Disposable bipolar irrigated sealer (Aquamantys(®)) for liver resection: use with caution

Incidence and outcomes of post-hepatectomy diaphragmatic hernia: a systematic review

BACKGROUND

Post-hepatectomy diaphragmatic hernia is the second most common cause of acquired diaphragmatic hernia. This study aims to review the literature on this complication's incidence, treatment and prognosis.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed for all studies related to acquired diaphragmatic hernias after hepatectomy.

RESULTS

We included 28 studies in our final analysis, comprising 11,368 hepatectomies. The incidence of post-hepatectomy diaphragmatic hernia was 0.75% (n = 86). The most frequent type of hepatectomy performed was right hepatectomy (79%, n = 68), and the indications for liver resection were a liver donation for living donor transplantation (n = 40), malignant liver tumors (n = 13), and benign tumors (n = 11). The mean onset between liver resection and the diagnosis of diaphragmatic hernia was 25.7 months (range, 1-72 months), and the hernia was located on the right diaphragm in 77 patients (89.5%). Pain was the most common presenting symptom (n = 52, 60.4%), while six patients were asymptomatic (6.9%). Primary repair by direct suture was the most frequently performed technique (88.3%, n = 76). Six patients experienced recurrence (6.9%), and three died before diaphragmatic hernia repair (3.5%).

CONCLUSION

Diaphragmatic hernia is a rare complication occurring mainly after right liver resection. Repair should be performed once detected, given the not-negligible associated mortality in the emergency setting.

Hemostasis in a giant intraventricular tumor using a saline-cooled radiofrequency bipolar coagulator: technical note

BACKGROUND

Meningiomas are relatively rare in children and tend to be intraventricular and cystic, with often malignant behavior. Complete excision is associated with the most favorable outcome; moreover, the size and extent of these lesions often make complete excision in one step impossible because of the risk of intraoperative death from uncontrollable hemorrhage.

CASE PRESENTATION

A 10-year-old girl was admitted for headache in the last 3 months and was found to have a giant left intraventricular lesion with a volume of 166.63 cm3, which caused hydrocephalus and significant mass effect. Very large draining veins were evident within the tumor, draining into the thalamostriates and internal cerebral veins. Cerebral angiography showed multiple feeders originating mainly from branches of the posterior left choroidal artery with distal afferents that could not be embolized. Therefore, a left parietal transcortical approach was chosen. Given the vascularity of the tumor, saline-cooled radiofrequency coagulation (Aquamantys®) was used to reduce blood loss intraoperatively. Gross total resection (GTR) was achieved with an estimated blood loss of 640 mL. Pathology analysis was consistent with WHO grade 1 transitional meningioma. Postoperatively, the patient was neurologically intact, and MRI confirmed complete resection.

CONCLUSION

Aquamantys® is a novel bipolar coagulation device that employs a new bipolar coagulation technique combining radiofrequency energy and saline to achieve hemostatic sealing by denaturing collagen fibers. This offers the possibility of achieving adequate hemostasis even in giant intraventricular tumors in infants to obtain GTR resection with minimal blood loss.

Incarcerated diaphragmatic hernia after right hepatectomy: an autopsy case with a review of 45 previous cases

An iatrogenic diaphragmatic hernia after major hepatic resection is a rare complication. Incarceration of the abdominal organ through a diaphragmatic defect can have a fatal prognosis. Here, we report a case of incarcerated diaphragmatic hernia after right hepatectomy, which was diagnosed only after the autopsy. The deceased, who had right hepatectomy 1 year previously, complained of severe chest pain, and 4 days later was found dead. Localized decomposition in his chest and abdomen suggested a late complication of the surgery because the location was consistent with the prior surgical area. In the autopsy, there was a small defect in his right diaphragm, resulting in the herniation and incarceration of the small intestine. Gross and microscopic findings of the herniated small intestine were consistent with ischemic enteritis. Different from our case, most of the previously reported cases showed a good prognosis after surgical repair, except one lethal one. Even though its overall incidence is very low, an incarcerated diaphragmatic hernia is one of the critical complications of major hepatic resection. The clinicians should warn the patients to avoid preventable morbidity and mortality. Reviewing this fatal complication would be also helpful for forensic pathologists and death investigators.

Diaphragmatic hernia following liver resection: case series and review of the literature

BACKGROUNDS/AIMS

Postoperative diaphragmatic hernia, following liver resection, is a rare complication.

METHODS

Data of patients who underwent major hepatectomy for liver tumors, between 2011 and 2015 were retrospectively reviewed. The literature was searched for studies reporting the occurrence of diaphragmatic hernia following liver resection.

RESULTS

Diaphragmatic hernia developed in 2.3% of patients (3/131) with a median delay of 14 months (4-31 months). One patient underwent emergency laparotomy for bowel obstruction and two patients underwent elective diaphragmatic hernia repair. At last follow-up, no recurrences were observed. Fourteen studies including 28 patients were identified in the literature search (donor hepatectomy, n=11: hepatectomy for liver tumors, n=17). Diaphragmatic hernia was repaired emergently in 42.9% of cases and digestive resection was necessary in 28.5% of the cases. One patient died 3 months after hepatectomy, secondary to sepsis, from a segment of small bowel that perforated into the diaphragmatic hernia.

CONCLUSIONS

Although rare, diaphragmatic hernia should be considered as an important complication, especially in living donor liver transplant patients. Diaphragmatic hernia should be repaired surgically, even for asymptomatic patients.