Laparoscopic Repair Of Traumatic Diaphragmatic Hernia

Laparoscopic Repair of Traumatic Diaphragmatic Hernia Marc Zerey, MD, FRCSC, B. Todd Heniford, MD, FACS, and Ronald F. Sing, DO, FACS, FCCP

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iaphragmatic injuries are not uncommon with rates as high as 5% for patients hospitalized after motor vehicle accidents, and 15% for patients after penetrating injuries to the lower chest and upper abdomen.1-3 Left-sided rupture is more common than right-sided rupture (68.5% vs. 24.2%, respectively), owing to hepatic protection and increased strength of the right hemidiaphragm.4 During the initial evaluation and hospitalization of the trauma patient, diaphragmatic injuries from either penetrating or blunt thoracoabdominal trauma frequently are missed. Investigative techniques to diagnose traumatic diaphragmatic injuries [chest roentgenogram, diagnostic peritoneal lavage, ultrasound, and computed tomography (CT) scan] are limited by their low sensitivity and high false-negative rates.5,6 Reports have documented the effectiveness of laparoscopy as a means to diagnose intraabdominal injury in penetrating thoracoabdominal trauma. The surgeon may effectively visualize abnormal fluid collections as well as injury to the peritoneum or diaphragm with the introduction of a laparoscope. If there are no apparent signs of visceral injury it is mandatory that the surgeon perform a systemic examination of the supra- and infracolic compartment and pelvis. The intestines should be run using as many additional ports as necessary and the lesser sac inspected through a defect in the lesser omentum and gastric traction and elevation. When a diaphragmatic laceration or hernia has been identified, repair is mandatory. Latent repair of missed traumatic diaphragmatic hernias has been associated with a 20% to 36% mortality rate.7,8 Over the past decade, a select group of trauma surgeons and advanced laparoscopic surgeons have applied minimally invasive surgical techniques for the repair of acute diaphragmatic lacerations and chronic traumatic diaphragmatic hernias.9-12 The laparoscopic repair in the acute setting is limited by the frequent presence of concomitant injuries that reflect

Department of Trauma, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC. Address reprint requests to Ronald F Sing, DO, FACS, FCCP, Department of Trauma, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, 1000 Blythe Blvd MEB 601, Charlotte NC 28203. E-mail: [email protected]

1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.04.006

the severity of the traumatic event. The laparoscopic repair of chronic diaphragmatic hernias is more difficult because of entrapment of organs and presence of adhesions. Symptoms of a chronic diaphragmatic hernia are related to the incarceration of abdominal contents in the defect or to impingement of the lung, heart, or thoracic esophagus by abdominal viscera and include abdominal pain, respiratory distress, and cardiac dysfunction. Nevertheless, with the recent increase in the proficiency in laparoscopic technique, the number of patients having this condition dealt with laparoscopically is increasing. Once the diagnosis is made, operative repair is mandated. The decision to proceed laparoscopically depends on the hernia itself, the patient, and the surgeon. A hernia amendable to laparoscopic repair is one that is typically located on the left side, that may or may not communicate with the esophageal hiatus but that is less than 10 cm in diameter. The surgeon must possess advanced laparoscopic skills to perform dissection and intracorporeal knot tying. The presence of multiple injuries is not necessarily a contraindication to laparoscopic repair unless the patient is unstable.

Operative Techniques Positioning of Patient and Surgeon The patient is placed in the supine position with legs apart enough to accommodate the operating surgeon (see Fig. 1). The first assistant is located to the patient’s left and second assistant (laparoscope operator) to the patient’s right. We favor entry into the abdominal cavity using the open Hasson technique where a 10-mm port will be placed. Use of a 30degree (and occasionally a 45-degree) laparoscope is required. After CO2 insufflation, an exploratory laparoscopy is performed to verify the presence of concomitant injuries or conditions in addition to visualizing the hernia. Four additional 5-mm ports are placed along the subcostal margin at the right midclavicular, subxiphoid, left midclavicular, and left anterior axillary positions.

Primary Repair of Diaphragmatic Injury Following visualization of the hernia defect (see Fig. 2), the decision to repair primarily depends on the ability to approx27

M. Zerey, B.T. Heniford, and R.F. Sing

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Figure 1 Positioning.

imate the edges without undue tension. The standard repair involves placement of simple, horizontal mattress (Fig. 2B, C) or figure-of-eight zero or number one nonabsorbable braided sutures. After the suture is placed across the defect the needle is cut and the two free ends are kept together using a titanium clip. This process is repeated to avoid blindingly placing a needle across the defect and injuring structures in the chest or mediastinum. Once all the sutures have been placed the clip is removed and sutures are progressively tied intracorporeally. A red rubber catheter may be placed in the pleural cavity and the air suctioned as the final suture is tied to minimize a postoperative pneumothorax. Alternatively, a chest tube should be placed in the presence of lung injury.

Repair of Diaphragmatic Injury Using Prosthetic Biomaterial Laparoscopic visualization reveals incarcerated abdominal viscera through diaphragmatic defect (see Fig. 3). Laparoscopic grasper and scissors are used to reduce hernia contents. Use of electrocautery or harmonic instruments is avoided to prevent injury to hernia contents and structures present in thoracic cavity and mediastinum (Fig. 3B). When it has been determined that hernia will be unable to be closed without undue tension, prosthetic biomaterial is required (Fig. 3C). Prosthetic repairs are performed with expanded polytetrafluoroethylene (ePTFE) mesh (Soft Tissue Patch, W.L. Gore & Associates, Flagstaff, AZ) secured by 0 or 1

nonabsorbable braided suture, ensuring some overlap beyond the diaphragmatic defect (Fig. 3D).

Results We recently reported on the feasibility and limitations of a laparoscopic approach for the repair of acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias.13 Thirteen traumatic diaphragmatic injuries were repaired laparoscopically with four (two acute and two chronic) requiring conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using ePTFE and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5-12 cm). The mean operative time was 134.7 minutes (range, 55-200 minutes). The mean estimated blood loss was 108.5 mL (range, 30-500 mL), and the postoperative length of stay was 4.4 days (range, 1-12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n ⫽ 2) or communicating with the esophageal hiatus (n ⫽ 2). The four patients undergoing laparotomy had a

Laparoscopic repair of traumatic diaphragmatic hernia

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Figure 2 (A) Diaphragmatic hernia seen laparoscopically; (B) placement of Ethibond suture (Ethicon Inc., Somerville, NJ) across defect; (C) intracorporeal knot tying to close defect; (D) repaired diaphragmatic hernia.

mean postoperative discharge date of 8.7 days (range, 6-14 days). The feasibility of repairing acute diaphragmatic lacerations and chronic traumatic diaphragmatic hernias laparoscopically appears to be based mostly on experience but also on location. Hernias directly communicating with the esophageal hiatus or anterior to the esophageal hiatus and adjacent

to the pericardium are extremely difficult to repair using a minimally invasive approach. Anterior to the esophageal hiatus the diaphragm is thin, taut, relatively immobile, and in close proximity to the pericardium. The immobility of the diaphragm anterior to the esophageal hiatus also impedes visualization cephalad into the mediastinum, even with an angled laparoscope. Sutures placed too deep in this location

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Figure 2 Continued

Laparoscopic repair of traumatic diaphragmatic hernia

Figure 3 (A) Diaphragmatic hernia with incarcerated abdominal viscera; (B) reduction of hernia contents and mobilization of hernia sac; (C) placement of ePTFE mesh onto diaphragmatic defect; (D) repaired diaphragmatic hernia with ePTFE mesh.

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Figure 3 Continued

Laparoscopic repair of traumatic diaphragmatic hernia

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Table 1 Indications and contraindications of laparoscopic repair of diaphragmatic hernia Indications

Contraindications

Presence of hernia

Unstable patient (absolute) Hernia > 10 cm (relative) Hernia communicating with esophageal hiatus (relative)

4. 5. 6.

7. 8.

may violate the pericardium, and sutures placed too superficially risk hernia recurrence. The hemidiaphragm is more mobile laterally and near the central tendon, and greater visualization is provided by retracting the edges of the defect and placing the laparosocope into the hemithorax. Table 1

References 1. Brandt ML, Luks FI, Spigland NA, et al: Diaphragmatic injury in children. J Trauma 32:298-301, 1992 2. Ward RE, Flynn TC, Clark WP: Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 21:35-38, 1981 3. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic

9.

10.

11. 12.

13.

laparoscopy for penetrating abdominal trauma: A multicenter experience. J Trauma 42:825-829, 1997; discussion 829-831 Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic rupture of diaphragm. Ann Thorac Surg 60:1444-1449, 1995 Aronoff RJ, Reynolds J, Thal ER: Evaluation of diaphragmatic injuries. Am J Surg 144:571-575, 1982 Schneider C, Tamme C, Scheidbach H, et al: Laparoscopic management of traumatic ruptures of the diaphragm. Langenbecks Arch Surg 385: 118-123, 2000 Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 188:229-233, 1978 Madden MR, Paull DE, Finkelstein JL, et al: Occult diaphragmatic injury from stab wounds to the lower chest and abdomen. J Trauma 29:292-298, 1989 Cougard P, Goudet P, Arnal E, Ferrand F: Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position. Ann Chir 125:238-241, 2000 Matz A, Landau O, Alis M, et al: The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture. Surg Endosc 14:537539, 2000 Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: Spectrum of radiographic findings. Radiographics 18:49-59, 1998 Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmatic rupture: Associated injuries and outcome. Ann R Coll Surg Engl 82:97100, 2000 Matthews BD, Bui H, Harold KL, et al: Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 17:254-258, 2003