Traumatic diaphragmatic hernia: Management by video assisted thoracoscopic repair.

Report of the use of video assisted thoracic surgery for traumatic diaphragmatic hernia repair in two children.

INTRODUCTION

Isolated diaphragmatic injuries are rare in children[1] and are traditionally managed by laparotomy or thoracotomy. Nowadays, increasing numbers of adult patients are being treated using minimally invasive surgery.[23] We report two children in whom video assisted thoracic surgery (VATS) repair of traumatic diaphragmatic hernia was successfully done.

CASE REPORTS

Case 1

A 12-year-old boy presented with trauma to upper abdomen during Karate practice. It was followed by sudden onset chest pain and dyspnoea. The patient was tachypnoeic with diminished air entry in left hemithorax. There were no abdominal signs. The chest radiograph (CXR) was suggestive of left hydropneumothorax. A computed tomogram (CT) scan showed left sided traumatic diaphragmatic hernia [Figure 1] and ruled out any abdominal injury. The patient underwent VATS, which revealed spleen, stomach, large gut and omentum inside the chest cavity [Figure 2]. After reduction of the hernial contents, the diaphragmatic defect was identified [Figure 3] and repaired using interrupted 2/0 Polyester sutures [Figure 4].

Figure 1

CT Scan showing bowel loops inside left hemithorax

Figure 2

Thoracoscopic view showing spleen, stomach and omentum inside left hemithorax

Figure 3

Thoracoscopic view showing diaphragmatic tear

Figure 4

Thoracoscopic view after complete repair of traumatic diaphragmatic hernia

Case 2

A 1.5-year-old boy presented to a peripheral hospital 2 days after blunt chest trauma due to fall over a stone. The patient had respiratory distress with diminished air entry in left hemithorax and had no signs of abdominal injury. Initial CXR showed haziness over left hemithorax for which intercostal drain (ICD) was placed which drained blood. The patient was referred to our hospital 8 days after trauma. When the drain output decreased, ICD was removed. Post ICD removal CXR showed that the stomach was completely displaced inside the thorax. At VATS, we found the stomach, spleen, greater omentum, and loops of the small intestine in the thorax. The hernial contents were reduced and the defect was repaired as in the previous case.

OPERATIVE TECHNIQUE

VATS repair was performed under general anesthesia with conventional endotracheal intubation in lateral position. The first port was placed at mid axillary line in the 3rd intercostal space. A 5 mm, 30 degree telescope was used. CO2 gas was insufflated through telescopic port for pressure augmented reduction of hernial contents. Initially, low pressure and low flow rate was used, however higher pressures upto 10-12 mmHg and flow rate of 5-6 litres /minute were required for complete reduction of the hernial contents. After reduction, lower pressure of 6-8 mmHg with flow rate of 1 litre/min could be used. Two working ports were placed under vision; one at the anterior axillary line in the 4th intercostal space and another in the posterior axillary line in the 5th intercostal space for needle holder and Maryland forceps respectively. 5 mm hand instruments were used for the first case, while 3 mm instruments were used for the second. The diaphragmatic tears were sutured using nonabsorbable 2-0 polyester sutures tied intracorporeally. An intermittent mattress suture technique permitted approximation without tension. The chest tubes were removed once ICD column movement stopped.

RESULTS

The minimally invasive approach was successful in both patients. No patient required conversion. Mean operating time was 130 minutes (range: 120–140 minutes). Intraoperative blood loss was minimal. Both the patients tolerated the procedure very well, were extubated immediately after surgery. Mean duration of ICD was 3 days. No recurrences were detected by radiologic imaging or ultrasonography on follow-up after 2 and 3 years.

DISCUSSION

Traumatic rupture of diaphragm occurs in up to 5% of trauma patients requiring laparotomy.[45] The chest radiographs may be initially normal in 30% to 50% of cases.[6] Therefore, repeat radiographs should be obtained in a suspected case of diaphragmatic injury. The diagnosis can be confirmed by intestinal contrast studies. These may not be possible in all patients, wherein CT with multiplanar reconstruction may be helpful. Recently, laparoscopy and thoracoscopy were reported to be helpful in both the diagnosis and treatment of traumatic diaphragmatic rupture.[78] In a study by Bagheri et al., the diagnostic accuracy of thoracoscopy in occult diaphragmatic injury after penetrating injury was 100%.[9] Laparoscopic repair has also been done successfully.[10] However, all the cases reported are in adults and there have been no reports of thoracoscopic diaphragmatic tear repair in children so far.

If intra-abdominal injuries can be excluded, by a detailed clinical examination along with radiological investigations, a minimally invasive surgical approach may be preferred. However, in acute setting thoracoscopy may miss associated intra-abdominal injuries. Even CT scan can miss the same. According to Meyer et al. the laparoscopic approach has the significant advantage of being able to reposit herniated abdominal organs more easily with excellent visualization of abdominal organs, especially the spleen and liver.[11] However, two prospective studies have described penetrating intestinal injuries that were missed during laparoscopy.[1213]

Martin et al. described four patients diagnosed at laparoscopy with a ruptured diaphragm. One patient had a left-side rupture amenable to laparoscopic repair. Three patients underwent laparoscopy, which revealed two right-sided and one extensive left-side rupture, both requiring conversion.[8] Because of liver bulk, right-side ruptures are not amenable to laparoscopic repair, however can be repaired thoracoscopically. Tension pneumothorax has been described during laparoscopy with a diaphragmatic defect. By performing gasless laparoscopy using an abdominal lifting device, this can be minimized. Power et al. also experienced a significant loss of insufflatory pressure and observed a tension pneumothorax during the laparoscopic procedures. They recommend to place a chest tube before a pneumoperitoneum is created.[14] Meyer et al. recommend that if a chest tube is necessary, it should be introduced under direct visual control during laparoscopy.[11]

There have been single reports of successful repairs using VATS in adults.[2715] Kurata et al. expressed their preference for thoracoscopic approach for diaphragmatic tear because of pulmonary complications due to the pneumoperitoneum during laparoscopy.[7] Thoracoscopic approach can facilitate the reposition of herniated abdominal organs in chronic traumatic diaphragmatic hernias. However, Jackson and Ferreira showed that intrapleural adhesions may occur as early as 24 hours after trauma, and that these adhesions may make a thoracoscopic approach more difficult.[2] Also, single-lung ventilation and lateral positioning during thoracoscopy may pose a problem if the patient requires laparotomy for other reasons during the procedure. However, there were no adhesions and difficulty during the diaphragmatic repairs in our experience. In our both the cases double lung ventilation was used without any difficulty during the procedure. Koehler and Smith used thoracoscopy to repair penetrating diaphragmatic rupture in two patients. They suggested that combined thoracoscopy and laparoscopy may offer both therapeutic and diagnostic benefits in stable patients with penetrating injuries.[15]

Various techniques have been used for diaphragmatic repair. Hernia stapler has also been used as it is easy to handle and keeps operating time to a minimum.[15] We used mattress sutures because they offer greater stability and strength. Use of alloplastic mesh was reported by Rau et al. in some cases with an older defect to achieve adequate closure.[16] However, in our opinion in most cases of acute traumatic rupture, direct suture should be possible. Rasiah and Crowe[17] described an alternative suture method that they used to repair a tear near the costal margin—an unusual location for a diaphragmatic hernia. The suture was passed through the abdominal wall, and the knot was tied on top of the outer fascia through a separate skin incision. However, in most cases, the ruptures are located centrally and this technique is not applicable.

Ben has stated that in stable patients, VATS is safe and well tolerated by the patients, with less post-operative morbidity and better cosmesis.[18] We believe that VATS is indicated in select cases, who are hemodynamically stable and are able to tolerate pressure carbopneumothorax in lateral position for 2-3 hours and not have solid or hollow visceral injury. This is certainly a limitation to the number of patients that can be chosen for this procedure.

CONCLUSIONS

VATS is feasible in stable children with suspected isolated diaphragmatic tear following trauma both as a diagnostic and therapeutic tool. Careful case selection is essential to success of this procedure.