Acquired hernias of the diaphragm

Imaging and Treatment of Complications of Abdominal and Pelvic Mesh Repair

Surgical mesh is used most frequently for tension-free repair of abdominal wall hernias in adults, because the rate of hernia recurrence is lower with mesh than with primary soft-tissue repair. Since the introduction of polypropylene mesh in the middle of the 20th century, many mesh materials and configurations for specific surgical procedures have been developed. In addition to abdominal wall hernia repair, mesh may be used for repair of diaphragmatic hernias, urinary incontinence in women (female slings), genitourinary prolapse (vaginal mesh and sacrocolpopexy), rectal prolapse (rectopexy), and postprostatectomy male urinary incontinence (male slings). General mesh repair complications include chronic pain; fluid collections such as seromas, hematomas, and abscesses; adhesions that may lead to intestinal blockage; erosion into solid or hollow viscera including enterocutaneous fistulizing disease; and mesh failure characterized by mesh shrinkage, detachment, and migration with repair malfunction. Several mesh complications are often diagnosed with imaging, primarily with CT and less frequently with MRI and US, despite variable mesh visibility at imaging. This article reviews the common surgical mesh applications in the abdomen and pelvis, discusses imaging of mesh repair complications, and provides complication treatment highlights.^©RSNA, 2020.

Incidence, Diagnosis and Repair of a Diaphragmatic Hernia Following Hepatic Surgery: A Single Center Analysis of 3107 Consecutive Liver Resections

Diaphragmatic hernia (DH) after a liver resection (LR) is an uncommon but potentially severe complication. In this retrospective study, we aim to share our experience with DH in our hepatic surgery center. We retrospectively analyzed 3107 patients who underwent a liver resection between January 2012 and September 2019. The diagnosis of DH was based on clinical examination and radiological imaging and confirmed by intraoperative findings during surgical repair. Five out of 3107 (0.16%) patients after LR developed DH. Especially, all five DH patients had a major right-sided LR before (n = 716, 0.7%). The mean time interval between initial LR and occurrence of DH was 30 months (range 15 to 44 months). DH exclusively occurred after a right or extended right hepatectomy. Two patients underwent emergency surgery, three were asymptomatic, and DH was diagnosed in follow-up imaging. Three of these five treated patients (60%) developed DH recurrence: two of three (67%) patients after suture repair alone and the only patient after suture repair in combination with an absorbable mesh. The patient who was treated with a composite mesh implant did not show any signs of DH recurrence after 52 months of follow-up. In patients who develop DH after liver surgery, a mesh augmentation with nonresorbable material is generally recommended. In order to diagnose these patients in an early state, we recommend that special attention be paid and a prompt and targeted diagnostic examination of patients with abdominal complaints after right-sided liver resections take place.

Laparoscopic cholecystectomy in adult with asymptomatic partial agenesis of the right diaphragm: Case report and the literature

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Diaphragmatic agenesis is a rare condition.

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In adults with partial diaphragmatic agenesis, laparoscopic cholecystectomy can be performed successfully.

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A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done.

Introduction

The importance of unilateral diaphragmatic agenesis (DA) in adults for performing a laparoscopic cholecystectomy has not been well described in literature.

Presentation of case

A 60-year-old female patient entered our ward in March 2019 for laparoscopic cholecystectomy after 6 months history of epigastric pain and multiple episodes of biliary colic treated conservatively. She never complained of pulmonary symptoms. Preoperative chest Computed tomography (CT) was negative for diaphragmatic or pulmonary pathologies. Laparoscopic cholecystectomy was performed in 60 min with intraoperative detection of a thoracoabdominal communication with partial right hemidiaphragm agenesis. A chest CT and x-ray were performed in the postoperative period with progressive reduction of an asymptomatic small pneumothorax. The patient was discharged at home without complications on the fifth postoperative day. Thoracopulmonary surgery examination was performed without indications for diaphragmatic repair.

Discussion

DA is a rare condition and usually occurs in early neonatal period. The congenital form occurs in 1 out of 2200–12500 live births and is traditionally divided into anterior (Morgagni’s: 10%) and posterolateral (Bochdalek’s: 90%) hernias. Chest and abdomen CT with coronal and sagittal reconstructions is the most effective and useful imaging technique for the diagnosis of diaphragmatic hernia. In literature there are former two case reports of asymptomatic DA in cholelithiasis in which laparoscopic cholecystectomy was performed effectively.

Conclusion

In adults with partial DA, laparoscopic cholecystectomy can be performed successfully. A conservative management only with gallstones dissolution therapy can be used if laparoscopy cannot be done. Further studies with a higher level of evidence are needed.

Left diaphragmatic hernia following thoracoabdominal aortic repair: A case report

INTRODUCTION

Diaphragmatic hernias are somewhat rare complications of thoracoabdominal interventions. Given their late clinical manifestations and misdiagnosis, their incidence is unknown. These hernias have a high mortality risk when an emergency intervention is warranted due to complications from visceral strangulation.

CASE PRESENTATION

We present the case of a 67-year-old male with prior history of thoracoabdominal aortic repair, who reconsults due to upper gastrointestinal bleeding. Upon arrival, imaging shows a left diaphragmatic herniation with migration of the stomach, omentum and spleen to the thoracic cavity. Through laparoscopic approach, a left diaphragmatic hernial defect is identified with protrusion of half the stomach, omentum and the posterior aspect of the spleen with a sub capsular tear. Additionally, a severe adhesion syndrome on the chest wall and diaphragm were also evident, with entrapment of the inferior lobe of the left lung. The contents were successfully reduced, however pulmonary decortication and extensive adhesiolysis through thoracoscopy was required for complete extraction, enabling a primary repair without tension.

CONCLUSIONS

We present an infrequent pathology without an established incidence, which has relevant clinical and surgical implications at any level of care, in this case requiring interdisciplinary management. The suspicion of diaphragmatic hernia in a patient with past medical history of thoracoabdominal aortic repair with non-specific gastrointestinal symptoms is essential. We emphasize the importance of clinical suspicion of this complication once the surgical precedent has been identified.

Enterothorax After Hepatic Surgery: A Single-Center Experience

BACKGROUND

Enterothorax (ET) is a rare complication after hepatic surgery. The literature in this field is limited and mainly based on case reports. The aim of this study was to review our department's experience.

PATIENTS AND METHODS

We retrospectively analyzed 602 patients who underwent hepatic resection between November 2008 and December 2016. Major hepatic surgery (n = 321) was defined as right or extended right hepatectomy (n = 227), left or extended left hepatectomy (n = 63), trisegmentectomy (n = 13), and living donor liver transplantation (n = 18). ET cases were identified by analyzing clinical courses and radiological imaging.

RESULTS

ET was observed in five out of 602 patients (0.8%). All patients developed the complication after major hepatic surgery (five out of 321, 1.6%). ET exclusively occurred after right (n = 3) or extended right hepatectomy (n = 2). Median time to diagnosis was 22 months. Radiological imaging showed herniation of small (n = 2), large bowel (n = 2), or omental fat (n = 1) with a median diaphragmatic defect of 3.9 cm. Two patients presented with acute incarceration and underwent emergency surgery, one patient reported recurrent pain and underwent elective repair, and two patients refused surgery. Follow-up imaging in two operated patients showed no recurrence of ET after 36 and 8 months.

CONCLUSIONS

Patients after right hepatectomy have a substantial risk of ET. Acute right upper quadrant pain and/or dyspnea after hepatectomy should be investigated with adequate radiological imaging. Elective surgical repair of ET is recommended to avoid emergency surgery in case of incarceration.

Delayed Presentation of Posttraumatic Diaphragmatic Hernia Masquerading as Recurrent Acute Asthmatic Attack

Diaphragmatic hernia following blunt abdominal injury is extremely rare and often diagnosed late. Missed diagnosis is also common with this condition. We herein present a delayed presentation of diaphragmatic hernia following blunt abdominal injury that was initially misdiagnosed as recurrent acute asthmatic attack due to repeated presentation with episodic difficulty in breathing.

Right-sided Bochdalek hernia in an elderly adult: a case report with a review of surgical management

Background

Bochdalek hernias are one of the most common types of diaphragmatic hernia, with most cases diagnosed during the neonatal period. In contrast, diagnosis of a Bochdalek hernia in an adult is rare and is typically observed on the left side of the diaphragm. Even more rare is the diagnosis of a right-sided Bochdalek hernia in an adult, where there is concurrent visceral malformation in most cases.

Case presentation

We describe a case of an 89-year-old female who presented with abdominal pain. An abdominal computed tomography (CT) scan showed decreased intravenous contrast uptake and thickening of the wall of herniated small intestine through the right side of the diaphragm, which led to the diagnosis of a strangulated diaphragmatic hernia. The patient underwent emergent laparotomy and required a partial resection of the necrotic ileum and a hernia repair with direct closure. Interestingly, in this case, organ malformation was not observed. The patient was discharged approximately 2 weeks after surgery without complication.

Conclusions

Adult right-sided Bochdalek hernia with strangulation in the absence of hepatic atrophy is a rare entity. Considering the severity of this condition, accurate diagnosis and proper treatment are needed. A tailored operative approach is required on an individual case basis.

Follow-up of asymptomatic adult diaphragmatic hernia: should patients with this condition undergo immediate operation? A report of two cases

BACKGROUND

Asymptomatic diaphragmatic hernia is generally thought to be rare among adults. We present two different types of asymptomatic diaphragmatic hernia diagnosed with computed tomography (CT) and discuss treatment strategies.

CASE PRESENTATION

Case 1: A 37-year-old woman was diagnosed with catamenial pneumothorax in the right diaphragm. Partial resection of the diaphragm and lung was performed using a linear stapler. She was asymptomatic after the operation and gave birth 2 years later. After delivery, she experienced recurrent pneumothorax, and CT revealed a right diaphragmatic defect with herniation of a part of the liver into the thorax. An iatrogenic diaphragmatic hernia was diagnosed. There has been no change in the size of the hernia and no symptoms due to the diaphragmatic hernia for more than 3 years after it was diagnosed. Case 2: A 75-year-old woman was previously diagnosed with rectal cancer and had undergone surgery after chemoradiotherapy. One year after surgery, herniation of a 3 × 1.3-cm section of retroperitoneal fat tissue into the left thoracic cavity was observed incidentally at a follow-up CT and was diagnosed as an adult Bochdalek hernia (BH). We reviewed the patient's past CT findings and confirmed that the same finding had been present since the first scan. A wait-and-see approach was chosen because there had been no change in the size of hernia, there were no symptoms, the patient was elderly, and there was a high risk of recurrence of the rectal cancer. She has had no symptoms to date, and careful follow-up has been performed.

CONCLUSIONS

There are few reports of asymptomatic adult diaphragmatic hernia. Although symptomatic diaphragmatic hernia is generally treated surgically, there are cases in which a wait-and-see approach has been applied, such as our asymptomatic cases.

Diaphragmatic hernia masquerading as a pulmonary metastasis

Iatrogenic injury accounts for the second most common cause of acquired diaphragmatic hernias after penetrating trauma. An increased incidence of these hernias has been observed with the widespread use of laparoscopic surgery. We present the case of a 65-year-old woman who initially underwent sigmoid resection for an adenocarcinoma and a subsequent liver resection for metastasis. She was noted to have a left lower lobe pulmonary nodule on surveillance computed tomography, for which she underwent a mini-thoracotomy for a planned resection. At the time of surgery, the pulmonary nodule was discovered to be a diaphragmatic hernia, most probably of iatrogenic origin. We discuss the difficulty in diagnosis given her history and the location of such a lesion.

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.

Right diaphragmatic iatrogenic hernia after laparoscopic fenestration of a liver cyst: report of a case and review of the literature

Iatrogenic right diaphragmatic hernia is very rare. We report the first case of a patient who had a diaphragmatic hernia after laparoscopic fenestration of liver cyst. A herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Diaphragmatic hernias are not as common as the traumatic type. Surgeons can easily miss diaphragmatic injuries during the operation especially after laparoscopy. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. Ct scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients. The incidence of iatrogenic diaphragmatic hernia after surgery may be reduced if the surgeon checks for the integrity of the diaphragm before the end of the operation. A review of the literature is also performed regarding this rare complication.

Diaphragmatic hernia after hepatic resection: case series at a single Western institution

BACKGROUND

Diaphragmatic hernia (DH) after hepatic resection (HR) is a rare and not well-described complication. We report our experience with DH following a high volume of HRs in a tertiary center.

METHODS

Records of patients undergoing major HR for liver tumors between April 1992 and November 2011 were reviewed. The definitive diagnosis of DH was made based on radiologic studies. Primary repair was used for defects <10 cm in size. Transthoracic repair was used in patients with recurrent or complex hernias. Univariate analysis was performed to determine risk factors associated with posthepatectomy DH.

RESULTS

DH developed in 10 out of 993 patients (1%) at a median time interval of 15 months after HR. DH was not associated with old age (m = 48.5 years), gender (male = 50%), or high body mass index (m = 24.5). However, mean tumor size was large (m = 9.2 cm). The majority of patients presented with symptoms (80 %), small (60%) and right-sided (80%) hernias, and underwent elective repair via an abdominal approach (70%). Large defects (>10 cm; 30%) were successfully repaired with prosthetic mesh. Increased incidence of DH was associated with diaphragmatic resection at the time of HR (5.4 vs. 0.7%, p = 0.001). At a median follow-up of 36 months (range, 10-167 months) after hernia repair, recurrence occurred in one patient.

CONCLUSION

Diaphragmatic resection at the time of HR and large tumor size may put patients at risk of developing posthepatectomy DH. Early detection and prompt treatment is associated with low recurrence and offers the advantage of primary repair.

Intestinal obstruction from diaphragmatic hernia following colonoscopy

Diaphragmatic hernias caused or exacerbated by colonoscopy are rare with only few cases reported. The author reports here an unusual case of herniation and incarceration of the colon into the left thoracic cavity without bowel perforation after an uneventful screening colonoscopy, through an occult focal diaphragmatic weakness from the patient's prior trauma.