsequently developed a right DH, with strangulation ileus of the small intestine. He underwent laparotomy 3 months after the initial surgery. The defect was observed to be clearly separate from the previously sutured area of the diaphragm. Five years after treatment, the patient developed abdominal pain and vomiting due to incarceration of the transverse colon in the right intrathoracic space (detected via abdominal computed tomography and radiography). The patient was again diagnosed with DH and underwent laparoscopic repair of the hernia with direct closure. The patient was discharged 11 days after surgery without further complication.ConclusionsA laparoscopic approach was feasibly and safely used to repair a recurrent DH after hepatectomy. The surgical approach will need to be decided in a patient-specific manner.

Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

“…A possible explanation was that the excessive use of thermal electric cautery and argon beamer applied to the thin and vulnerable bare area during right liver mobilization in order to secure hemostasis might have led to the development of a secondary ADH, in addition to concomitant increase of post-operative abdominal pressure on an uncovered diaphragm (especially in the two cases of pregnancies). Up to now, 12 publications have described the occurrence of DH in 22 live donors [ 1 , 2 , 5 , 7 , 13 - 20 ], with an incidence ranging from 1.6% to 2.7% ( Table 2 ). Findings are concordant, as it is often a late complication after RH in living donor patients caused by chronic elevation of abdominal pressure on an uncovered diaphragm which is subjected to a thermic injury during surgery.…”

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

“…Additionally, cautery-related thermal injury is most often mentioned in this context. Nevertheless, the etiology seems to be multifactorial [ 4 , 5 , 7 , 20 , 21 , 22 ].…”

“…Regarding the surgical treatment of DH, some authors recommend that a hernia smaller than 10 cm should be treated with a primary suture and a hernia larger than 10 cm with mesh [ 4 , 5 , 7 ]. Based on our experience, we do not recommend primary suture repair but prefer mesh augmentation, because the treatment of a small hernia without mesh led to a recurrence, which had negative influence on the clinical outcome and morbidity of the patient ( Table 1 ).…”

“…In this study, only abdominal approaches were chosen. If technically possible, this should always be preferred to the thoracic approach, in order to avoid a two-cavity procedure [ 5 , 7 , 8 ]. On the other hand, Tabrizian et al suggested that a thoracic approach is useful for recurrence of DH after repair by an abdominal approach [ 5 ].…”

“…The incidence of DH following trauma is 3.4% for blunt trauma and 2.1% for penetrating trauma [ 3 ]. Hence, a right-sided hernia can occur after liver resections, especially following a right-sided extended hepatectomy [ 4 , 5 , 6 , 7 , 8 , 9 ]. There are also some cases of DH after living donor transplantation described in the literature [ 10 ].…”