Laparoscopic repair of an incarcerated diaphragmatic hernia after right hepatectomy for hepatic injury: a case report
- 358 Downloads
Diaphragmatic 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.
A 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.
A 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.
KeywordsDiaphragmatic hernia Right hepatectomy Laparoscopic surgery
Diaphragmatic hernias (DH) are generally classified as either congenital or acquired. Acquired DHs are generally caused by trauma with the majority occurring on the left side , since the anatomical location of the liver minimizes the possibility of a right-sided hernia. DH is a rare complication following hepatectomy. After right-sided major hepatectomy, the large surface area of the right diaphragm, previously covered by the liver, may allow the right colon and small bowel to migrate into the infra-diaphragm fossa.
The first successful repair of a DH was performed in 1886 by Riolfi . Currently, surgical repair of a DH can be performed by laparotomy, laparoscopy, or thoracoscopy. Although laparoscopic surgery has become a widely accepted technique, including for DH repair, a laparoscopic approach is usually not considered for repair of a recurrent DH after right hepatectomy because of the dense abdominal adhesion formation.
In this case, we report on our successful laparoscopic repair of a recurrent DH that developed 5 years after right hepatectomy.
A 30-year-old man underwent right hepatectomy at previous hospital, due to trauma, in August 2012. At that time, a thoracotomy in the eighth intercostal space was performed for direct closure of the diaphragm. Pooling of right pleural effusion was treated with drainage up to postoperative day (POD) 9. The patient recovered and was discharged on POD 14. In November 2012, he presented with a right DH and strangulation of the ileus of the small intestine. He underwent laparotomy at the same previous hospital, found the defect which was separated from the previously sutured area of the diaphragm, and repaired it.
Diaphragmatic hernia is a rare complication after hepatectomy, with some case reports having been published and only two case series of treatment outcomes [3, 4]. Normally, the liver serves as a block against herniation of abdominal contents into the right thorax and, therefore, diaphragmatic hernia rarely occurs on the right side in persons without surgical history . The clinical manifestation of diaphragmatic hernia can differ widely, depending on the side of involvement of the herniated organs. All DH that develop following right hepatectomy are right-sided [3, 4] which, in our case, included symptoms resulting from the entrapment of the ileus. Francesco et al. reported an incidence rate of postoperative DH following right-sided hepatectomy of 2.3% (3/131), with the DH development with a median delay of 14 months in their case series .
The risk factors for DH after hepatectomy include (1) undetected direct injury or thermal injury by electrocautery to the diaphragm during mobilization of the liver; (2) a fragile thin musculature in the congenitally weak area of the posterior diaphragm, between the costal and lumbar portions of the diaphragm; and (3) the pressure gradient between the abdominal and thoracic cavities. 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 . 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 . 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. Similarly, at the time of our DH repair, the defect was confirmed as being different from the suture area. In our patient, although the cause of DH was still unclear, thermal injury by electrocautery might have weakened the diaphragm during the previous procedure.
DH repair can be performed by laparotomy, laparoscopy, or thoracoscopy, with the approach selected based on the preference of a surgeon, the anatomical location of the defect, and the degree of sub-diaphragmatic adhesions. Tabrizian et al. reported that a thoracic approach might be the best approach when dealing with recurrence after an abdominal repair . In our case, we selected a laparoscopic approach as it provided a better approach than thoracotomy for instrument and bowel manipulation, as well as being deemed to be more appropriate based on the expectation of adhesions in the thoracic due to prior thoracotomy. Moreover, the approach allowed us to separate the adhesion of the herniated bowel to the right of the diaphragm and to subsequently repair the damaged pleural lining using a laparoscopic transdiaphragmatic route.
Our review of the literature in PubMed, using “diaphragmatic hernia” and “hepatectomy” or “liver surgery” or “liver resection” as keywords, identified only two cases of DH after hepatectomy with both being repaired by laparoscopic procedure [4, 8]. We did not find reports of laparoscopic surgery for recurrent DH after hepatectomy. Therefore, our case is important in demonstrating the effectiveness of laparoscopic surgery for repair of a diaphragmatic defect, providing a sufficient working space and an increased field of view.
With regard to the repair of the defect itself, some authors have reported on the use of prosthetic material as reinforcement, whereas other authors preferred simple suturing of the defect. However, it is generally agreed that defects larger than 20–30 cm2 do require use of a prosthesis . Different types of mesh can be used for DH repair, including polypropylene, composite, or biological mesh, with a polypropylene mesh being most commonly used. Although polypropylene mesh is more expensive than other types of mesh, it is preferred due to the low associated rate of infection . In our case, the diaphragmatic defect was sufficiently small, allowing us to proceed with a direct suture repair and, thereby, avoiding adverse events associated with using a mesh.
In conclusion, in this rare case of recurrence of DH following hepatectomy for trauma, laparoscopic surgery was found to be effective for the diagnosis and repair of a DH.
We would like to thank Editage (www.editage.jp) for English language editing.
The authors declare that this study was not funded externally.
ST, TT, and SF performed the surgery, ST drafted the manuscript, TT revised it critically, and KT, YM, TM, YK, MY, KN, MO, MM, and YD conceived of the study and participated in its design and coordination and helped to draft the manuscript. All authors approved the final manuscript.
Ethics approval and consent to participate
This report is approved by the institutional review board in Osaka University hospital (No. 08226-6).
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
- 5.Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: a diagnostic challenge? Radiographics: a review publication of the Radiological Society of North America, Inc, vol. 22; 2002. p. Spec No:S103–16. discussion S16–8Google Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.