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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00958-1
10.1016/j.ijscr.2024.110177
110177
Case Report
Combined minimally invasive approach for an incarcerated diaphragmatic hernia with a perforated stomach in a young adult female – A video case report
Mir Iqbal Saleem
Samoon Abdul Hamid
Rashid Arshad
Arah Refut
Mushtaq Mosin
Pamecha Rishab rishabpamecha29@gmail.com
⁎
Department of Minimal Access and General Surgery, Government Medical College, Srinagar, Jammu and Kashmir 190010, India
⁎ Corresponding author at: 202, Resident Doctor's Hostel, Government Medical College, Karan Nagar, Srinagar 190010, India. rishabpamecha29@gmail.com
14 8 2024
10 2024
14 8 2024
123 11017726 6 2024
9 8 2024
13 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Diaphragmatic hernia is most commonly congenital; however, it can also be acquired, most often due to trauma. It is a life-threatening condition resulting in abdominal visceral incarceration and subsequent mortality.

Presentation of case

Our patient was a 27-year-old mother who presented with upper abdominal pain associated with breathlessness. There was no history of trauma. The chest X-ray suggested the diagnosis of a diaphragmatic hernia which was further confirmed on CT. The decision was made to operate on the patient through a laparoscopic approach using single-lung ventilation. A diaphragmatic rent was identified with the incarceration of the stomach and omentum. The rent was widened further which allowed partial reduction of contents and visualization of the left hemithorax which was entirely contaminated. An additional thoracic approach was opted for which enabled reduction of the herniated stomach. A large perforation was present along the greater curvature, which was resected using a linear endo stapler. The diaphragmatic rent was then repaired primarily. Adequate lavage, aspiration, and mopping were performed along with chest tube drainage. The patient remained stable post-operatively.

Discussion

An optimal surgical repair along with sound perioperative care is essential for the successful management of diaphragmatic hernia. A minimally invasive approach avoided extensive open surgery and the complications that would come with it for a young nursing mother.

Conclusion

Such technically challenging cases can be successfully managed with a minimally invasive approach using sound surgical skills and necessary improvisations.

Highlights

• Idiopathic incarcerated diaphragmatic hernia in a young adult female

• Combined laparoscopic-thoracoscopic approach utilized

• Challenging case managed successfully with sound skills and improvisation

Keywords

Laparoscopy
Thoracoscopy
Diaphragm
Hernia
Perforation
Case report
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pmc1 Introduction

A diaphragmatic hernia is a protrusion of abdominal contents through a defect within the diaphragm into the corresponding thoracic cavity [1]. It was first reported by Lazarus Riverius during the post-mortem examination of a 24-year-old male [2].

Diaphragmatic hernia is most commonly congenital due to improper fusion of the embryological components forming the diaphragm. Congenital diaphragmatic hernia (CDH) has an incidence of 0.8–5/10,000 live births [3]. CDH interferes with normal lung development resulting in fetal and neonatal complications.

Diaphragmatic hernias may also rarely be acquired, most commonly occurring as a result of blunt trauma with concurrent injuries. The incidence is <1 % in all trauma [4], rising to 3 % in abdominal injuries [5]. The mechanism suggested is a sudden increase in pleuroperitoneal pressure gradient, surpassing the diaphragmatic tensile strength and leading to rupture at areas of potential weakness along embryological fusion points [[6], [7], [8]]. Acquired diaphragmatic hernia (ADH) can also extremely rarely occur iatrogenically or spontaneously, with just a handful of case studies of the same [9]. Sometimes, these injuries may go undetected or untreated and present as a chronic condition where diaphragmatic rents increase in size over time, eventually leading to herniation and subsequent complications.

ADH is a life-threatening condition due to its propensity to cause abdominal visceral incarceration and gastrointestinal strangulation with an overall mortality rate of up to 31 % [6]. Herniation of the stomach, small bowel, mesentery spleen, and pancreas have all been documented [6].

The treatment of ADH is essentially operative, regardless of the presentation. The surgical approach utilized depends on several factors such as the patient's haemodynamic stability, other associated injuries, and the surgeon's expertise. The most common approach remains a formal laparotomy following the principles of operative trauma. In case of a chronic injury, some time may be afforded to allow optimization of the patient and surgery in a semi-elective setting with a minimally invasive approach. Whichever approach is opted for, the principles of surgery remain the same – identification of the defect, reduction of herniated contents, and repair of the diaphragm. As with any hernia, a tension-free repair is essential to prevent failure or recurrence. An optimal surgical repair along with sound perioperative care is fundamental to the successful management of these patients.

The following case report is of an idiopathic incarcerated diaphragmatic hernia with a perforated stomach in a young adult female which was managed by a combined laparoscopic-thoracoscopic approach. Along with the text are the operative videos of the same, showcasing the technical challenges faced and the improvisations made to deal with them.

The following work hereby presented has been reported in line with the SCARE Surgical Case Report criteria [10].

2 Presentation of case

Our patient was a 27-year-old lactating mother hailing from rural Kashmir. Her primary complaint was pain in the upper abdomen for the past 5 days, which was moderate in intensity to begin with but had become increasingly severe since the past 1 day, prompting referral to a tertiary care centre. The pain was aggravated with oral intake and associated with nausea and breathlessness.

A thorough history was taken, which revealed little further clues to the diagnosis. There was no history of any trauma. The patient gave birth to a healthy child 6 months back through a normal vaginal delivery and was still in lactational amenorrhea.

At presentation, the patient was conscious, oriented, and hemodynamically stable. She was maintaining an oxygen saturation of 90 % on room air. Chest examination was significant for decreased breath sounds over the left lower lung zones. Abdominal examination revealed distension and tenderness over the epigastric area.

We then proceeded to investigate the patient. The complete blood picture was normal with no leucocytosis. The biochemistry revealed an elevated serum amylase to the order of 835 U/L, suggesting a provisional diagnosis of acute pancreatitis. Other biochemical parameters were all within normal limits. However, the most striking investigations, and those which turned the diagnosis on its head, were the chest and abdominal X-rays (Fig. 1, Fig. 2) which showed the presence of the gastric air bubble in the left thoracic cavity, suggesting the rare possibility of a diaphragmatic hernia.Fig. 1 Chest X-ray showing the presence of gastric air bubble in the left thorax.

Fig. 1

Fig. 2 Abdominal X-ray showing the same findings of diaphragmatic hernia.

Fig. 2

An ultrasound scan was also done, which revealed left-sided pleural effusion, but no other significant abdominal findings. Following these investigations, a contrast-enhanced CT scan was carried out (Fig. 3). It reported a 25 mm defect in the middle portion of the left diaphragm with herniation of the stomach fundus through the defect into the left hemithorax causing loss of left lung volume along with moderate pleural effusion. The right lung fields and the rest of the abdomen and pelvis were unremarkable for any other findings.Fig. 3 CECT scan demonstrating findings of diaphragmatic hernia.

Fig. 3

The pleural fluid analysis showed a polymorphic leucocytosis, and an exudative effusion as per Light's criteria. Serum lipase was normal, and all other causes of pancreatitis were investigated for and ruled out.

With the patient developing a rising trend of leucocytosis and dropping oxygen saturation to below 70 % on room air, the decision was made to operate the patient through a laparoscopic approach using single lung ventilation with the help of a double lumen endotracheal tube. A total of seven ports were utilized – 4 abdominal ports followed by a further 3 thoracic ports (Fig. 4).Fig. 4 Port placement utilized for the surgery.

Fig. 4

See Inline Supplementary Video 1

Inline Supplementary Video 1

Introduction to the case

Inline Supplementary Video 1

A supraumbilical incision was made and pneumoperitoneum was created using the closed technique. Upon entry into the abdomen, a quick diagnostic laparoscopy was performed to identify the diaphragmatic rent with incarceration of the stomach and omentum. The abdominal working ports were then inserted as shown in the figure above.

Attempts were made to reduce the herniated contents but adhesions were encountered. The rent was further widened using a monopolar energy device followed by an ultrasonic scalpel. On opening up the rent, sero-purulent fluid was found pouring from the thoracic cavity into the abdomen.

The widening of the defect enabled the reduction of the herniated omentum. The scope was then passed through the rent and up into the left hemithorax. The entire left pleural cavity was filled with stomach contents, pus flakes, and infected fluid which was promptly aspirated.

See Inline Supplementary Video 2

Inline Supplementary Video 2

Diagnostic laparascopy and adhesiolysis

Inline Supplementary Video 2

The difficulty encountered in reducing the hernia through an abdominal approach made us opt for a thoracic approach. A thoracic optical port was inserted which further revealed the extent of local contamination. Thoracic working ports were inserted and finally, with a combination of traction from above and below, the herniated stomach was reduced into the abdomen.

On inspecting the stomach, a large perforation was found along the greater curvature near the fundus. The anaesthetist was asked to insert a nasogastric tube which was quickly passed along beyond the perforation into the distal portion of the stomach. Given the extensive size of the perforation, a stapled resection was performed using a 60 mm linear endo stapler.

See Inline Supplementary Video 3

Inline Supplementary Video 3

Thoracoscopy, hernia reduction and stomach resection

Inline Supplementary Video 3

Following this, generous lavage and aspiration were performed in the thoracic cavity. We then proceeded to repair the diaphragmatic rent from the thoracic side as it provided better visualization and convenience in suturing. Since the thoracic working ports were only 5 mm in size, the suture was introduced through an abdominal working port and passed into the thorax through the rent. The margins of the defect were freshened and a primary repair was performed using 2–0 barbed delayed absorbable sutures in a continuous manner. The repair was done primarily without the use of a mesh given the extensive contamination present.

See Inline Supplementary Video 4

Inline Supplementary Video 4

Repair of diaphragm

Inline Supplementary Video 4

After the repair was complete, the anaesthetist was asked to inflate the left lung which expanded well. Final lavage of the abdomen was done and the specimen was retrieved. Lastly, an intercostal chest tube was placed to facilitate drainage of any residual effusion, along with an abdominal drain.

See Inline Supplementary Video 5

Inline Supplementary Video 5

Lavage and lung expansion

Inline Supplementary Video 5

The patient remained stable in the post-operative period, initially requiring intensive care but with quick improvement was shifted to regular inpatient care. The post-operative X-ray is shown (Fig. 5). Following clinical improvement, the nasogastric tube was removed on POD3 and the patient was initiated on clear oral liquids. The patient was weaned off oxygen support and the intercostal chest tube was removed on POD5. The abdominal drain was removed on POD7 and the patient was discharged satisfactorily. Sutures were removed on the first follow-up after a week. The patient remained on regular follow-up, with no further complications.Fig. 5 Post-operative day 1 chest X-ray.

Fig. 5

See Inline Supplementary Video 6

Inline Supplementary Video 6

Post-operative course

Inline Supplementary Video 6

3 Discussion & conclusion

The case report outlines the successful management of an idiopathic incarcerated diaphragmatic hernia with a perforated stomach through a unique combination of laparoscopy and video-assisted thoracoscopy. It yet again highlights the unpredictability of surgery and the adversities posed to a surgeon. However, with sound surgical skills and the incorporation of necessary improvisations, such technically challenging cases can be managed smoothly.

The use of a combined laparoscopic and thoracoscopic approach has been well published in literature primarily for diaphragmatic hernias and esophageal malignancies [[11], [12], [13]] but also for rare conditions such as hepatocellular carcinoma [14], epiphrenic diverticulum [15] and retroperitoneal compound paraganglioma [16].

A combined approach was described for a large traumatic diaphragmatic hernia by Zubaidah et al. in 2015 [17]. It has also been published for congenital diaphragmatic hernia in a child [18], in an adult [19] and with right-sided intrathoracic kidney [20]. Similar to the case described in this report, the use of a combined laparoscopic and thoracoscopic approach in an emergency setting in India was published by Gandhi et al. in 2019 for tension gastrothorax in a foramen of Bochdalek hernia [21].

The use of a minimally invasive approach avoided the formal laparotomy and possible additional thoracotomy which such a case would usually entail, and the complications that would have come with it to a young nursing mother. It allowed for an earlier and easier recovery, minimizing the inevitable post-operative respiratory complications, especially since the patient was already compromised from a respiratory standpoint before surgery. It is to be remembered that such cases not only rely on fine surgical expertise but also anaesthetic proficiency, the unwavering support of whom is invaluable to performing such a procedure.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Identifying details of the patient have been omitted.

Ethical approval

The study is exempt from ethnical approval in our institution.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Prof. (Dr.) Iqbal Saleem Mir: Paper concept and design, primary operating surgeon.

Dr. Abdul Hamid Samoon: Paper concept and design.

Dr. Arshad Rashid: Data collection, writing the paper.

Dr. Refut Arah: Data collection.

Dr. Mosin Mushtaq: Data collection, operating surgeon.

Dr. Rishab Pamecha; Data collection, writing the paper, assisting surgeon.

Guarantor

Prof. (Dr.) Iqbal Saleem Mir.

Research registration number

None.

Conflict of interest statement

The authors have no sources of funding or conflicts of interest to disclose.
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