John P Skendelas, MD, Jody Kaban, MD, FACS, Ajay Chopra, MD. Albert Einstein College of Medicine / Jacobi Medical Center
Introduction: Post-traumatic diaphragmatic hernias with delayed presentation are an insidious clinical entity with variable presentation following blunt thoracoabdominal trauma. While the majority of these injuries are identified early and amenable to laparoscopic repair, symptoms may develop years or even decades following injury. The true incidence of these injuries remains elusive and only a constellation of case reports exist highlighting their complexity.
Case Presentation: Here we report the case of a 33 year old male with history of blunt thoracic injury 20 years prior who presented with dyspnea on exertion and chest x-ray findings consistent with left diaphragmatic hernia containing the stomach, pancreas, small bowel, and colon. The patient underwent comprehensive preoperative evaluation and consented to procedural intervention. The surgery began with a laparoscopic approach, allowing for complete reduction of the foregut contents; however, the limited insufflated space was quickly obliterated. To proceed, a left thoracotomy was made for further visualization and attempted takedown of dense colonic adhesive attachments. This too posed challenging and required midline laparotomy for definitive adhesiolysis, colonic hernia reduction, and esophageal hiatus reconstruction with an overlay 9cm partially-absorable lightweight mesh. Due to difficult ventilation and the risk of abdominal compartment syndrome, the patient remained intubated post-operatively. The abdomen was partially closed with a Wittman’s patch.
The patient returned to the operating room on POD#1 for persistent air leak, left lower lobe wedge resection, and reduction of recurrent diaphragmatic hernia. Primary abdominal closure occurred on POD#5. Post-operative recovery was prolonged by left lower lobe MSSA pneumonia with discharge on POD#31. The patient was followed closely in the outpatient setting until recognition of left lung empyema on POD#56, which required chest tube drainage. At this point, the role of decortication was proposed to the patient, who refused. Instead, intrapleural irrigation using piperacillin/tazobactam was administered for 14 days with resolution of the patient’s underlying symptoms, leukocytosis, and radiologic evidence of empyema. The patient remained well on last follow up appointment 10.5 months after the index operation.
Conclusion: Management of longstanding diaphragmatic hernias pose a complex clinical problem whose solutions are highly dependent on the chronicity and magnitude of thoracic herniation. Anticipation of intra- and post-operative complications is integral to recognize the need for a thoracic surgeon or open thoracoabdominal operative approach to address limitations of laparoscopy, for the takedown of dense thoracic adhesions or loss of abdominal domain, as evident in this case of massive herniation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92488
Program Number: P535
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster