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Laparoscopic repair of a congenital diaphragmatic hernia (CDH)
Eligibility criteria for the thoracoscopic approach in case of a congenital diaphragmatic hernia (CDH) in infants were jointly addressed at the ESPES/IPEG-ESPU Masterclass in March 2017 held at IRCAD, and also published on WeBSurg.
This video aims to show a series of technical details in case of thoracoscopy for CDH grade B according to the currently accepted international classification. At the beginning of the procedure, short intrathoracic low pressure carbon dioxide insufflation at 4mmHg and 1.5 Liter per minute was performed during hernia reduction. The posterior diaphragmatic border was then freed and a diaphragmatic suture was performed using non-absorbable separate 2/0 stitches. A GoreTex DualMesh® patch was used to complete the external suturing of the diaphragm and to achieve fixation stitches.
I Kauffmann, F Becmeur
Surgical intervention
1 year ago
3189 views
15 likes
0 comments
04:17
Laparoscopic repair of a congenital diaphragmatic hernia (CDH)
Eligibility criteria for the thoracoscopic approach in case of a congenital diaphragmatic hernia (CDH) in infants were jointly addressed at the ESPES/IPEG-ESPU Masterclass in March 2017 held at IRCAD, and also published on WeBSurg.
This video aims to show a series of technical details in case of thoracoscopy for CDH grade B according to the currently accepted international classification. At the beginning of the procedure, short intrathoracic low pressure carbon dioxide insufflation at 4mmHg and 1.5 Liter per minute was performed during hernia reduction. The posterior diaphragmatic border was then freed and a diaphragmatic suture was performed using non-absorbable separate 2/0 stitches. A GoreTex DualMesh® patch was used to complete the external suturing of the diaphragm and to achieve fixation stitches.
Inanimate model to train for the thoracoscopic repair of all varieties of left congenital diaphragmatic hernia (CDH)
We present a new low-cost model designed for training skills and strategies for the thoracoscopic repair of left congenital diaphragmatic defects. We will present guidelines to make this type of models, the educational strategy that we use in our advanced training models, the defects that can be trained, and the scope of this model. Advanced training, learning tips and tricks from experts, and the use of innovative ideas from other authors used in our model are outlined. This educational tool was developed for pediatric surgeons requiring advanced training. It reinforces the concept of advanced and continuous training, in a safe environment, and it is assisted by experienced surgeons. This model shows a scenario where dimensions and anatomical repairs are carefully preserved.
We share our vision of continuous endosurgical education to encourage all enthusiastic surgeons to train in safe and controlled environments.
Materials and methods: The model consists in a plastic 3D printed left rib cage, extracted from a 6-month-old baby CT-scan combined with simulated mediastinal structures, diaphragm, bowel, lung, and spleen made of latex, silicone, and polyester sponge respectively. A self-adhesive film is used as parietal pleura. A removable part (spare part) represents the last three ribs where the diaphragm is partially inserted, and a base as the upper abdomen is assembled to the left rib cage (ribs 1 to 9). Abdominal viscera (plastic or animal) are placed in this base. The cost of materials is 150 US$.
The model is meant to simulate the most frequent diaphragmatic defects such as type A, B, and C, with or without sac. However, other rare defects can also be simulated. Live animal tissues such as diaphragm or intestine also can be used, as it was already published by other authors. However, the main characteristic of this model is to be inanimate, portable, and easily reloadable to be reused.
The video shows a junior surgeon in his advanced training process. In the model, we perform the reduction of the viscera slid to the thorax. In this case, it is the rabbit intestine, but we usually use latex simulated intestine. The spleen is completely synthetic and bleeds if the instruments damage it during the reduction.
We use 3mm regular instruments. The repair of the defect is made with separate stitches of 2/0 or 3/0 braided polyester as usual, and we encourage trainees to practice the intracorporeal sliding knot and running suture. We collect the performance data in a specially prepared form and carry out the debriefing.
Conclusions: With this model, we can reinforce the concept of low cost, but with a high precision environment simulation, included within a standardized training program in minimally invasive neonatal surgery. We believe that it is a very useful tool. In addition, this type of models allows the use of new surgical techniques, tips and tricks given by experienced surgeons who assist in the training process.
M Maricic, M Bailez
Surgical intervention
1 year ago
1545 views
8 likes
1 comment
08:14
Inanimate model to train for the thoracoscopic repair of all varieties of left congenital diaphragmatic hernia (CDH)
We present a new low-cost model designed for training skills and strategies for the thoracoscopic repair of left congenital diaphragmatic defects. We will present guidelines to make this type of models, the educational strategy that we use in our advanced training models, the defects that can be trained, and the scope of this model. Advanced training, learning tips and tricks from experts, and the use of innovative ideas from other authors used in our model are outlined. This educational tool was developed for pediatric surgeons requiring advanced training. It reinforces the concept of advanced and continuous training, in a safe environment, and it is assisted by experienced surgeons. This model shows a scenario where dimensions and anatomical repairs are carefully preserved.
We share our vision of continuous endosurgical education to encourage all enthusiastic surgeons to train in safe and controlled environments.
Materials and methods: The model consists in a plastic 3D printed left rib cage, extracted from a 6-month-old baby CT-scan combined with simulated mediastinal structures, diaphragm, bowel, lung, and spleen made of latex, silicone, and polyester sponge respectively. A self-adhesive film is used as parietal pleura. A removable part (spare part) represents the last three ribs where the diaphragm is partially inserted, and a base as the upper abdomen is assembled to the left rib cage (ribs 1 to 9). Abdominal viscera (plastic or animal) are placed in this base. The cost of materials is 150 US$.
The model is meant to simulate the most frequent diaphragmatic defects such as type A, B, and C, with or without sac. However, other rare defects can also be simulated. Live animal tissues such as diaphragm or intestine also can be used, as it was already published by other authors. However, the main characteristic of this model is to be inanimate, portable, and easily reloadable to be reused.
The video shows a junior surgeon in his advanced training process. In the model, we perform the reduction of the viscera slid to the thorax. In this case, it is the rabbit intestine, but we usually use latex simulated intestine. The spleen is completely synthetic and bleeds if the instruments damage it during the reduction.
We use 3mm regular instruments. The repair of the defect is made with separate stitches of 2/0 or 3/0 braided polyester as usual, and we encourage trainees to practice the intracorporeal sliding knot and running suture. We collect the performance data in a specially prepared form and carry out the debriefing.
Conclusions: With this model, we can reinforce the concept of low cost, but with a high precision environment simulation, included within a standardized training program in minimally invasive neonatal surgery. We believe that it is a very useful tool. In addition, this type of models allows the use of new surgical techniques, tips and tricks given by experienced surgeons who assist in the training process.
Laparoscopic postpartum right diaphragmatic hernia reduction
A 35-year-old patient was referred to our emergency department for acute abdominal pain and respiratory distress. The patient gave natural childbirth three days before the episode, a childbirth without immediate complications.
Clinically, the patient presented with tachypnea, tachycardia, and desaturation, nauseas and constipation, depressible abdomen with generalized pain on palpation. The absence of vesicular murmur and right lung dullness were noted.
Blood lab findings showed increased inflammatory parameters.
An abdominothoracic CT-scan with contrast was performed. It showed a voluminous right diaphragmatic hernia containing the omentum, a distended colon and liver segment VIII with signs of hypoperfusion.
A surgical procedure was performed. A laparoscopic approach was performed and the patient’s hiatal hernia was reduced by closing the defect with a non-absorbable suture and by placing a Vicryl mesh.
The patient recovered with no complications and was discharged on postoperative day 3.
A D'Urso, P Saleg, D Mutter, J Marescaux
Surgical intervention
2 years ago
1869 views
112 likes
0 comments
09:10
Laparoscopic postpartum right diaphragmatic hernia reduction
A 35-year-old patient was referred to our emergency department for acute abdominal pain and respiratory distress. The patient gave natural childbirth three days before the episode, a childbirth without immediate complications.
Clinically, the patient presented with tachypnea, tachycardia, and desaturation, nauseas and constipation, depressible abdomen with generalized pain on palpation. The absence of vesicular murmur and right lung dullness were noted.
Blood lab findings showed increased inflammatory parameters.
An abdominothoracic CT-scan with contrast was performed. It showed a voluminous right diaphragmatic hernia containing the omentum, a distended colon and liver segment VIII with signs of hypoperfusion.
A surgical procedure was performed. A laparoscopic approach was performed and the patient’s hiatal hernia was reduced by closing the defect with a non-absorbable suture and by placing a Vicryl mesh.
The patient recovered with no complications and was discharged on postoperative day 3.
Laparoscopic repair of a diaphragmatic hernia after thoracic surgery with mesh insertion
Traumatic diaphragmatic hernias have been well described after blunt trauma. Diaphragmatic ruptures can occur in up to 0.8 to 7% of blunt abdominal trauma, with large left-sided defects being the most common. If the injury goes unrecognized, progressive herniation of abdominal contents may follow.
We report the case of a diaphragmatic hernia in a 48-year-old woman. The patient reports dyspnea and vomiting after left diaphragmatic node resection (diaphragmatic granuloma) one year ago.
A CT-scan demonstrated a large defect within the left hemi-diaphragm, associated with a herniation of the antrum, body of the stomach, colon, and spleen into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with a big herniation is shown. The hernia was reduced laparoscopically, and the defect was repaired with interrupted absorbable sutures and reinforced with continuous sutures. An intraperitoneal mesh was placed. The patient recovered uneventfully.
Diagnosis of a traumatic diaphragmatic hernia in the acute setting can be very challenging. In the chronic period, a myriad of symptoms and radiological findings may arise. Plain films, CT-scan, magnetic resonance imaging, and even diagnostic laparoscopy can help with the diagnosis. Laparoscopy is a safe and feasible method to repair traumatic diaphragmatic hernias, especially in the chronic setting, with the advantage of evaluating the entire abdomen and both hemi-diaphragms simultaneously.
FE Viamontes Ugalde, A Abascal Amo, J Delgado Valdueza
Surgical intervention
3 years ago
1608 views
64 likes
1 comment
12:52
Laparoscopic repair of a diaphragmatic hernia after thoracic surgery with mesh insertion
Traumatic diaphragmatic hernias have been well described after blunt trauma. Diaphragmatic ruptures can occur in up to 0.8 to 7% of blunt abdominal trauma, with large left-sided defects being the most common. If the injury goes unrecognized, progressive herniation of abdominal contents may follow.
We report the case of a diaphragmatic hernia in a 48-year-old woman. The patient reports dyspnea and vomiting after left diaphragmatic node resection (diaphragmatic granuloma) one year ago.
A CT-scan demonstrated a large defect within the left hemi-diaphragm, associated with a herniation of the antrum, body of the stomach, colon, and spleen into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with a big herniation is shown. The hernia was reduced laparoscopically, and the defect was repaired with interrupted absorbable sutures and reinforced with continuous sutures. An intraperitoneal mesh was placed. The patient recovered uneventfully.
Diagnosis of a traumatic diaphragmatic hernia in the acute setting can be very challenging. In the chronic period, a myriad of symptoms and radiological findings may arise. Plain films, CT-scan, magnetic resonance imaging, and even diagnostic laparoscopy can help with the diagnosis. Laparoscopy is a safe and feasible method to repair traumatic diaphragmatic hernias, especially in the chronic setting, with the advantage of evaluating the entire abdomen and both hemi-diaphragms simultaneously.
Full laparoscopic repair of a post-traumatic diaphragmatic hernia with mesh insertion
This is the case of a 34-year-old man who suffered from a blunt trauma, 8 months before this surgery. He presented with oppressive chest pain, lasting for a week, increasing while exercising and decreasing when lying down. No history of chronic pathology or smoking was reported. He was admitted to hospital. CT-scan of the abdomen and thorax showed a left diaphragmatic hernia. A laparoscopic diaphragmatic hernioplasty was decided upon. The patient is placed in a right semi-lateral decubitus position, with a 45-degree tilt.
Three trocars were placed; two 5mm trocars in the left upper quadrant, in the anterior axillary line, and in the epigastrium, while a 12mm optical trocar is placed in the upper left quadrant, in the midclavicular line.
The left lung is collapsed. Laparoscopy revealed a left diaphragmatic defect, with a diaphragmatic hernia which contains the spleen, small bowel loops, and the omentum. The hernia contents are reduced into the abdominal cavity. The diaphragmatic defect is then sutured with non-absorbable material. A GORE® DUALMESH® biomaterial is placed over the previous defect and attached to the diaphragm with steel ENDO TACKERS™. A pleurostomy tube is placed and the lung is expanded. The patient outcome was uneventful and he was discharged 5 days after the procedure.
F Terrazas, J Lorenzo Silva, D Molina, A Gonzalez, H Bravo
Surgical intervention
3 years ago
2331 views
121 likes
0 comments
06:34
Full laparoscopic repair of a post-traumatic diaphragmatic hernia with mesh insertion
This is the case of a 34-year-old man who suffered from a blunt trauma, 8 months before this surgery. He presented with oppressive chest pain, lasting for a week, increasing while exercising and decreasing when lying down. No history of chronic pathology or smoking was reported. He was admitted to hospital. CT-scan of the abdomen and thorax showed a left diaphragmatic hernia. A laparoscopic diaphragmatic hernioplasty was decided upon. The patient is placed in a right semi-lateral decubitus position, with a 45-degree tilt.
Three trocars were placed; two 5mm trocars in the left upper quadrant, in the anterior axillary line, and in the epigastrium, while a 12mm optical trocar is placed in the upper left quadrant, in the midclavicular line.
The left lung is collapsed. Laparoscopy revealed a left diaphragmatic defect, with a diaphragmatic hernia which contains the spleen, small bowel loops, and the omentum. The hernia contents are reduced into the abdominal cavity. The diaphragmatic defect is then sutured with non-absorbable material. A GORE® DUALMESH® biomaterial is placed over the previous defect and attached to the diaphragm with steel ENDO TACKERS™. A pleurostomy tube is placed and the lung is expanded. The patient outcome was uneventful and he was discharged 5 days after the procedure.
Single incision laparoscopic non-traumatic left lateral diaphragmatic hernia repair
Background: A diaphragmatic hernia is a quite uncommon disease, being congenital or post-traumatic. Its diagnosis is frequently incidental. The surgical treatment can be performed through the abdomen as well as through the chest. Laparoscopy and thoracoscopy offer a surgical benefit, because of reduced abdominal wall trauma and added advantages provided by minimally invasive surgery (MIS). Transumbilical single incision laparoscopy (TSIL), in addition to improved cosmetic results, can offer other advantages to MIS such as reduced postoperative pain, a shorter hospital stay, and improved patient comfort.
Video: The authors report the case of a 45-year-old man who consulted for a non-traumatic left lateral diaphragmatic hernia, which was discovered incidentally, and which was treated using TSIL suture and mesh reinforcement.
Results: Laparoscopic time was 104 minutes and perioperative bleeding was insignificant. The final umbilical scar was 15mm. During the postoperative course, only 4 grams of paracetamol were used. The patient was discharged on the 1st postoperative day, after chest X-ray control. At consultation, the patient did not report the use of painkillers and, at 1, 6, and 12 months, the chest X-ray control was negative for recurrence.
Conclusions: Uncommon conditions, such as a lateral diaphragmatic hernia, can be approached using TSIL, because this technique adds an improved cosmetic result, a reduced postoperative pain, a shorter hospital stay, and an improved patient comfort.
G Dapri, K Jottard, K Grozdev, D Guta, GB Cadière
Surgical intervention
3 years ago
1053 views
32 likes
0 comments
07:14
Single incision laparoscopic non-traumatic left lateral diaphragmatic hernia repair
Background: A diaphragmatic hernia is a quite uncommon disease, being congenital or post-traumatic. Its diagnosis is frequently incidental. The surgical treatment can be performed through the abdomen as well as through the chest. Laparoscopy and thoracoscopy offer a surgical benefit, because of reduced abdominal wall trauma and added advantages provided by minimally invasive surgery (MIS). Transumbilical single incision laparoscopy (TSIL), in addition to improved cosmetic results, can offer other advantages to MIS such as reduced postoperative pain, a shorter hospital stay, and improved patient comfort.
Video: The authors report the case of a 45-year-old man who consulted for a non-traumatic left lateral diaphragmatic hernia, which was discovered incidentally, and which was treated using TSIL suture and mesh reinforcement.
Results: Laparoscopic time was 104 minutes and perioperative bleeding was insignificant. The final umbilical scar was 15mm. During the postoperative course, only 4 grams of paracetamol were used. The patient was discharged on the 1st postoperative day, after chest X-ray control. At consultation, the patient did not report the use of painkillers and, at 1, 6, and 12 months, the chest X-ray control was negative for recurrence.
Conclusions: Uncommon conditions, such as a lateral diaphragmatic hernia, can be approached using TSIL, because this technique adds an improved cosmetic result, a reduced postoperative pain, a shorter hospital stay, and an improved patient comfort.
Laparoscopic management of a left diaphragmatic hernia in a newborn
Laparoscopic treatment of delayed diaphragmatic hernias in children has been described in 1995 by Klaas Bax and David Van der Zee. Since 2001, we managed to convince the community of pediatric surgeons that it was probably easier to choose a thoracoscopic approach. In some particular conditions, newborns with a congenital diaphragmatic hernia could be treated by thoracoscopy. Until now, more than 400 newborns have been operated on by thoracoscopy to treat a diaphragmatic hernia. Guidelines to specify the appropriate group of newborns for this approach remain discussed in the literature.
Reference:
Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. J Pediatr Surg 2013;48:488-95.
F Becmeur, C Gomes Ferreira
Surgical intervention
6 years ago
2074 views
51 likes
0 comments
03:45
Laparoscopic management of a left diaphragmatic hernia in a newborn
Laparoscopic treatment of delayed diaphragmatic hernias in children has been described in 1995 by Klaas Bax and David Van der Zee. Since 2001, we managed to convince the community of pediatric surgeons that it was probably easier to choose a thoracoscopic approach. In some particular conditions, newborns with a congenital diaphragmatic hernia could be treated by thoracoscopy. Until now, more than 400 newborns have been operated on by thoracoscopy to treat a diaphragmatic hernia. Guidelines to specify the appropriate group of newborns for this approach remain discussed in the literature.
Reference:
Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. J Pediatr Surg 2013;48:488-95.
Laparoscopic repair of post-traumatic diaphragmatic hernia with mesh insertion
Traumatic injuries of the diaphragm are rare (0.8%-5.8% of all blunt trauma). Early diagnosis is difficult, and many reports have described delayed presentation of diaphragmatic hernia with subsequent significant morbidity and mortality.

We report a case of an acute diaphragmatic hernia in a 47-year-old male presenting 4 years after the traumatic episode (significant fall from a ladder). The patient was admitted to the emergency department with severe vomiting and dehydration. Once the patient was stabilised with fluid resuscitation and nasogastric tube aspiration, an urgent CT-scan was performed. This demonstrated a large defect within the left hemi-diaphragm, associated with herniation of both the antrum and body of the stomach, into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with herniation and rotation of the stomach was confirmed. The hernia was reduced laparoscopically, and the defect repaired with interrupted, non-absorbable polyester sutures (Ethibond 2/0, Ethicon) and a composite mesh (Proceed™, Ethicon). The patient made an uneventful recovery.
Emergency repair of the diaphragm is usually performed via a thoracotomy or/and laparotomy. In our experience, if the patient is haemodynamically stable and major organ injuries have been excluded, a laparoscopic approach can be considered safe and effective.
A Rotundo, T Knowles, S Kadirkamanathan, M Harvey
Surgical intervention
8 years ago
4601 views
46 likes
0 comments
10:21
Laparoscopic repair of post-traumatic diaphragmatic hernia with mesh insertion
Traumatic injuries of the diaphragm are rare (0.8%-5.8% of all blunt trauma). Early diagnosis is difficult, and many reports have described delayed presentation of diaphragmatic hernia with subsequent significant morbidity and mortality.

We report a case of an acute diaphragmatic hernia in a 47-year-old male presenting 4 years after the traumatic episode (significant fall from a ladder). The patient was admitted to the emergency department with severe vomiting and dehydration. Once the patient was stabilised with fluid resuscitation and nasogastric tube aspiration, an urgent CT-scan was performed. This demonstrated a large defect within the left hemi-diaphragm, associated with herniation of both the antrum and body of the stomach, into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with herniation and rotation of the stomach was confirmed. The hernia was reduced laparoscopically, and the defect repaired with interrupted, non-absorbable polyester sutures (Ethibond 2/0, Ethicon) and a composite mesh (Proceed™, Ethicon). The patient made an uneventful recovery.
Emergency repair of the diaphragm is usually performed via a thoracotomy or/and laparotomy. In our experience, if the patient is haemodynamically stable and major organ injuries have been excluded, a laparoscopic approach can be considered safe and effective.
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.
F Signorini, S Reimondez, P Maldonado, V Gorodner, L Obeide, F Moser, N Bollati
Surgical intervention
1 year ago
2864 views
180 likes
0 comments
10:10
Laparoscopic repair of giant left Bochdalek hernia in adults: resolution of 2 cases
A Bochdalek hernia is a congenital diaphragmatic defect which results from the improper fusion of the septum transversum and of the pleuroperitoneal folds. It rarely persists asymptomatically until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases, using open surgery or laparoscopy/thoracoscopy.
We present two cases of fully laparoscopic repair of a giant Bochdalek hernia in adults. In both cases, we used a GORE® DUALMESH® biomaterial and we had no complications and no recurrence. It is worth mentioning that the hernia sac was not found in any of the cases. This has been described as a distinct characteristic, which confirms the diagnosis.
Bochdalek hernia in adults is a rare entity, which requires surgical treatment to prevent any complications.
Thoracoscopic Bochdalek hernia repair in a newborn
Congenital diaphragmatic hernias (CDH) occur when muscle portions of the diaphragm fail to develop normally, resulting in the displacement of abdominal components into the thoracic cavity.
CDHs occur mainly during the eighth to the tenth weeks of fetal life. Bochdalek hernias, caused by posterolateral defects of diaphragm, usually present with severe respiratory distress immediately after birth, which is life-threatening. Once diagnosed, Bochdalek hernias should be surgically treated during the neonatal period.
We present a clinical case of a newborn with 38 weeks of gestation with the prenatal diagnosis of left diaphragmatic hernia. A thoracoscopic repair was performed with parent agreement.
C Sousa, A Coelho, F Carvalho
Surgical intervention
3 years ago
1493 views
71 likes
0 comments
02:43
Thoracoscopic Bochdalek hernia repair in a newborn
Congenital diaphragmatic hernias (CDH) occur when muscle portions of the diaphragm fail to develop normally, resulting in the displacement of abdominal components into the thoracic cavity.
CDHs occur mainly during the eighth to the tenth weeks of fetal life. Bochdalek hernias, caused by posterolateral defects of diaphragm, usually present with severe respiratory distress immediately after birth, which is life-threatening. Once diagnosed, Bochdalek hernias should be surgically treated during the neonatal period.
We present a clinical case of a newborn with 38 weeks of gestation with the prenatal diagnosis of left diaphragmatic hernia. A thoracoscopic repair was performed with parent agreement.
Laparoscopic repair of a large right-sided Morgagni’s hernia
Morgagni’s hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is unknown. This video presents a morbidly obese woman with oxygen-dependent chronic obstructive pulmonary disease (COPD) along with a Morgagni’s hernia that compresses her entire right lung. Omentum and colon are seen herniating through the 10 by 15 centimeter defect. Through a laparoscopic approach, the intra-abdominal contents were reduced, the defect primarily closed, and reinforced with mesh. After the repair, the patient had significant improvements in her pulmonary status. Laparoscopic repair with mesh reinforcement is a viable and easily accomplished approach for Morgagni’s hernia repair.
D Lawrence, YV Wu, MJ Rosen
Surgical intervention
6 years ago
3690 views
72 likes
0 comments
08:45
Laparoscopic repair of a large right-sided Morgagni’s hernia
Morgagni’s hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is unknown. This video presents a morbidly obese woman with oxygen-dependent chronic obstructive pulmonary disease (COPD) along with a Morgagni’s hernia that compresses her entire right lung. Omentum and colon are seen herniating through the 10 by 15 centimeter defect. Through a laparoscopic approach, the intra-abdominal contents were reduced, the defect primarily closed, and reinforced with mesh. After the repair, the patient had significant improvements in her pulmonary status. Laparoscopic repair with mesh reinforcement is a viable and easily accomplished approach for Morgagni’s hernia repair.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
1 year ago
3850 views
11 likes
1 comment
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Winslow's hiatal hernia: laparoscopic treatment
Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.
JL Limon Aguilar, CO Castillo Cabrera
Surgical intervention
27 days ago
919 views
10 likes
1 comment
09:56
Winslow's hiatal hernia: laparoscopic treatment
Less than 200 cases of internal hernia have been described through the hiatus of Winslow, usually related to congenital or acquired anatomical defects. The most frequent affectation corresponds to the colon, small intestine and, rarely, to the gallbladder. There is usually occlusion with variable grade ischemia, but it can also occur as obstructive jaundice, biliary colic, secondary pancreatitis and non-symptomatic herniation.
The association of Winslow’s hiatus hernia with various anatomical abnormalities (high or subhepatic caecum, mobile ascending colon, large and long colonic mesentery, etc.) may actually correspond to different degrees of intestinal malrotation and, although the diagnosis of “malrotation” is not usually specified, we believe that this could underlie part of Winslow’s hiatus hernia associated with non-acquired anatomical defects.
Hiatal hernia corresponds to 0.2-0.9% of all cases of intestinal obstruction, of which 8% are from Winslow’s hiatus. If pre-surgical diagnosis is difficult, it occurs in less than 10% of cases.
Mortality is around 50% when it has vascular implication. We have not thought of applying the omentum to seal the defect because we did not have adequate surgical anchor sites since we were working millimeters from the vena cava, extrahepatic bile duct, duodenum, and perirenal area. We decided to fix the colon from the hepatic flexure to the right iliac fossa with continuous stitches, from the colonic serosa to Toldt’s fascia, as it is from the embryonic stage.
Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
6 months ago
9107 views
4 likes
0 comments
03:00
Complex cases in laparoscopic recurrent and incisional hernia repair: multi-recurrence, infections, fistulas, difficult abdomen
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
A D'Urso, D Mutter, J Marescaux
State of the art
7 months ago
2217 views
11 likes
0 comments
00:00
Recurrent and incisional hernia repair: complex cases
The term ‘‘complex (abdominal wall) hernia’’ is often used by general surgeons and other specialists working in the abdomen to describe abdominal wall hernias which are technically challenging and time-consuming.

Four categories were created to classify and discuss the criteria, which were proposed to be included in the definition of ‘‘complex abdominal wall hernia’’: defect size and location, patient history and risk factors, contamination and soft tissue condition, and clinical scenario.
Defect size is an important variable; increased size is a risk factor for 30-day readmission rate and recurrence.
Wound contamination is usually classified according to the US National Research Council Group including clean, clean-contaminated, contaminated, and dirty/infected. It is well-known that contamination and subsequent infection are an important cause of wound dehiscence and reherniation which impair wound healing dynamics.
A recurrent hernia is considered a risk factor for a new recurrence.
Patient status is an important factor. Conditions such as abnormal collagen type I/type III ratio and genetic connective tissue disorders are associated with an increased risk of herniation. Older age, male gender, chronic pulmonary disease, coughing, ascites, jaundice, anemia, emergency surgery, wound infection, obesity, steroid use, hypoalbuminemia, hypertension, perioperative shock are also important risk factors.

The reported incidence of incisional hernia is about 2 to 11% after all laparotomies.
The ideal repair for an abdominal incisional hernia is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. However, 30 to 50% of defects larger than 6cm recur after primary closure.
The insertion of a synthetic mesh helps to decrease or relieve tension on the suture line and can reduce the incidence of recurrence to 10% or less.
But foreign prosthetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization.
Laparoscopic repair has provided further improvements with lower infection rates, shorter hospital stay, and a reduction in recurrence with rates of 4 to 16% in recent studies.
In this topic addressing complex laparoscopic cases, we show different scenarios including recurrent infected incisional hernia, fistulization, multi-recurrent incisional hernia, migration, and conversion.
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
S Morales-Conde, T Urade, D Mutter, J Marescaux
Surgical intervention
9 months ago
5248 views
19 likes
2 comments
42:53
Left iliac fossa incisional hernia: live laparoscopic repair
Dr. Salvador Morales-Conde presents the clinical case of a 59-year old female patient managed for an incisional hernia with a 6-7cm sac in the left lower quadrant. The patient’s history included a left iliac fossa laparotomy to control bleeding caused by an epigastric artery injury following a laparoscopic appendectomy. The patient was placed in a Trendelenburg position. An optical port and two 5mm operating ports were inserted on the right lateral side of the abdomen. Peritoneal dissection was performed to expose anatomical landmarks including pubic bone, iliac crest, and iliac vessels for proper mesh fixation. The defect of the abdominal wall was closed using a continuous suture. A trimmed mesh (Parietex™ Composite Mesh) was inserted and fixed with tackers to Cooper’s ligament, to the iliac crest, and to the abdominal wall to sufficiently cover the sutured defect. Finally, the preperitoneal flap was fixed on the mesh to prevent intestines from getting into the mesh gap.
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
D Mutter, T Urade, J Marescaux
Surgical intervention
9 months ago
10521 views
73 likes
0 comments
46:18
Laparoscopic TAPP approach to bilateral reducible inguinal hernia: live interactive procedure
We present the clinical case of a 57-year old male patient managed for a bilateral reducible inguinal hernia. The patient’s history included a right inguinal hernia repair in his childhood. A first port was inserted 1cm above the umbilicus and two 5mm ports were placed 7cm away from the umbilicus on the right and left side. Peritoneal dissection starts with a horizontal incision and parietalization is performed carefully to avoid injury to the vessels and deferent duct. After the myopectineal orifice has been sufficiently exposed, polypropylene meshes (Parietene™) trimmed to a 13 by 12cm size are inserted into the preperitoneal cavity and fixed using absorbable tacks. Finally, the meshes are fully covered using peritoneal flaps.
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
B Dallemagne, T Urade, D Mutter, J Marescaux
Surgical intervention
9 months ago
2617 views
23 likes
1 comment
39:46
Laparoscopic TEP unilateral inguinal hernia repair: a live interactive procedure
We present the clinical case of a 45-year old male patient managed for a right direct inguinal hernia. The patient’s history included a former approach for right inguinal hernia in his childhood and a laparoscopic left inguinal hernia repair. A first port was inserted below the umbilicus and access to the pubic bone was gained on the midline without using balloon. In this case, dissection of adhesions related to the previous operation was required. Attempts were made to identify anatomical landmarks after insertion of 5mm ports. The direct hernia content was dissected and reduced with blunt dissection. Once anatomical landmarks including pubic symphysis, Cooper’s ligament, epigastric vessels, spermatic cord, and psoas muscle were identified, a trimmed polypropylene mesh was inserted and the myopectineal orifice was sufficiently covered without fixation. Finally, the preperitoneal cavity was desufflated to complete the procedure.
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.
A D'Urso, D Mutter, J Marescaux
Surgical intervention
9 months ago
3029 views
15 likes
2 comments
08:23
Laparoscopic Spigelian hernia repair
Spigelian hernia is a rare condition and it is difficult to diagnose it clinically. It has been estimated to account for 0.12% of abdominal wall hernias. The hernia ring is a well-defined defect in the transversus abdominis aponeurosis. The hernia sac, surrounded with extraperitoneal adipose tissue, often lies interparietally passing through the transversus abdominis and the internal oblique muscle aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique muscle. The laparoscopic repair is well-established. Most authors use a transperitoneal approach either by placing the mesh in an intraperitoneal position or by raising the peritoneal flap and placing the mesh in the extraperitoneal space. In this video, we demonstrate the laparoscopic repair of a Spigelian hernia through the transabdominal preperitoneal (TAPP) placement of a composite mesh.