Laparoscopic repair of traumatic diaphragmatic injuries

Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs

PURPOSE

To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures.

METHODS

Five male dogs were used in this study. Under laparoscopic approach, a defect of 7 cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period.

RESULTS

All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable.

CONCLUSIONS

Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.

Ex vivo biomechanical comparison of V-LOC 180® absorbable wound closure device and standard polyglyconate suture for diaphragmatic herniorrhaphy in a canine model

OBJECTIVE

To compare 2-0 polyglyconate barbed suture (V-LOC™ 180 Absorbable Wound Closure Device, Covidien, Mansfield, MA) to standard 2-0 monofilament absorbable polyglyconate suture (Maxon™, Covidien) for maximum load to failure and failure mode when used to appose standardized defects in canine diaphragm muscle.

STUDY DESIGN

Randomized, cadaveric ex vivo mechanical testing.

SAMPLE POPULATION

Canine cadaveric hemi-diaphragmatic specimens (n = 32 pairs).

METHODS

Thirty-two cadaveric diaphragm specimens were collected and divided to obtain 64 muscle specimens (9 cm × 4 cm). Paired specimens were bisected in the midpoint of their 9 cm length in the direction of the muscle fibers and apposed using either 2-0 polyglyconate or 2-0 barbed polyglyconate (V-LOC™ 180 Absorbable Wound Closure Device) in a simple continuous pattern. Increasing tension was applied perpendicular to the suture line until specimen failure. Failure mode and maximum load to failure were recorded for each specimen.

RESULTS

Mean ± SD failure load of simulated herniorrhaphies performed with barbed polyglyconate suture (54.5 ± 10.27 N) was not significantly different than repair with polyglyconate (56.9 ± 10.87 N). Failure mode for both construct types was suture tear out rather than suture failure.

CONCLUSIONS

Clinical application of 2-0 barbed polyglyconate suture can be considered as an alternative to the use of 2-0 polyglyconate for diaphragmatic herniorrhaphy.

Biomechanical strength of two laparoscopic herniorrhaphy techniques in a cadaveric diaphragm and in a neoprene model

OBJECTIVES

Our objectives were to 1) Biomechanically compare two laparoscopic repair techniques; an automated suturing device and a stapling device to conventional open suturing, and 2) Evaluate a model for canine diaphragmatic tissue by comparisons to similar constructs in fresh diaphragms. We hypothesized that automated suturing is biomechanically superior to laparoscopic stapling in dogs, and that neoprene defect repair is an acceptable model for experimental cadaveric diaphragm herniorrhaphy.

MATERIALS AND METHODS

Samples of diaphragm pars costalis were prepared with defects mimicking radial muscular tears. Defects were repaired using conventional open suturing, laparoscopic automated suturing, and laparoscopic stapling techniques. Similar defects were created in 6.35 mm thick single-sided neoprene. Samples were biomechanically tested across a biaxial loading machine. Site and mode of failure were noted for all samples.

RESULTS

In both the diaphragm muscle and neoprene, the laparoscopic stapling technique was significantly weaker. The neoprene model showed a similar failure load as the diaphragm in both laparoscopic techniques, and a similar stiffness in an open-sutured and stapled diaphragm compared to the neoprene samples. Site and mode of failure in neoprene were similar to cadaveric diaphragmatic tissue, but the overall median load-to-failure was higher for the neoprene.

CONCLUSION

The strength of laparoscopically repaired simulated diaphragmatic hernias was higher with an automated suture technique than with a stapling technique. Neoprene defect repair is an acceptable model of canine diaphragmatic herniorrhaphy for biomechanical testing.

Hepatothorax: a rare outcome of high-speed trauma

Diaphragmatic ruptures are the result of severe blunt trauma or penetrating trauma. Motor vehicle crashes are a common mechanism associated with blunt diaphragmatic rupture (BDR). Incorporating diagnostic tools and laparotomy assist in the diagnosis and treatment of BDR. However, diagnosing BDR can be a challenge for practitioners. Early diagnosis and treatment improve the patient's outcomes. This paper details the events of a patient received in a level I trauma unit.

A refined radio-telemetry technique to monitor right ventricle or pulmonary artery pressures in rats: a useful tool in pulmonary hypertension research

Implantable radio-telemetry methodology, allowing for continuous recording of pulmonary haemodynamics, has previously been used to assess effects of therapy on development and treatment of pulmonary hypertension. In the original procedure, rats were subjected to invasive thoracic surgery, which imposes significant stress that may disturb critical aspects of the cardiovascular system and delay recovery. In the present study, we describe and compare the original trans-thoracic approach with a new, simpler trans-diaphragm approach for catheter placement, which avoids the need for surgical invasion of the thorax. Satisfactory overall success rates up to 75% were achieved in both approaches, and right ventricular pressures and heart and respiratory rates normalised within 2 weeks. However, recovery was significantly faster in trans-diaphragm than in trans-thoracic operated animals (6.4 ± 0.5 vs 9.5 ± 1.1 days, respectively; p < 0.05). Stable right ventricular pressures were recorded for more than 4 months, and pressure changes, induced by monocrotaline or pulmonary embolisms, were readily detected. The data demonstrate that right ventricular telemetry is a practicable procedure and a useful tool in pulmonary hypertension research in rats, especially when used in combination with echocardiography. We conclude that the described trans-diaphragm approach should be considered as the method of choice, for it is less invasive and simpler to perform.