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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
2918 views
14 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
1489 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
1 year ago
1775 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
1550 views
64 likes
0 comments
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
2 years ago
2264 views
120 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
1015 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
5 years ago
2031 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
7 years ago
4575 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
2495 views
179 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
1442 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
3648 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
10 months ago
3307 views
8 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.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, F Longo, D Mutter, J Marescaux
Surgical intervention
1 year ago
5614 views
440 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
P Vorwald, G Salcedo, M Posada, C Lévano Linares, ML Sánchez de Molina, R Restrepo, C Ferrero
Surgical intervention
3 years ago
2095 views
79 likes
0 comments
09:13
Relaxing incision for crural repair in type III paraesophageal hernia
This video shows the laparoscopic repair of a large type III paraesophageal hernia in a 55-year-old woman. After dissection of the hernia sac, partial resection is performed. Very high intramediastinal dissection of the esophagus is performed, taking special care not to injure the posterior and anterior vagal trunk. First, as the hiatal defect is very large, a right relaxing incision is performed. The crural repair is performed by interrupted Ethibond® 2/0 stitches buttressed with a polypropylene mesh. Finally, the diaphragmatic defect is covered with a non-reabsorbable mesh (Physiomesh™) and a 180-degree posterior fundoplication is performed.
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
S Perretta, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
3 years ago
952 views
32 likes
0 comments
12:26
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
B Dallemagne, S Perretta, S Tzedakis, D Mutter, J Marescaux
Surgical intervention
4 years ago
8217 views
284 likes
0 comments
16:21
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
1 day ago
135 views
3 likes
1 comment
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
S Perretta, B Dallemagne, J Marescaux
Surgical intervention
6 years ago
3408 views
35 likes
0 comments
09:11
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
B Dallemagne, E Marzano, S Perretta, J Marescaux
Surgical intervention
7 years ago
4817 views
83 likes
0 comments
21:43
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.