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Laparoscopic Sleeve Gastrectomy in a patient with agenesis of the left hemidiaphragm

C Hassan, LF Gonzalez Ciccarelli, A Gangemi, M Masrur, F Bianco, P Quadri, L Sanchez-Johnsen, P Giulianotti. University of Illinois at Chicago

Introduction: Diaphragm agenesis (DA) is the most severe form of a diaphragmatic defect and a rare occurrence in adults. DA has a high mortality ranging from 40-60% and is associated with lung and cardiac anomalies. We present a case of an asymptomatic 58-year-old female with an incidental intraoperative finding of a left hemi-diaphragm agenesis concurrently with a sleeve gastrectomy.

Methods and Results: 58-year-old female patient with a BMI of 40 kg/m2 and a past medical history of overactive thyroid and a bilateral total hip replacement. As part of the pre-surgical evaluation, a fluoroscopy and chest x-ray showed an elevation of the left hemi-diaphragm concurrent with a type II para-esophageal hernia of the stomach and stasis of contrast in the stomach. The patient elected to undergo a laparoscopic sleeve gastrectomy and a repair of para-esophageal hernia.

Diagnostic laparoscopy was performed with no visualization of a para-esophageal hernia. An incidental finding of a complete absence of the left hemi-diaphragm with an open communication between the abdomen and the left thorax was diagnosed. The stomach was mostly intrathoracic extending into the apex of the left chest. The pylorus was identified 10 cm to the left of the falciform ligament. Visualization and dissection of the short gastric were was extremely difficult due to the thoracic location of the spleen. Creation of pneumoperitoneum caused supraventricular tachycardia due to the pressure on the heart. There was no attempt to repair the defect due to the patient age, asymptomatic history and complexity of the repair. Standard sleeve gastrectomy was performed using a 40 French Bouguie. Intraoperative air-leak test was negative. Operative time was 116 minutes with an estimated blood loss of approximately 5 ml. Postoperative fluoroscopy showed no evidence of contrast extravasation. Patient was discharged tolerating a liquid diet on postoperative day one. Postoperative course was uncomplicated. Patient was doing well at one month follow up.

Conslusion: Sleeve gastrectomy surgery was performed with a patient who had left hemi-diaphragm agenesis and this procedure appeared to be safe and feasible. Even with a thorough preoperative evaluation, the diagnosis of asymptomatic DA is difficult task.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 95860

Program Number: V369

Presentation Session: Video Loop Day 4

Presentation Type: VideoLoop

38

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