Laparoscopic repair of post-traumatic diaphragmatic hernia: a case report

Introduction
The use of laparoscopy in abdominal trauma remains a debated and controversial topic, particularly in blunt trauma. A recent indication for laparoscopy is the management of post-traumatic complications (1): biliary and hematic collections in nonoperative management of hepatic trauma, post-traumatic acute cholecystitis, post-traumatic mesenteric ischemia, feeding jejunostomy, and post-traumatic hernias (2, 3).
Until 2002 there were only 11 articles in the English language literature reporting successful laparoscopic repair of post-traumatic diaphragmatic hernia (PTDH) (4).
We present a case of PTDH that was diagnosed and managed laparoscopically.

Case presentation
A 26-year-old male patient came to our emergency department complaining of epigastric, colic pain that radiated to the left shoulder and left upper quadrant, of 12 hours duration, accompanied by vomiting. His recent medical history was remarkable for a stab wound to the anterior left chest, just below the nipple, 2 months prior. He was admitted to the hospital, where the wound was evaluated as non-penetrating and sutured. The patient was discharged 48 hours later in good condition. On physical examination the patient was hemodynamically stable, with normal respiratory functions, and weight/ height ratio within normal range. The examination of the chest revealed a 3 cm long scar, below the left nipple. Routine haematological and biochemical investigations included blood count, blood sugar, urea nitrogen, and creatinine levels that were within normal limits. A chest X-ray showed an elevated colon at the base of the left lower chest (diaphragmatic hernia?) (Fig.1). A CT scan failed to delineate a left disrupted diaphragm, describing the aspect as “typical for a left diaphragmatic relaxation and an elevated transverse colon” and recommended “further interpretation in concurrence with the patient’s clinical status” (Fig. 2). Seventy-two hours after admission, the patient underwent exploratory laparoscopy for a suspected post-traumatic diaphragmatic hernia.

The surgical intervention
The patient, under general anesthesia, was placed in a supine 25° reverse Trendelenburg position, and the surgeon stood between the legs of the patient and the assistants on either side of the patient. Laparoscopic video units were placed on the patient’s left side, behind his shoulder. The pneumoperitoneum (12 mmHg) was established in the closed technique, and the Veress needle was inserted below the left costal margin, on the midclavicular line. The 30° laparoscope was introduced through a supraumbilical port. Two 5 mm working ports were placed subcostally on both sides along the midclavicular lines. In order to avoid iatrogenic injuries in reducing the herniated viscera, the existing defect was extended by 0.5 cm using a hook with monopolar coagulation. After reducing and inspecting the herniated abdominal viscera (Fig. 3), which included a jejunal loop, part of the transverse colon (Fig. 4), and a fragment part of the greater omentum, a nonabsorbable suture was placed at the upper pole of the defect. A 5 mm port was then introduced just below the xiphoid for a grasper that exerted traction on the suture for better exposure and further repairing the defect (Fig. 5). A total of three interrupted, horizontal, nonabsorbable sutures (polipropilene 2-0; 26 mm 4/8 triangular needle) were placed and tied intracorporeally (Fig. 6). Using bipolar electrocautery (LigaSure Atlas™ Valleylab, Covidien, USA) the adhesions were dissected between the greater omentum and the edges of the diaphragmatic defect. In order to reinforce the suture an 8/5 cm polietilene mesh with a resorbable hydrophilic adhesion prevention film was placed (Parietene®, Sofradim, Trévoux, France) and fixed to the parietal peritoneum using an internal fixation device with resorbable clips (I-clips®, Sofradim, Trévoux, France) (Fig. 7). At the end a 16 Fr polyethylene drain was positioned under the left hemidiaphragm (Fig. 8). Operating time was 46 min. Intraoperative blood loss was 150 ml from an omental tear generated during hernia reduction. The patient was extubated immediately after surgery. The postoperative course was uneventful. The patient resumed oral fluid intake and active motion within 12 hours, and oral feeding was started on the first postoperative day. Twenty-four hours after surgery the chest x-ray was unremarkable and the drain was removed. The patient was discharged 4 days after surgery afebrile, tolerating oral intake and bowel movements. Postoperative 30-day follow-up examination included a clinical exam and a chest x-ray both within normal limits.

Discussion
PTDH is a less common, difficult-to-diagnose disorder characterized by a diaphragmatic defect, usually a complication of trauma, through which various abdominal viscera herniate (5). Penetrating thoraco-abdominal injuries (PTA) account for over 90% of PTDH; blunt abdominal trauma, as well as iatrogenic causes render less than 10% of PTDH (5, 6). The thoraco-abdominal region landmarks are between the nipple line anteriorly, scapular tips, the costal margin posteriorly, and anterior and posterior axillary lines laterally. Most PTDH occur on the left side, and the pressure gradient across the diaphragm is the trigger for abdominal viscera herniation. Diaphragmatic injuries occur in 2.1% of patients with blunt abdominal trauma and 3.4% of patients with penetrating abdominal injuries (7).The risk of injuring the diaphragm in PTA ranges between 9-47%. The incidence of occult diaphragmatic lesions (no signs or symptoms requiring an exploratory laparotomy present) is 6-26% (8). This type of occult injury, missed at the initial evaluation, later causes PTDH, illustrated by the case presented in this report. The traumatic diaphragmatic, pancreatic, small bowel, and mesenteric injuries are the most notorious to be missed at the initial evaluation, both clinically and at imaging (ultrasonography, CT) (2). Clinical signs include epigastric pain, typically radiated to the left shoulder and left upper quadrant evidence of bowel obstruction and varying degrees of respiratory distress due to herniated organs (5).The mortality rate ranges between 10-28% following major complications affecting the herniated viscera, including strangulation, necrosis, and gastric or colonic perforation (9,10). The initial CXR in cases of PTA injuries is normal or inconclusive in 32-87% of cases (8), as it is in PTDHs in over 50% of cases (5). Ultrasound and CT scan indicate a diaphragmatic injury in just 50% of cases (11). Spiral CT has a sensitivity of 14-78% and a specificity of 76-100% in confirming diaphragmatic defects following PTA injuries (11). Diaphragmatic injuries are difficult to be visualized with spiral CT in patients without visceral herniation. Multislice CT scans and magnetic resonance imaging have an accuracy of over 90%(5). Diagnostic laparoscopy is the best method to diagnose diaphragmatic injuries and laparos-copic repair is probably one of the most used procedures within the minimally invasive surgery approach of abdominal trauma (13,14,15). In our case neither the CXR nor the CT scan confirmed the diaphragmatic hernia, although the chest film was surprisingly more relevant.
Considering the highly-advanced laparoscopic and trauma training of our team and possessing appropriate laparos-copic equipment, we selected laparoscopy as the best minimally invasive method to diagnose and repair the diaphragmatic injury, as opposed to a classical and more aggressive approach such as thoracotomy or laparotomy which are associated with high morbidity and long post-operative recovery. Thoracoscopy allows an improved dissection of possible intrathoracic adhesions, but requires selective intubation, lateral position of the patient, a more difficult reposition, and complete exploration of herniated abdominal viscera (16,17). Laparoscopy allows good visualization of abdominal organs and easy abdominal reposition of herniated viscera. Gas embolism seems to be a more theoretical complication (18). Approaching the hernia sac, which can be excised or not, was not necessary in this case. Since there were no gas imbalances or respiratory distress during and after surgery and the CO2/air absorption ratio was 20:1 (17, 18), a chest tube was not placed.
The diaphragmatic defect was fairly small, therefore, no difficulties in repairing it were encountered. It is recommended that a substitution mesh be placed in large defects for a tension-free suture (11, 16, 19). The suture was reinforced with a composite mesh fixed with resorbable clips as metal clips are potentially dangerous in this area (19).
This case presentation addresses a PTDH secondary to an occult injury, initially overlooked, that became symptomatic 2 months later. CT scan was not reliable, whereas the laparoscopic approach allowed diagnosis and definitive treatment of the underlying injury, once again commending the benefits of minimally invasive surgery.

References
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