Right diaphragmatic iatrogenic hernia after laparoscopic fenestration of a liver cyst: report of a case and review of the literature

  • Mehdi Soufi1, 2, 3Email author,

    Affiliated with

    • Hélène Meillat1 and

      Affiliated with

      • Yves-Patrice Le Treut1

        Affiliated with

        World Journal of Emergency Surgery20138:2

        DOI: 10.1186/1749-7922-8-2

        Received: 16 September 2012

        Accepted: 20 December 2012

        Published: 3 January 2013

        Abstract

        Iatrogenic right diaphragmatic hernia is very rare. We report the first case of a patient who had a diaphragmatic hernia after laparoscopic fenestration of liver cyst. A herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Diaphragmatic hernias are not as common as the traumatic type. Surgeons can easily miss diaphragmatic injuries during the operation especially after laparoscopy. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. Ct scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients. The incidence of iatrogenic diaphragmatic hernia after surgery may be reduced if the surgeon checks for the integrity of the diaphragm before the end of the operation. A review of the literature is also performed regarding this rare complication.

        Keywords

        Diaphragm injury Iatrogenic right diaphragmatic hernia Laparoscopic Fenestration of liver cyst Central tendon of the diaphragm

        Introduction

        Liver cysts are benign congenital malformations resulting from isolated aberrant biliary ducts [1]. Laparoscopic fenestration is the treatment of choice for symptomatic simple liver cysts. The indication for surgery should be limited to symptomatic, which involves 5% to 10% of all liver cysts [2]. Acquired diaphragmatic hernias are generally the result of blunt or penetrating thoraco-abdominal trauma or iatrogenic injury [3]. Postoperative iatrogenic diaphragmatic hernia right is very rare. We describe a iatrogenic right diaphragmatic hernia after laparoscopic fenestration of right liver cyst.

        Case report

        A 61-year-old female with a past medical history of laparoscopic fenestration, one year ago, of a huge right liver benign cyst (Figure 1) presented to our department with right upper abdominal and thoracic pain without vomiting. Chest x-ray showed an elevated right hemidiaphragm. Abdominal examination was normal. Computed tomography CT- scan showed a right posterior diaphragmatic hernia and passive atelectasis due to an ascent of the colon with corresponding mesos and Omentum in the chest cavity (Figures 2 and 3). Laboratory tests showed no abnormality. After coeliotomy through right subcostal incision and reduction of the herniated organs, a defect 10 cm in diameter was found at the central tendon of the right diaphragm. Direct herniorrhaphy of the diaphragmatic defect was easily carried out. The patient had an uneventful postoperative recovery and the thoracic drain was removed on the second postoperative day. The patient was discharged on the seventh postoperative day.
        http://static-content.springer.com/image/art%3A10.1186%2F1749-7922-8-2/MediaObjects/13017_2012_279_Fig1_HTML.jpg
        Figure 1

        CT scan showing the 20 x 14 cm simple liver cyst.

        http://static-content.springer.com/image/art%3A10.1186%2F1749-7922-8-2/MediaObjects/13017_2012_279_Fig2_HTML.jpg
        Figure 2

        CT scan Transversal computed tomography (CT) showing the loop of colon in the right-sided diaphragmatic hernia.

        http://static-content.springer.com/image/art%3A10.1186%2F1749-7922-8-2/MediaObjects/13017_2012_279_Fig3_HTML.jpg
        Figure 3

        CT scan Transversal computed tomography (CT) showing the loop of colon in the right-sided diaphragmatic hernia.

        Discussion

        Surgery is the mainstay of therapy in benign liver cyst. Lin and al [4] first described the technique of fenestration or deroofing of the cysts in 1968 and laparoscopic fenestration was first reported in 1991. Many complications have been reported such as bile leakage, ascites and pleural effusion [5]. In our knowledge, a right diaphragmatic hernia after laparoscopic fenestration of a liver benign cyst had never been reported in the literature review. It’s the originality of our case.

        The diaphragmatic hernia is a herniation of abdominal structures within the thoracic cavity. It can be either congenital or acquired. Diaphragmatic acquired defects are most commonly traumatic in origin, followed by iatrogenic lesions and spontaneous defects [3]. These are usually on the left side, attributed to the cushioning effect of the liver protecting the right hemidiaphragm [3]. Right-sided traumatic diaphragmatic hernias are more often related to penetrating injuries, but may also occur as a complication of surgery. Iatrogenic right diaphragmatic hernias have been reported after laparoscopic cholecystectomy [6], laparoscopic hepatectomy [7], splenectomy [8], laparoscopic gastric banding [9] splenopancreatectomy [10], gastrectomy [11] and after living donor liver transplant [12, 13]. Mostly, this complication has been known to develop after esophagectomy and nephrectomy [1417] (Table 1).
        Table 1

        The characteristics of the reported cases of iatrogenic diaphragmatic hernia

        Case

        Age

        Gender

        Time to diagnosis

        Initial surgical procedure

        Localisation of defect

        Surgical procedure

        Year

        1[6]

        53

        Women

        6 weeks

        Laparoscopic cholecystectomy

        Right

        Thoracotomy

        1999

        2[7]

        31

        Women

        9 months

        Laparoscopic hepatectomy

        Left

        Thoracotomy

        2003

        3[8]

        35

        Women

        24 months

        Laparoscopic gastric banding

        Left

        Laparotomy approach

        2008

        4[9]

        60

        Man

        6 weeks

        Splenectomy for Hydatid cyst

        Left

        Thoracotomy

        2010

        5 [10]

        51

        Man

        4 years

        Splenopancreatectomy

        Left

        Thoracotomy

        2006

        6[11]

        81

        Women

        8 months

        Laparoscopy assisted total Gastrectomy total

        Left

        Laparoscopy

        2012

        7[12]

        44

        Man

        28 months

        Living donor liver transplant

        Right

        Laparotomy approach

        2010

        8[13]

        54

        Man

        3 years

        Right donor and Hepatectomy

        Right

        Thoracotomy

        2006

        9[14]

        50

        Man

        6 months

        Nephrectomy

        Left

        Thoracotomy

        1995

        10[15]

        74

        Man

        5 years

        Nephrectomy

        Right

        Thoracotomy

        1996

        11[16]

        69

        Man

        3 years

        Nissens procedure

        Left

        Thoracotomy

        1996

        11[18]

        39

        Women

        35 years

        Transthoracic oesophagogastrectomy

        Left

        Laparotomy

        1988

        12[19]

        47

        Women

        1 day

        Nephrectomy

        Left

        Thoracotomy

        2008

        13[24]

        60

        Man

        4 months p

        Lung resection

        Left

        Thoracotomy

        2010

        14[25]

        19

        Women

        2 years

        Lower lobectomy

        Left

        Laparoscopy

        2000

        Current study

        61

        Women

        1 year

        Laparoscopic fenestration right liver benign cyst

        Right

        Laparotomy

        2012

        A late presentation of a iatrogenic hernia diaphragm was reported in 5%–62% of cases in different series, with the longest reported delay of 35 years [18].

        Grasping instrument and electrocautery and dissection near of the diaphragm may cause diaphragmatic injuries after surgery. The energy generated by these instruments especially the ultrasonic activated scissor can provoke a weak point in the diaphragm [11].

        That’s why surgeons must be careful handling the instruments, thermofusion and ultrasonic dissector during laparoscopy [6, 19]. A small diathermy injury may not be observed during surgery; any such defect in the diaphragm is likely to increase in size as a result of the gradient of pressure between the abdominal and pleural cavities. This is what probably happened in our patient who had a 10 cm defect.

        Patients with large diaphragmatic defects can have critical problems shortly after surgery due to cardiorespiratory disturbances. Unexplained pain in post operative is not specific but should suspect this complication. Other patients may be asymptomatic or have vague symptoms, which may delay the diagnosis. Our patient presented pain one year after the first surgery. The diagnosis of a cyst recurrence was suspected firstly but not the diagnosis of a diaphragmatic hernia.

        The clinical features are usually chronic symptoms such as upper abdominal and lower chest pain, nausea, dyspnea, and reflux after meals, which may develop into an acute presentation with severe epigastric pain, vomiting, and intestinal obstruction [11, 19].

        The radiological diagnosis is often complex and includes several imaging modalities [18]. Chest radiograph is a good screening examination, but only 50% of patients show an abnormality [18, 19]. CT scan is the best imaging modality to diagnose diaphragmatic hernias. Its sensitivity is high but specificity is only 50% for the right side [20, 21]. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even in asymptomatic patients.

        Some authors think that the thoracotomy is the elective surgical approach that can correct anatomical restoration of the chest and abdominal cavity especially when it is the approach during the initial surgical procedure [2224]. Though patients who had a thoracotomy approach had the longest length of stay with a higher need for postoperative mechanical ventilation than those undergoing an abdominal approach after diaphragmatic hernia repair. Paul et al. found that the thoracotomy approach is an independent predictor of the development of a pulmonary embolism [25]. We think that laparotomy through a right subcostal incision is a more efficient approach into the abdominal cavity.

        Treatment by laparoscopy is feasible with a shorter length of stay. This approach is especially used in left diaphragmatic hernia repair [11, 26].

        Because of liver bulk, right side hernia is not amenable to laparoscopic repair, with a high level of conversion. However some authors described this approach with success [27]. In our patient, the hernia was in the right side of hepatic vein, this was the reason we preferred a laparotomy approach.

        Herniated contents are reduced, the muscular defect is treated and an endothoracic drain is placed [28]. In some cases a bowel resection might be needed in case of ischemia. The mortality following emergency surgery for these cases rises between 20% and 80%. [14, 15].

        The majority of these defects can be repaired safely with non-absorbable sutures without the need for a prosthetic mesh [21, 28]. With an increase in the number of laparoscopic surgery performed, it is likely that this complication will increase. It is therefore important that surgeons be aware of this potentially serious complication by looking to the diaphragm in the end of each surgical procedure [29]

        Conclusion

        Iatrogenic herniation of abdominal contents after laparoscopic fenestration of liver cyst is a rare complication. Iatrogenic diaphragmatic injury can be missed during surgery. Surgeon must take precaution to avoid it by precise dissection when using the instruments during surgery. The incidence of iatrogenic diaphragmatic hernia after surgery may be reduced if a final look of diaphragm is systematically realized at the end of each laparoscopic operation.

        Consent

        Written informed consent was obtained from the patient for publication of this case report and accompanying images.

        Abbreviation

        CT: 

        Computed tomography.

        Declarations

        Authors’ Affiliations

        (1)
        Division of digestive Surgery and transplantation, Hopital de la Conception
        (2)
        Faculty of medicine, University Mohammed First
        (3)
        Division of digestive Surgery, Oujda CHU, University Mohammed first, Faculty of medicine Bp 4847 Oujda University

        References

        1. Fabiani P, Mazza D, Toouli J, Bartels AM, Gugenheim J, Mouiel J: Laparoscopic fenestration of symptomatic nonparasitic cysts of the liver. Br J Surg 1997, 84:321–322.PubMedView Article
        2. Farges O, Bismuth H: Fenestration in the management of polycystic liver disease. World J Surg 1995, 19:25–30.PubMedView Article
        3. Crandall M, Popowich D, Shapiro M, West M: Posttraumatic hernias: historical overwiew and review of the literature. Am Surg 2007, 73:845.PubMed
        4. Lin TY, Chen CC, Wang SM: Treatment of non-parasitic cystic disease of the liver: a new approach to therapy with polycystic liver. Ann Surg 1968, 168:921–927.PubMedView Article
        5. Bai XL, Liang TB, Yu J, Wang WL, Shen Y, Zhang M, Zheng SS: Long-term results of laparoscopic fenestration for patients with congenital liver cysts. Hepatobiliary Pancreat Dis Int 2007, 6:600–603.PubMed
        6. Armstrong PA, Miller SF, Brown GR: Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy. Surg Endosc 1999, 13:817–818.PubMedView Article
        7. Sugita M, Nagahori K, Kudo T, Yamanaka K, Obi Y, Shizawa R, Yoshimoto N, Shimada H: Diaphragmatic hernia resulting from injury during microwave-assisted laparoscopic hepatectomy. Surg Endosc 2003, 17:1849–1850.PubMedView Article
        8. Ajarmeh K, Qassed N, Amireh A, Shuraydeh Z, Shabaneh M, Khraisat K: Iatrogenic left diaphragmatic hernia as a complication of hydatid splenectomy. J R Med Serv 2010,17(Supp 1):75–78.
        9. Boyce S, Burgul R, Pepin F, Shearer C: Late presentation of a diaphragmatic hernia following laparoscopic gastric banding. Obes Surg 2008,18(11):1502–1504.PubMedView Article
        10. Testini M, Vacca A, Lissidini G, Di Venere B, Gurrado A, Loizzi M: Acute intrathoracic gastric volvulus from a diaphragmatic hernia after left splenopancreatectomy: Report of a case. Surg Today 2006,36(11):981–984.PubMedView Article
        11. Suh Y, Lee JH, Jeon H, Kim D, Kim W: Late onset iatrogenic diaphragmatic hernia after laparoscopy-assisted total gastrectomy for gastric cancer. J Gastric Canc 2012,12(1):49–52.View Article
        12. Perwaiz A, Mehta N, Mohanka R, Kumaran V, Nundy S, Soin AS: Right-sided diaphragmatic hernia in an adult after living donor liver transplant: a rare cause of post-transplant recurrent abdominal pain. Hernia 2010, 14:547–549.PubMedView Article
        13. Hawxby AM, Mason DP, Klein AS: Diaphragmatic hernia after right donor and hepatectomy: a rare donor complication of partial hepatectomy for transplantation. Hepatobiliary Pancreat Dis Int 2006, 5:459–461.PubMed
        14. Axon PR, Whatling PJ, Dwerryhouse S, Forrester-Wood CP: Strangulated iatrogenic diaphragmatic hernia: a late complication. Eur J Cardiothorac Surg 1995, 9:664–666.PubMedView Article
        15. Peterli R, Ackermann C, Tondelli P: Incarcerated diaphragmatic hernia as a sequela of iatrogenic diaphragmatic defect. 2 case reports. Chirurg 1996, 67:1050–1052.PubMedView Article
        16. Sancho LM, Paschoalini Mda S, Jatene FB, Rodrigues Junior AJ: Iatrogenic diaphragmatic hernia following abdominal esophagogastrofundoplication: report of a case. Rev Hosp Clin Fac Med Sao Paulo 1996, 51:250–252.PubMed
        17. Aly A, Watson DI: Diaphragmatic hernia after minimally invasive esophagectomy. Dis Esophagus 2004, 17:183–186.PubMedView Article
        18. Johnson CD, Ellis H: Acquired hernias of the diaphragm. Postgrad Med J 1988, 64:317–321.PubMedView Article
        19. De Meijer VE, Vles WJ, Kats E, den Hoed PT: iatrogenic diaphragmatic hernia complicating nephrectomy: top-down or bottom-up? Hernia 2008, 12:655–658.PubMedView Article
        20. Peer SM, Devaraddeppa PM, Buggi S: Traumatic diaphragmatic hernia our experience. Int J Surg 2009, 7:547–549.PubMedView Article
        21. Dapri G, Himpens J, Hainaux B, Roman A, Stevens E, Capelluto E, Germay O, Cadière GB: Surgical technique and complications during laparoscopic repair of diaphragmatic hernias. Hernia 2007, 11:179–183.PubMedView Article
        22. Singh M, Singh G, Pandey A, Cha CH, Kulkarni S: Laparoscopic repair of iatrogenic diaphragmatic hernia following radiofrequency ablation for hepatocellular carcinoma. Hepatol Res 2011,41(11):1132–1136.PubMedView Article
        23. Divisi D, Imbriglio G, De Vico A, Crisci R: Right diaphragm spontaneous rupture: a surgical approach. Sci World J 2011, 5:1036–1040.View Article
        24. Fukami T, Konoeda C, Kitano K, Sakamoto M, Sano A, Yoshida Y, Mura T, Nakajima J: Iatrogenic diaphragmatic hernia following partial resection of the lung via video-assisted thoracoscopy. Kyobu Geka 2010,63(13):1151–1154.PubMed
        25. Paul S, Nasar A, Port JL, Lee PC, Stiles BC, Nguyen AB, Altorki NK, Sedrakyan A: Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database. Arch Surg 2012, 147:607–612.PubMedView Article
        26. Shah S, Matthews BD, Sing RF, Heniford BT: Laparoscopic repair of a chronic diaphragmatic hernia. Surg Laparosc Endosc Percutan Tech 2000,10(3):182–186.PubMed
        27. Rossetti G, Brusciano L, Maffettone V, et al.: Giant right post-traumatic hernia: laparoscopic repair without mesh. Chir Ital 2005, 57:243–246.PubMed
        28. Guner A, Ozkan OF, Bekar Y, Kece C, Kaya U, Reis E: Management of delayed presentation of a right-side traumatic diaphragmatic rupture. World J Surg 2012, 36:260–265.PubMedView Article
        29. Potter SR, Kavoussi LR, Jackman SV: Management of diaphragmatic injury during laparoscopic nephrectomy. J Urol 2001, 165:1203–1204.PubMedView Article

        Copyright

        © Soufi et al.; licensee BioMed Central Ltd. 2013

        This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

        Advertisement