Incarcerated Diaphragmatic Hernia After Convergent Maze Procedure

Tejwant S Datta, MD, John P Breard, MD, Thomas Guirkin, MD

Southside Regional Medical Center

Background: The convergent maze procedure (CMP) is a minimally invasive technique used for the surgical treatment of atrial fibrillation (AF). This technique combines an epicardial and endocardial ablation using radiofrequency energy. The endocardial component is performed via a venous catheter, usually placed in the femoral vein. The epicardial ablation is performed via an abdominal incision and transdiaphragmatic trocar (nContact, Inc., Morrisville, NC). We present a case report of a patient with an incarcerated hernia through the transdiaphragmatic window used for convergent maze procedure.

Case: EP is a 65 year-old African American male who presented to the emergency department with acute onset epigastric abdominal pain with nausea. His surgical history is significant for convergent maze procedure (performed at another institution) five months prior to his presentation. He was initially diagnosed with a partial small bowel obstruction and treated conservatively with nasogastric tube decompression and bowel rest. His obstruction resolved, but he developed high fevers and recurrent epigastric symptoms. A repeat CT scan demonstrated pneumopericardium, but was further clarified, showing a diaphragmatic hernia containing transverse colon. EP was taken to the OR for laparoscopic reduction of the hernia with repair using two Ventralex™ hernia patches (Bard Davol, Inc. Warwick, RI). EP was uneventfully discharged and was free of symptoms on surgical follow-up.

Conclusion: Convergent maze procedure is a relatively new surgical technique used to treat patients with AF. To our knowledge, this is the first reported case of diaphragmatic hernia with bowel incarceration after CMP. More data is required to determine the incidence of diaphragmatic hernia after CMP. Early suspicion and diagnosis is essential to prevent mediastinal sepsis. Laparoscopic repair of incisional diaphragmatic hernias after CMP is feasible.

Session: Video Channel Day 1

Program Number: V037

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