monthly focus

surgical intervention video

This is the case of a 34-year-old man who had a car accident which caused a left diaphragmatic rupture, a post-traumatic aortic isthmus rupture, and a femur fracture. An emergency surgery was indicated, and a laparoscopic approach was first recommended. A strangulated diaphragmatic hernia containing the stomach and the greater omentum was found. The hernia content was reintegrated into the abdomen with a diaphragmatic repair. Starting the procedure with a laparoscopic approach is a good option for the treatment of traumatic diaphragmatic ruptures. However, it is still rarely used. In this video, a prosthesis was not placed as the procedure was performed in an emergency, the patient was young, and the diaphragmatic defect was closed without tension. 



Bibliographic reference:

Complicated Diaphragmatic Hernia in Emergency Surgery: Systematic Review of the Literature. Gennaro Perrone World J Surg. 2020 Dec;44(12):4012-4031. 

Laparoscopic repair of a post-traumatic diaphragmatic rupture 

Réparation cœlioscopique d'une rupture diaphragmatique post-traumatique

This video presents the case of a 20-year-old man who underwent an elective surgery for an abdominal blunt trauma. The aim of this video was to describe the laparoscopic management of this trauma in a stepwise fashion in order to easily expose, reduce the abdominal content, and safely close a left diaphragmatic rupture.

Laparoscopic repair of acute diaphragmatic rupture: a stepwise approach

Prise en charge laparoscopique d'une rupture diaphragmatique aiguë : une approche par étapes

This is the case of a 46-year-old woman who presented with cough and vomiting without any other symptoms and without any epidemiological history. X-ray of the chest and CT-scan showed a 52 by 44mm cyst in the anterior segment of the left lower lobe. After 15 days with albendazole, the surgical team decided to perform a VATS cystotomy with capitonnage. The postoperative period was uneventful and the patient was discharged on postoperative day 3. The histopathological exam revealed a pericystic layer in the lung tissue due to a hydatid cyst and a hydatid chitinous layer.

Surgical treatment of a pulmonary hydatid cyst: video-assisted thoracoscopic surgery (VATS) cystotomy with capitonnage

Traitement chirurgical d'un kyste hydatique pulmonaire : cystotomie par chirurgie thoracique vidéo-assistée avec capitonnage

The authors present the case of a 53-year-old woman with a medical history of hypothyroidism and high blood pressure who presented moderate right upper abdominal pain that appeared 30 days earlier. She did not present any other associated symptoms. CT-scan and magnetic resonance imaging revealed a right diaphragmatic hernia, with hepatic protrusion. It was decided to perform a thoracoscopic repair of the right diaphragmatic hernia. The postoperative period was uneventful and the patient was discharged on postoperative day 2 without pleural drainage. 

Discussion: A diaphragmatic hernia is the incursion of abdominal contents into the thoracic cavity through a defect in the diaphragm. Congenital diaphragmatic hernias are rare, occurring in 1 in 3,000 live births, and usually occur early in life (1). Surgical repair is the definitive treatment for diaphragmatic hernia and involves reducing herniated organs into the abdominal cavity and repairing the diaphragmatic defect (1) using primary repair, primary repair with mesh reinforcement, or only mesh interposition techniques (2). 

Given the uncommon and heterogeneous nature of the disease, there is no consensus in the literature regarding the optimal timing and approach for the surgical intervention (3). Nevertheless, the thoracic approach has emerged as an acceptable surgical strategy, usually performed with video-assisted thoracic surgery (VATS) (1). Obata et al. conclude that the thoracoscopic approach may be better for the repair of late congenital diaphragmatic hernia (4). Most particularly, in right-sided diaphragmatic hernia, the thoracic approach offers better access since, in the abdominal approach, access to the herniated organ becomes difficult due to the liver on the right side (1). 



Take-home message:

Patients with a diaphragmatic hernia with liver content can be treated via a primary repair of the diaphragmatic hernia. The surgery was performed with a thoracoscopic approach due to the safety and optimal results of the surgical technique.



Bibliography:

1. Oh S, Lim SK, Cho JH, et al. Surgery for Diaphragmatic Hernia Repair: A Longitudinal Single-Institutional Experience. J Chest Surg. 2023;56(3):171-176. doi:10.5090/jcs.22.129

2. Fernández-Moreno MC, Barrios Carvajal ME, López Mozos F, Garcés Albir M, Martí Obiol R, Ortega J. When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review. Surg Endosc. 2022;36(5):3347-3355. doi:10.1007/s00464-021-08651-3

3. Jones EK, Andrade R, Bhargava A, Diaz-Gutierrez I, Rao M. Surgical management of delayed-presentation diaphragm hernia: A single-institution experience. JTCVS Tech. 2022;13(C):263-269. doi:10.1016/j.xjtc.2022.04.012

4. Obata S, Souzaki R, Fukuta A, et al. Which Is the Better Approach for Late-Presenting Congenital Diaphragmatic Hernia: Laparoscopic or Thoracoscopic? A Single Institution’s Experience of more than 10 Years. J Laparoendosc Adv Surg Tech. 2020;30(9):1029-1035. doi:10.1089/lap.2019.0162

Dislocation of a liver segment due to a right diaphragmatic hernia: thoracoscopic primary repair

Dislocation d'un segment hépatique due à une hernie diaphragmatique droite : prise en charge primaire par voie d'abord thoracoscopie

video lecture

Résections sous-lobaires pour cancer du poumon au stade précoce : prise en charge des problèmes oncologiques

In this key lecture, Dr. Dominique Gossot, MD outlines sublobar resections for early-stage lung cancer, shedding light on the management of oncological issues.

Sublobar resections for early-stage lung cancer: managing oncological issues

In this authoritative lecture, Prof. Khalid Amer, MD, FRCS provides his experience with video-assisted thoracoscopic complications.

Focus on thoracic surgery (VATS & RATS)

Laparoscopic repair of a post-traumatic diaphragmatic rupture

Laparoscopic repair of acute diaphragmatic rupture: a stepwise approach

Surgical treatment of a pulmonary hydatid cyst: video-assisted thoracoscopic surgery (VATS) cystotomy with capitonnage

Dislocation of a liver segment due to a right diaphragmatic hernia: thoracoscopic primary repair

Sublobar resections for early-stage lung cancer: managing oncological issues

My VATS complications