Acute pancreatitis secondary to an incarcerated diaphragmatic hernia repaired laparoscopically with mesh

Ricardo Mohammed, DO, Richard Y Greco, DO, Jennifer To, DO, Robert Madlinger, DO, FACOS, Erwin Douyon, MD

St. Joseph’s Regional Medical Center

The majority (90%) of diaphragmatic herniations occur on the left side because of the protection offered by the liver on the right, and the relative weakness of the posterolateral aspect on the left side as it originates from the pleuroperitoneal membrane. A hernia that develops in this area is known as a Bochdalek’s hernia and usually presents at birth resulting from the failure of closure of the pleuroperitoneal canal.3 Traumatic diaphragmatic ruptures may be missed in up to 40-62% of cases and have been diagnosed 50 years later. These patients may present with multi-visceral herniation with or without signs of intestinal strangulation or cardiovascular collapse and may require immediate resuscitation and operative intervention.
We present here a case of pancreatitis secondary to an incarcerated diaphragmatic hernia in a middle-aged man with no known history of trauma that was repaired laparoscopically with mesh. He had a chest x-ray that revealed the presence of intestine in the left hemithorax and after a subsequent CT scan revealed an incarcerated left diaphragmatic hernia containing pancreas, spleen, and splenic flexure, as well as gastric volvulus he underwent laparoscopic reduction and repair of the hernia with mesh.

Acute pancreatitis secondary to an incarcerated diaphragmatic or paraesophageal hernia is a very unusual presentation. Due to the retroperitoneal location and attachments of the pancreas this has rarely been reported in the literature. The mechanisms of pancreatitis have been thought to be due to the repetitive trauma to the pancreas as it crosses the hernia defect with traction on the vascular pedicle of the pancreas, leading to anoxia and ischemia of the pancreas, or as a result of the intermittent folding of the pancreatic duct.

There are only a few reports in the literature of repairing diaphragmatic defects with incarceration of the pancreas in the thorax or mediastinum. Laparoscopic repair of diaphragmatic defects is an acceptable therapeutic option and obviates the need to open the abdominal or thoracic cavity in carefully selected cases, but should be considered carefully if solid organ or bowel injury is anticipated. It is very important to establish the diagnosis early and be aggressive with operative intervention as the morbidity and mortality can approach 20 to 50% with emergent surgery.

Session: Poster Presentation

Program Number: P552