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aparoscopic Repair of Traumaticiaphragmatic Hernia

arc Zerey, MD, FRCSC, B. Todd Heniford, MD, FACS, andonald F. Sing, DO, FACS, FCCP

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iaphragmatic injuries are not uncommon with rates ashigh as 5% for patients hospitalized after motor vehicle

ccidents, and 15% for patients after penetrating injuries tohe lower chest and upper abdomen.1-3 Left-sided rupture isore common than right-sided rupture (68.5% vs. 24.2%,

espectively), owing to hepatic protection and increasedtrength of the right hemidiaphragm.4

During the initial evaluation and hospitalization of therauma patient, diaphragmatic injuries from either penetrat-ng or blunt thoracoabdominal trauma frequently are missed.nvestigative techniques to diagnose traumatic diaphrag-atic injuries [chest roentgenogram, diagnostic peritoneal

avage, ultrasound, and computed tomography (CT) scan]re limited by their low sensitivity and high false-negativeates.5,6 Reports have documented the effectiveness of lapa-oscopy as a means to diagnose intraabdominal injury inenetrating thoracoabdominal trauma. The surgeon may ef-

ectively visualize abnormal fluid collections as well as injuryo the peritoneum or diaphragm with the introduction of aaparoscope. If there are no apparent signs of visceral injury its mandatory that the surgeon perform a systemic examina-ion of the supra- and infracolic compartment and pelvis. Thentestines should be run using as many additional ports asecessary and the lesser sac inspected through a defect in the

esser omentum and gastric traction and elevation. When aiaphragmatic laceration or hernia has been identified, repair

s mandatory. Latent repair of missed traumatic diaphrag-atic hernias has been associated with a 20% to 36% mor-

ality rate.7,8

Over the past decade, a select group of trauma surgeonsnd advanced laparoscopic surgeons have applied minimallynvasive surgical techniques for the repair of acute diaphrag-

atic lacerations and chronic traumatic diaphragmatic her-ias.9-12 The laparoscopic repair in the acute setting is limitedy the frequent presence of concomitant injuries that reflect

epartment of Trauma, Division of Gastrointestinal and Minimally InvasiveSurgery, Carolinas Medical Center, Charlotte, NC.

ddress reprint requests to Ronald F Sing, DO, FACS, FCCP, Department ofTrauma, Division of Gastrointestinal and Minimally Invasive Surgery,Carolinas Medical Center, 1000 Blythe Blvd MEB 601, Charlotte NC

d28203. E-mail: [email protected]

524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.oi:10.1053/j.optechgensurg.2006.04.006

he severity of the traumatic event. The laparoscopic repair ofhronic diaphragmatic hernias is more difficult because ofntrapment of organs and presence of adhesions. Symptomsf a chronic diaphragmatic hernia are related to the incarcer-tion of abdominal contents in the defect or to impingementf the lung, heart, or thoracic esophagus by abdominal vis-era and include abdominal pain, respiratory distress, andardiac dysfunction.

Nevertheless, with the recent increase in the proficiency inaparoscopic technique, the number of patients having thisondition dealt with laparoscopically is increasing.

Once the diagnosis is made, operative repair is mandated.he decision to proceed laparoscopically depends on theernia itself, the patient, and the surgeon. A hernia amend-ble to laparoscopic repair is one that is typically located onhe left side, that may or may not communicate with thesophageal hiatus but that is less than 10 cm in diameter. Theurgeon must possess advanced laparoscopic skills to per-orm dissection and intracorporeal knot tying. The presencef multiple injuries is not necessarily a contraindication toaparoscopic repair unless the patient is unstable.

perative Techniquesositioning of Patient and Surgeonhe patient is placed in the supine position with legs apartnough to accommodate the operating surgeon (see Fig. 1).he first assistant is located to the patient’s left and secondssistant (laparoscope operator) to the patient’s right. Weavor entry into the abdominal cavity using the open Hassonechnique where a 10-mm port will be placed. Use of a 30-egree (and occasionally a 45-degree) laparoscope is re-uired. After CO2 insufflation, an exploratory laparoscopy iserformed to verify the presence of concomitant injuries oronditions in addition to visualizing the hernia. Four addi-ional 5-mm ports are placed along the subcostal margin athe right midclavicular, subxiphoid, left midclavicular, andeft anterior axillary positions.

rimary Repair of Diaphragmatic Injuryollowing visualization of the hernia defect (see Fig. 2), the
ecision to repair primarily depends on the ability to approx-
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28 M. Zerey, B.T. Heniford, and R.F. Sing

mate the edges without undue tension. The standard repairnvolves placement of simple, horizontal mattress (Fig. 2B,) or figure-of-eight zero or number one nonabsorbableraided sutures. After the suture is placed across the defecthe needle is cut and the two free ends are kept together usingtitanium clip. This process is repeated to avoid blindinglylacing a needle across the defect and injuring structures inhe chest or mediastinum. Once all the sutures have beenlaced the clip is removed and sutures are progressively tied

ntracorporeally. A red rubber catheter may be placed in theleural cavity and the air suctioned as the final suture is tiedo minimize a postoperative pneumothorax. Alternatively, ahest tube should be placed in the presence of lung injury.

epair of Diaphragmatic Injury Usingrosthetic Biomaterialaparoscopic visualization reveals incarcerated abdominaliscera through diaphragmatic defect (see Fig. 3). Laparo-copic grasper and scissors are used to reduce hernia con-ents. Use of electrocautery or harmonic instruments isvoided to prevent injury to hernia contents and structuresresent in thoracic cavity and mediastinum (Fig. 3B). When

t has been determined that hernia will be unable to be closedithout undue tension, prosthetic biomaterial is required

Fig. 3C). Prosthetic repairs are performed with expandedolytetrafluoroethylene (ePTFE) mesh (Soft Tissue Patch,

Figure 1

.L. Gore & Associates, Flagstaff, AZ) secured by 0 or 1 (

onabsorbable braided suture, ensuring some overlap be-ond the diaphragmatic defect (Fig. 3D).

esultse recently reported on the feasibility and limitations of a

aparoscopic approach for the repair of acute traumatic dia-hragmatic lacerations and chronic traumatic diaphragmaticernias.13 Thirteen traumatic diaphragmatic injuries were re-aired laparoscopically with four (two acute and twohronic) requiring conversion. Among the laparoscopicallyepaired diaphragmatic injuries, three defects (chronic) wereepaired using ePTFE and nine were repaired primarily. Theean length of the diaphragmatic defects was 4.6 cm (range,

.5-12 cm). The mean operative time was 134.7 minutesrange, 55-200 minutes). The mean estimated blood loss was08.5 mL (range, 30-500 mL), and the postoperative lengthf stay was 4.4 days (range, 1-12 days). There were no intra-perative complications, but three patients developed pul-onary complications (atelectasis/pneumonia). Follow-up

valuation was available for 11 patients. There were no doc-mented recurrences after a mean follow-up period of 7.9onths (range, 1 week to 24 months). Conversion resulted

rom a reluctance or inability to perform laparoscopic suturef transverse diaphragmatic lacerations longer than 10 cmnterior to the esophageal hiatus and adjacent to the pericar-ium (n � 2) or communicating with the esophageal hiatus

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n � 2). The four patients undergoing laparotomy had a

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Laparoscopic repair of traumatic diaphragmatic hernia 29

ean postoperative discharge date of 8.7 days (range, 6-14ays).The feasibility of repairing acute diaphragmatic lacerations

nd chronic traumatic diaphragmatic hernias laparoscopi-ally appears to be based mostly on experience but also onocation. Hernias directly communicating with the esopha-

Figure 2 (A) Diaphragmatic hernia seen laparoscopicallyNJ) across defect; (C) intracorporeal knot tying to close

eal hiatus or anterior to the esophageal hiatus and adjacent a

o the pericardium are extremely difficult to repair using ainimally invasive approach. Anterior to the esophageal hi-

tus the diaphragm is thin, taut, relatively immobile, and inlose proximity to the pericardium. The immobility of theiaphragm anterior to the esophageal hiatus also impedesisualization cephalad into the mediastinum, even with an

lacement of Ethibond suture (Ethicon Inc., Somerville,; (D) repaired diaphragmatic hernia.

; (B) p

ngled laparoscope. Sutures placed too deep in this location


Figure 2 Continued


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


Figure 3 Continued

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ay violate the pericardium, and sutures placed too superfi-ially risk hernia recurrence. The hemidiaphragm is moreobile laterally and near the central tendon, and greater vi-

ualization is provided by retracting the edges of the defectnd placing the laparosocope into the hemithorax. Table 1

eferences1. Brandt ML, Luks FI, Spigland NA, et al: Diaphragmatic injury in chil-

dren. J Trauma 32:298-301, 19922. Ward RE, Flynn TC, Clark WP: Diaphragmatic disruption secondary to

blunt abdominal trauma. J Trauma 21:35-38, 1981

able 1 Indications and contraindications of laparoscopic re-air of diaphragmatic hernia

Indications Contraindications

resence of hernia Unstable patient (absolute)Hernia > 10 cm (relative)Hernia communicating with

esophageal hiatus (relative)

3. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic

laparoscopy for penetrating abdominal trauma: A multicenterexperience. J Trauma 42:825-829, 1997; discussion 829-831

4. Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic ruptureof diaphragm. Ann Thorac Surg 60:1444-1449, 1995

5. Aronoff RJ, Reynolds J, Thal ER: Evaluation of diaphragmatic injuries.Am J Surg 144:571-575, 1982

6. Schneider C, Tamme C, Scheidbach H, et al: Laparoscopic managementof traumatic ruptures of the diaphragm. Langenbecks Arch Surg 385:118-123, 2000

7. Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation oftraumatic diaphragmatic hernia. Ann Surg 188:229-233, 1978

8. Madden MR, Paull DE, Finkelstein JL, et al: Occult diaphragmaticinjury from stab wounds to the lower chest and abdomen. J Trauma29:292-298, 1989

9. Cougard P, Goudet P, Arnal E, Ferrand F: Treatment of diaphragmaticruptures by laparoscopic approach in the lateral position. Ann Chir125:238-241, 2000

0. Matz A, Landau O, Alis M, et al: The role of laparoscopy in the diagnosisand treatment of missed diaphragmatic rupture. Surg Endosc 14:537-539, 2000

1. Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic inju-ries: Spectrum of radiographic findings. Radiographics 18:49-59, 1998

2. Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmaticrupture: Associated injuries and outcome. Ann R Coll Surg Engl 82:97-100, 2000

3. Matthews BD, Bui H, Harold KL, et al: Laparoscopic repair of traumatic
diaphragmatic injuries. Surg Endosc 17:254-258, 2003

laparoscopic repair of traumatic diaphragmatic hernia

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