Combined mini-invasive endoscopic-laparoscopic treatment of an acute post-traumatic diaphragmatic hernia

F. Villa, M. Marengo, I. Marsteller, A. Guerra

Objective

To demonstrate that a combined mini-invasive endoscopic-laparoscopic treatment may be a safe and effective alternative to reduce a complicated acute diaphragmatic hernia.

Methods

We present the case of a 26-year-old man with sudden onset of heavy epigastric pain, vomiting and aphagia. One year before, he has had a blunt throracic trauma with left-sided multiple rib fractures and left-sided hemopneumothorax. An acute complicated diaphragmatic hernia was suspected. The working hypothesis was confirmed by contrast-enhanced CT scan, gastrografin swallow and finally by exploratory laparoscopy in combination with intraoperative upper endoscopy. Of note, that no hernial defect had been reported on previous CT scans.

Results

The patient underwent exploration in our emergency operating room. Initially, an exclusive endoscopic approach to reduce the hernia failed. The parallel endoscopic-laparoscopic approach provided evaluation of the gastric mucosa (hypoxic pattern) and endoscopic decompression with further local guidance of the surgeon, thus allowing a speedy reduction of the herniation through the defect. The reduction of the hernia and direct closure of the diaphragmatic defect was performed with multiple non-absorbable suture. The defect resulted 4 cm in diameter, and was located at 3 cm distance in left-lateral position to the esophageal hiatus. No perioperative complication occured.

Conclusion

Best surgical corrective procedure is controversial in treating symptomatic diaphragmatic hernias. However, there is evidence that mini-invasive techniques should be preferred even in the case of major complications, in order to avoid pain, blood loss and long-term hospital stay. In this report, we describe a successful combined mini-invasive endoscopic-laparoscopic treatment of an acute diaphragmatic hernia with gastric strangulation and ischemia, one year after blunt thoracic trauma. This report supports further research on combined mini-invasive approaches for treatment of acute diaphragmatic hernias.