Victoria Needham, MD, Alexandra Argiroff, MD, Diego Camacho, MD. Montefiore Medical Center
INTRODUCTION: While many diaphragmatic hernias (congenital or acquired) are asymptomatic, they may also present with subacute symptoms such as pain or dypsnea, or as a surgical emergency via organ strangulation. This case scenario illustrates an atypical presentation of a perforated viscus within the hernia sac leading to enterocutaneous fistula.
CASE REPORT: An 83-year-old female with a surgical history inclusive of hiatal hernia repair and multiple ventral hernia repairs presented to the emergency room with purulence from her left breast, after drainage of a breast abscess earlier that day in clinic. Upon review of her recent mammogram noting bowel loops in the left chest, the patient was directed to the emergency room for further workup. CT scan was performed showing a colon-containing diaphragmatic and ventral hernia protruding between left-sided ribs, with an overlying left breast collection, concerning for enterocutaneous fistula (Picture 1). She had normal vitals, laboratory results, and a benign abdominal exam. Decision was made for operative exploration after preoperative medical clearance.
An open incision was made via an existing upper abdominal chevron scar, revealing a mesh directly under the subcutaneous tissue. The mesh was opened and extensive lysis of adhesions was performed in the left upper quadrant, revealing a colon-containing hernia sac through the diaphragm and through the left lateral ribs into the breast (Picture 2). The hernia sac was dissected down into the abdominal cavity, revealing extensive colonic diverticulosis and inflammation as well as a perforated diverticulum with surrounding abscess. The distal transverse colon and splenic flexure were completely mobilized, and a segmental colectomy was performed to include the area of involved pathology, with primary anastomosis. Remaining hernia sac was dissected to identify clean fascial edges, and the diaphragmatic defect was repaired primarily (Picture 3). The patient’s postoperative course was uncomplicated.
CONCLUSIONS: It is important to consider unusual presentations of diaphragmatic hernia, including pathologies arising from any of the organs contained in the hernia sac, such as illustrated in this case report. Upon operative exploration, the hernia sac and its contents should be dissected from the chest, the diaphragmatic defect cleared, and in the absence of contraindications (such as contamination in our case), a mesh should be placed to reinforce the repair. If technicaly feasible, a laparoscopic abdominal approach is preferred to an open approach. In certain cases, transthoracic approach may be necessary to release long-standing adhesions.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95711
Program Number: P463
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster