James P Byrne, MD, Fayez Quereshy, MD, MBA, Timothy Jackson, MD, MPH, Allan Okrainec, MD, MHPE. University of Toronto
Diaphragmatic hernia is a rare condition in adults, most often traumatic in origin. Diaphragmatic injury occurs in 2.5-5% of blunt abdominal trauma, less than 20% in the right hemidiaphragm. Difficult to diagnose, 30-50% of diaphragmatic injuries are missed during the acute admission. As a result, patients may present years later with life-threatening visceral herniation. Repair is traditionally performed by open thoracic or abdominal approaches.
We present the case of a 40-year-old woman with a right-sided diaphragmatic hernia complicated by strangulation of the right colon. The patient had a history of motor vehicle collision years previously, following which no significant injury was identified. Reduction and primary repair of the diaphragmatic hernia was undertaken and completed successfully by laparoscopic approach. Right hemicolectomy with intracorporeal anastomosis was performed, as the right colon was not viable. Postoperatively, a right tube thoracostomy was inserted.
We found laparoscopy a safe and convenient approach to this acute surgical emergency. Excellent visualization of the right hemidiaphragm and hernia was attained, and with careful selection of port placement, repair was highly feasible. The patient’s postoperative course was uneventful, and she was discharged home in timely fashion on postoperative day 3. The usual benefits of laparoscopic surgery, namely reduced postoperative pain and quick recovery of gastrointestinal function, were observed. She remains well at 3-month follow-up.
Where laparoscopic expertise exists, repair of right diaphragmatic hernia complicated by acute incarceration or strangulation of bowel may be safely attempted by laparoscopic approach.