Journal of Minimal Access Surgery

UNUSUAL CASE
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Year : 2012  |  Volume : 8  |  Issue : 4  |  Page : 158--160

Reduced port laparoscopic repair of Bochdalek hernia in an adult: A first report

Pravin Hector John, John Thanakumar, Arunkumar Krishnan 
 Minimal Access, Bariatric and GI Surgery, Global Hospitals and Health City, Chennai, India

Correspondence Address:
John Thanakumar
Dr. Arunkumar Krishnan Global Hospital, 439, Cheran Nagar, Perambakkam, Chennai - 600100
India

Abstract

Bochdalek hernia is a congenital defect of the diaphragm that usually presents in the neonatal period with life-threatening cardiorespiratory distress. It is rare for Bochdalek hernias to remain silent until adulthood. A 57-year-old woman presented with history of difficulty in swallowing, as well as retching. There was no history of abdominal or thoracic trauma. A chest x-ray showed the herniated stomach clearly. Computed tomography (CT) of the abdomen showed a herniated volvulus of the stomach, along with left posterolateral diaphragmatic hernia. The defect was repaired by a single incision laparoscopic technique. We present the first case of a posterolateral diaphragmatic hernia repaired by a reduced port laparoscopic technique in an adult, after an extensive literature search yielded no precedents. This report validates the feasibility of reduced port laparoscopic repair of Bochdalek hernia in an adult, and should be within the remit of the advanced laparoscopic surgeon.



How to cite this article:
John PH, Thanakumar J, Krishnan A. Reduced port laparoscopic repair of Bochdalek hernia in an adult: A first report.J Min Access Surg 2012;8:158-160


How to cite this URL:
John PH, Thanakumar J, Krishnan A. Reduced port laparoscopic repair of Bochdalek hernia in an adult: A first report. J Min Access Surg [serial online] 2012 [cited 2019 Sep 18 ];8:158-160
Available from: http://www.journalofmas.com/text.asp?2012/8/4/158/103131


Full Text

 Introduction



Bochdalek hernia is a type of congenital diaphragmatic hernia that primarily manifests in children. First described in 1867 by Victor Alexander Bochdalek, [1] Bochdalek hernia is the most common type of diaphragmatic hernia; the prevalence is 1 in 5000 in neonates and it rarely presents in adulthood. Most cases are symptomatic at birth, and are diagnosed in the neonatal period. It is rare in adults, but actual prevalence in the population is unknown, with an estimated range between 0.17 and 6% of all diaphragmatic hernias. [2],[3] Surgical repair is mandatory and can be done via laparotomy, laparoscopic repair, thoracotomy, or thoracoscopic repair. To the best of our knowledge, we present the first case of a posterolateral diaphragmatic hernia repaired by a reduced port laparoscopic technique in an adult.

 Case Report



Our patient was a 57-year-old woman, with history of difficulty in swallowing, and retching, which was sudden in nature. She had nausea and vomiting of about 2 week duration, with no abdominal pain. There was no history of abdominal or thoracic trauma. Her medical history included tubal ligation and bronchial asthma. She consulted a surgeon, was treated symptomatically and referred to our hospital. A chest radiograph revealed the herniated stomach well above the left diaphragm. Computed tomography (CT), abdomen, [Figure 1] showed a herniated volvulus of stomach via the foramen of Bochdalek (left posterolateral diaphragmatic hernia), which was confirmed by upper gastrointestinal endoscopy. She was initially treated for acute bronchitis with bronchodilators, antibiotics and pulmonary care, followed by surgery.{Figure 1}

Under general anaesthesia, the patient was positioned supine, with legs abducted and flexed as in Lloyd Davies position. The surgeon stood between the legs with the camera person to his left. The scrub nurse stood to the right of the surgeon. The single monitor was situated at the head end of the patient.

A Karl Storz high definition camera was used with a xenon light source. A transumbilical vertical incision was made for a distance of 2 cm. Flaps were undermined just below the skin to create a space for the trocars. 10 mm trocar was inserted using direct vision method followed by CO 2 insufflation and a long bariatric telescope with 45 degree angle. Two trocars of 5 mm with threads (Apple trocars) were inserted by the side of the primary trocar using the same single incision. This was the initial single incision by multi trocar method. The liver was retracted by insertion of Nathanson's liver retraction subcostally without any trocars by a single 5 mm incision. More than half the stomach had herniated through the posterolateral defect situated lateral to the left crus of the diaphragm.

The table was tilted to 15 degree head up to expose the viscera well. Using bowel forceps, the stomach was reduced with difficulty, after releasing the dense omental adhesions with ACE harmonic scalpel. After complete reduction of the stomach, a nasogastric tube was passed by the anaesthetist to empty the stomach. Initial attempt to insert the nasogastric tube was futile as the herniated stomach did not allow passage of the tube into it. The sac in the mediastinum was large and this was carefully reduced and excised fully by blunt and sharp dissection. A small left pneumothorax was made inadvertently. As the hemodynamic equilibrium was maintained, no chest tube was inserted.

After excision of the sac, the defect was found to measure 4x4 cm [Figure 2]. This was situated just lateral to the left crus. This defect was repaired by suturing the diaphragm to the left crus using intracorporeal sutures with left and right needle holders. 2-0 ethibond sutures were used with atraumatic curved needles. Only straight conventional laparoscopic hand instruments were used. The sutures appeared to be adequate for the repair and there was no tension of the tissues after suturing [Figure 3]. As the defect was only 4 cm, sutures were under no tension and the repair appeared satisfactory, no expensive mesh was found necessary to reinforce this well done repair. Throughout surgery, the laparoscopic hand instruments were the standard straight instruments including long bariatric hand instruments. Sometimes, using a long bariatric handle on one hand and a standard handle on the hand were useful to prevent a clash of hands. No curved special instruments were necessary for dissection or suturing. Long bariatric laparscope was useful, as it kept the camera person's hands well clear of the operating site. A 45 degree of vision by the long telescope provided more than necessary vision for the surgery, including suturing without need for expensive flexible laparoscopes. {Figure 2}{Figure 3}

The stomach was then sutured to the anterior abdominal wall to create an anterior gastropexy using interrupted 2-0 ethibond sutures. An intraoperative gastroscopy was done with flexible Olympus gastroscope to ensure that there were no perforations and to confirm there was no gastric pathology. Hemostasis was verified and the abdomen was closed after withdrawal of all instruments, ports and evacuation of the CO 2 pneumoperitoneum, with no drainage. Post operatively, the patient made an uneventful recovery. Oral intake was recommenced on the first post operative day, and the patient was discharged after 48 hours. Patient remained remarkably pain free after surgery despite the magnitude of the surgery .

 Discussion



A Bochdalek hernia is a congenital posterior diaphragmatic defect resulting from failure of the retroperitoneal canal membrane to fuse with the dorsal oesophageal mesentery and the body wall. [3] The Bochdalek hernia has a female predominance and symptoms usually manifest during the first week of life. [4] However, a majority of these have presented in the first and second decade. The most common presenting symptoms include abdominal or chest pain with associated vomiting, dyspnea or intestinal obstruction. [5]

Bochdalek hernia in adults is diagnosed by radiographic examination. Many Bochdalek hernias are identified by gas-filled bowel loops or a soft tissue mass above the dome of the diaphragm. However, if the herniation is intermittent, radiographs may appear normal. In some cases, the abdominal radiographs reveal no pathology because of spontaneous reduction of the herniated viscera. A chest CT is necessary in order to make an accurate diagnosis. Chest CT includes focal defect in the diaphragm, herniated contents and thickening of the diaphragm, or crus. The present case highlights the importance of early CT scanning in reaching an early preoperative diagnosis, particularly, since a delay in diagnosis can result in significant morbidity and mortality. Once diagnosed, it is crucial to perform prompt surgical treatment.

Traditionally, this can be done using laparotomy, laparoscopic repair, thoracotomy, or thoracoscopic repair. The application of minimally invasive techniques offers obvious potential advantages for both diagnosis and treatment of this rare condition. [6],[7] There have been three reports of Bochdalek hernia presenting in adulthood repaired laparoscopically. [6] To our knowledge, this is the first report of such a defect being closed, using a single incision laparoscopic technique in an adult patient. This represents a technical step forward, not only since it proves the practicability of this precise procedure, but also because it signifies the next stage of progression in minimally invasive surgery. Minimally invasive techniques may result in reduced morbidity and might also aid hernia reduction, hemostasis, reduced pain and adhesiolysis.

The ergonomics of single incision and reduced port laparoscopic surgery is challenging. In this operation, the liver needed adequate retraction to see and repair the diaphragmatic defect. Hence, in addition to the transumbilical incision, a separate small incision was made to insert the liver retractor without any trochar. Unlike in most reduced port surgeries, the standard laparoscopic and bariatric instruments were used, rather than curved or specialized instruments. These straight instruments are readily available in most operating theaters and hence this approach is useful in most situations. Reduced port or single incision laparoscopic suturing differs from standard laparoscopic suturing, in that the hands moved forward and backward rather than sideways. While knotting, the C loop is kept close to resemble a narrow O rather than a wide C. While making the knot, one hand moves away and the other moves towards the surgeon. While suturing and knotting, it is useful to have either curved beaks or right angled instruments for knotting and suturing. This is due to a narrow angle between the two manipulating instruments.

In summary, Bochdalek hernia is very rare in adults. When symptomatic, accurate diagnosis and prompt surgery are essential for a favourable outcome. This report validates the feasibility of reduced port laparoscopic repair of Bochdalek hernia in an adult, and should be within the remit of the advanced laparoscopic surgeon in most laparoscopic operation theatres, without the need for any special instruments. Comparative studies are necessary to demonstrate its equivalence or superiority to current approaches.

References

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