Clinical evaluation and surgical intervention for diaphragmatic eventration mimicking peritoneopericardial hernia in a cat.

A 2-year-old spayed female British Shorthair cat presented with an increased frequency and duration of cough since infant period. Based on radiographic, ultrasonographic, and computed tomography findings, peritoneopericardial diaphragmatic hernia was considered so that repair surgery was planned. During celiotomy, lax diaphragm was identified instead of defect. Transabdominal diaphragmatic plication was performed to resolve lax diaphragm and to prevent recurrence by overlapping relatively normal part of diaphragm. Diagnosed with diaphragmatic eventration postoperatively, the cat showed improvement in clinical signs and imaging results. Transabdominal diaphragmatic plication is a suitable treatment; the patient maintained normally during a 14-month follow-up period.

A case of refractory hepatic hydrothorax due to pleuroperitoneal communication successfully controlled by diaphragmatic plication and subsequent peritoneovenous shunting.

In general, control of hepatic hydrothorax is difficult, and patients have a poor prognosis. A case in which hepatic hydrothorax was well controlled for a long time after diaphragm plication and subsequent Denver shunt placement is reported. A 70-year-old man with decompensated liver cirrhosis presented with progressive exertional dyspnea. 5 years before admission, hepatic ascites associated with portal hypertension appeared, and a left pleural effusion subsequently developed. The pleural effusion was not controlled by salt restriction and diuretics. Based on the clinical findings, the existence of pleuroperitoneal communication was strongly suspected, and surgical diaphragmatic plication was performed. After the treatment, the pleural effusion did not accumulate, but ascites increased significantly, and conservative therapy was ineffective. For the treatment of massive ascites, a peritoneovenous shunt (Denver shunt®) was placed. Although more than 2 years have passed, the thoracoabdominal effusions have not accumulated, and the patient has been asymptomatic. The present case suggests that multidisciplinary treatment may improve the prognosis of patients with refractory thoracoabdominal effusions.

Comparison of short-term outcomes of video-assisted thoracoscopic (VATS) plication of diaphragmatic eventration - a six-year prospective cohort study.

Diaphragmatic eventration is one of the rarest conditions characterized by elevation of the hemidiaphragm while maintaining its normal attachments. In recent years, video-assisted thoracoscopic surgery (VATS) has gained popularity for diaphragmatic surgery. In this study, we share our experience over six years with VATS plication of diaphragmatic eventration. We conducted a prospective study at our institute for six years from April 2016 to March 2021, which included 37 symptomatic patients with diaphragmatic eventration. The sample size reported in this study is one of the largest to date for VATS diaphragmatic plication. Of these, 18 patients underwent combined stapler and suture plication, and 19 patients underwent single modality approach (10-stapled resection, 9-suture alone plication). All patients were followed-up for a minimum of 2 years. Comparative analysis of the combined approach and the single modality approach was performed. The mean operative time was significantly longer with the combined approach (p value < 0.01). However, there was no difference in postoperative pain (p value = 0.50), analgesia requirement (p value = 0.72), or pleural drainage (p value = 0.32) between the two approaches. Although not statistically significant, the combined approach had fewer post-operative complications (p value = 0.32). Besides, the Single modality approach resulted in one recurrence (p value = 0.32) and one mortality (p value = 0.32). VATS diaphragmatic plication using staplers and/or sutures is safe and efficacious in the management of diaphragmatic eventration. Surgeons should consider using both staplers and sutures whenever possible, rather than selecting one over the other.

[Surgical Treatment of the Perforation of the Right Ventricle and Diaphragm by a Permanent Pacing Lead:Report of a Case].

An 97-year-old woman was diagnosed with complete atrioventricular block and underwent pacemaker implantation( PMI). Three days after the PMI, computed tomography revealed cardiac perforation and migration of the lead to the abdominal cavity. Surgical procedure through median sternotomy was performed, and the penetrated lead was removed. The holes of the right ventricle and diaphragm were repaired. Abdominal organ was not injured. She was discharged 14 days after the surgical procedure.

Development of a 3D-printed neonatal congenital diaphragmatic hernia model and standardisation of intra-operative measurement.

INTRODUCTION: Three-dimensional (3D) printing is frequently used for surgical simulation and training, however, no widely available model exists for neonatal congenital diaphragmatic hernia (CDH). The aim of this study was to develop a 3D-printed model of CDH and test interobserver variability in the simulated model for obtaining measurements of the diaphragmatic defect and ipsilateral diaphragm. METHODS: A term fetal MRI (3.5 kg) of thorax, diaphragm and defect (15 mm × 5 mm) were delineated and segmented after parental consent to produce 3D-printed models. Consultant and trainee paediatric surgeons were invited to measure the posterior-lateral diaphragmatic defect and ipsilateral diaphragm. Mean measurement error was calculated (millimetres). Data are presented as median (range) and number/total (%). RESULTS: An abdominal and thoracoscopic model were produced and tested by 52 participants (20 consultants and 32 trainees). Diaphragmatic defect via laparotomy measured 15 (10-20) mm (AP) × 16 (10-25) mm (ML) and thoracoscopically 14 (11-19) mm (AP) × 15 (11-22) mm (ML). Mean error per measurement was 4 (1-17) mm via laparotomy vs. 3 (0.5-9.5) mm thoracoscopically. Mean error was similar between consultants and trainees via laparotomy (4.3 vs. 3.9 mm, p = 0.70) and thoracoscopically (3 vs. 3 mm, p = 0.79). Error did not correlate with experience as operating surgeon via laparotomy (ß = 13.0 [95% CI - 55.9 to 82.0], p = 0.71) or thoracoscopically (ß = 1.4[95% CI - 6.4 to 9.2], p = 0.73. CONCLUSIONS: We have designed and built simulation models for CDH repair via laparotomy and thoracoscopically. Operators can reliably measure the diaphragmatic defect and ipsilateral diaphragm, regardless of surgical experience and operative approach.

Solitary Fibrous Tumor in the Retroperitoneal Space Arising from the Diaphragm.

BACKGROUND/AIM: We present a case of solitary fibrous tumor, arising from the diaphragm in the retroperitoneal space, that was resected with robotic assistance. CASE REPORT: An 85-year-old female patient was referred to our hospital for evaluation of a suspected right renal tumor. Abdominal contrast-enhanced computed tomography revealed a tumor (maximum diameter, 36 mm) protruding from the superior pole of the right kidney. The patient was scheduled for robot-assisted, retroperitoneoscopic, partial nephrectomy based on a preoperative diagnosis of renal cell carcinoma. Intraoperative findings revealed that the tumor originated from the diaphragm and had no continuity with the renal parenchyma. Pathological examination revealed a solitary fibrous tumor. CONCLUSION: Solitary fibrous tumors are rare soft-tissue neoplasms with a distinct molecular feature of the fusion of nerve growth factor-inducible A gene-binding protein 2 with signal transducer and activator of transcription 6 gene (NAB2::STAT6). We believe that this is the first reported case of a solitary fibrous tumor arising from the diaphragm in the retroperitoneal space.

Right robotic-assisted hybrid diaphragm plication.

Diaphragm paralysis can lead to significant dyspnoea and, in severe cases, the need for invasive ventilation. Surgical repair via diaphragm plication remains the only surgical option for these patients. Nerve transplantation and pacing have not proven to be effective alternatives. Nevertheless, diaphragm plication, whether through a thoracotomy or via minimally invasive techniques, has proven to yield high recurrence rates during the years following plication surgery. Re-exploration of recurrent cases has identified that plication relapse may be caused secondary to the elasticity of the non-plicated stretched muscle fibres. In contrast, a tendon does not possess elastic properties like those of muscle fibres and thus is not liable to expand gradually over time. We present a novel, minimally invasive technique for diaphragm plication that involves plication of a non-elastic central tendon to a fixed chest wall (central tendon fixation). Utilizing a robotic-assisted approach, our goal was to describe the techniques involved in achieving successful diaphragm plication with mid-term results (2-year follow-up).

Conservative rehabilitation therapy for respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor: A case series study.

RATIONALE: Cases of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor have rarely been studied in detail. Diaphragmatic dysfunction in such cases can lead to potentially fatal respiratory and circulatory disturbances. Therefore, timely diagnosis and intervention are important. Conservative rehabilitation therapy is the first choice for respiratory dysfunction due to diaphragmatic dysfunction. PATIENT CONCERNS, DIAGNOSES AND INTERVENTIONS: We present 3 patients with respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. The diagnostic methods and therapeutic procedures for diaphragmatic dysfunction for each patient are described in detail. This study highlights the role of ventilator support combined with physical therapy in the treatment of respiratory dysfunction in such cases. The diagnosis of diaphragmatic dysfunction as well as the risk assessment of phrenic nerve involvement are also discussed. The modalities of ventilator support, including modes and parameters, are listed. OUTCOMES AND LESSONS: This study provides experiences of diagnosis and treatment of respiratory dysfunction due to phrenic nerve sacrifice during resection of massive mediastinal tumor. Timely diagnosis of diaphragmatic dysfunction primarily relies on clinical manifestations and radiography. Conservative rehabilitation therapy can improve or restore diaphragmatic function in majority of patients, and avert or delay the need for surgical intervention. Preoperative assessment of the risk of phrenic nerve involvement is important in such cases.

Cadaver investigation of the usefulness of the transstyloid diaphragm approach for high-position plaque carotid endarterectomy.

OBJECTIVES: Patients sometimes present with high cervical internal carotid artery (ICA) stenosis. This study demonstrates the usefulness of the transstyloid approach to expose the distal ICA by dissection of the styloid diaphragm covering the distal cervical ICA for carotid endarterectomy (CEA). In particular, the possible exposure length achieved by this approach was investigated using cadaveric heads. METHODS: The procedure of the transstyloid diaphragm approach was confirmed in 10 cadaveric heads (20 sides). After the carotid triangle was opened, both the posterior belly of the digastric muscle (PBDM) and the stylohyoid muscle could be divided. Then, the carotid sheath was dissected, and the glossopharyngeal nerve was identified crossing over the distal ICA. The revealed length of the ICA was measured with or without dissection of both the PBDM and the stylohyoid muscle. The specimens were dissected under the surgical microscope. RESULTS: The transstyloid diaphragm approach was achieved successfully in all specimens. The revealed lengths of the ICA with and without dissection of the styloid diaphragm were 53.7 ± 5.9 mm and 38.8 ± 2.9 mm (mean ± standard deviation), respectively. Therefore, the revealed length of the distal ICA was 14.9 ± 4.5 mm greater using the transstyloid diaphragm approach compared to the regular CEA approach. CONCLUSIONS: More of the ICA can be revealed by dissection of both the PBDM and the stylohyoid muscle. The transstyloid diaphragm approach might be helpful to reveal the distal ICA in cases of high cervical ICA stenosis.

Ogilvie's Syndrome in a 66-Year-Old Man after Diaphragmatic Plication Surgery: A Rare Postoperative Complication.

BACKGROUND Mechanical and functional intestinal obstruction are serious postoperative complications. Acute colonic pseudo-obstruction (Ogilvie's syndrome) is an acute functional obstruction of the large intestine with various causes, including electrolyte disturbances, certain drugs, trauma, hypothyroidism, and, less often, certain procedures, such as abdominal, pelvic, orthopedic, cardiac, and, rarely, thoracic surgeries. It presents with abdominal distension without evidence of mechanical obstruction. This report is of a 66-year-old man with postoperative Ogilvie's syndrome 1 day after diaphragmatic plication surgery CASE REPORT We present a case of a 66-year-old man with no pre-existing chronic diseases who underwent diaphragmatic plication surgery performed to treat symptomatic diaphragmatic eventration, which was associated with chronic colonic dilation. One day after the procedure, the patient experienced hemodynamic instability, abdominal tenderness and distention, leukocytosis, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An abdominal CT scan revealed massive colonic dilation with interposition of the splenic flexure into the diaphragm. Consequently, the patient underwent emergency exploratory laparoscopy, which was later converted to upper laparotomy, during which colonic decompression was performed without identifying any evidence of incarceration. Subsequently, colonic decompression was repeated via sigmoidoscopy, and no mechanical obstruction was found. Lastly, medical treatment was effective in improving the patient's condition CONCLUSIONS In this complicated case, identifying the definite diagnosis was challenging due to the unusual presentation. This rare case might contribute to recognizing a new risk factor for postoperative colonic obstruction, which is preoperative colonic dilation. Also, this case has highlighted the importance of promptly diagnosing postoperative Ogilvie's syndrome to prevent large-bowel perforation.

Video-assisted thoracoscopic diaphragm oblique resection simplified with an endostapler for diaphragm eventration.

Diaphragm plication has recently become a standard operation for diaphragm eventration. The surgical experience for the patient has improved with the development of minimally invasive operations, but the operator's convenience has not improved significantly. We performed video-assisted thoracoscopic surgery for a diaphragm oblique resection using endostaplers in 10 patients. The total operation time was 39.5 minutes; all patients' symptoms disappeared postoperatively. This presentation will help more thoracic surgeons simplify this operation on the diaphragm.

Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications.

BACKGROUND: Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up. METHODS: A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both. RESULTS: Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15 months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%. CONCLUSIONS: A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate of hiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.

Giant Pancreatic Lymphangioma Herniating Above the Diaphragm.

Lymphangiomas of pancreatic origin are rare and can often be found with abdominal symptoms or incidentally on imaging. A 46-years-old female presented with epigastric abdominal pain and vomiting, and twenty-pound weight loss over 3 months. Computed tomography of the abdomen showed a septated mass of the distal pancreas measuring 25.4 cm in largest diameter and extending superiorly into the mediastinum via a hiatal hernia. Endoscopic ultrasound demonstrated abutment but no invasion of the esophagus and stomach. She underwent an exploratory laparotomy with retroperitoneal mass excision, distal pancreatectomy, splenectomy, and hiatal hernia repair with Dor fundoplication. Pathology was consistent with a cystic lymphangioma. Patient was discharged on postoperative day 3 and remained recurrence free for over a year.

Thoracoscopic repair for late-presenting congenital diaphragmatic hernia with thoracic kidney in a child.

Congenital diaphragmatic hernia (CDH) with a hernia sac and thoracic kidney is a very rare congenital anomaly. Recently, the usefulness of endoscopic surgery for CDH has been reported. We herein report a patient who underwent thoracoscopic repair of CDH with a hernia sac and thoracic kidney. A 7-year-old boy was referred to our hospital due to a diagnosis of CDH without clinical symptoms. Computed tomography showed herniation of the intestine into the left thorax and left-sided thoracic kidney. The key points of operation are resection of the hernia sac and identification of the suturable diaphragm under the presence of the thoracic kidney. In the present case, after repositioning the kidney to the subdiaphragmatic area completely, the border of the diaphragmatic rim was clearly visualized. Good visibility allowed resection of the hernia sac without damaging the phrenic nerve and closure of the diaphragmatic defect.

Combined thoraco-laparoscopic hepatectomy concomitant with resection of the diaphragm for solitary peritoneal seeding from cervical cancer: A case report.

Combined thoraco-laparoscopic resection can aid in precise resection of an invasive tumor of the diaphragm. A 44-year-old woman was referred to our department for resection of solitary peritoneal seeding from cervical cancer following systemic chemotherapy. The tumor was located in the right diaphragm with an ill-defined border of the liver. Combined thoraco-laparoscopic resection was proposed. Laparoscopy portrayed that the right diaphragm was partially attached to the liver, and the depth of tumor invasion to the diaphragm was ambiguous. Observation from the thoracic cavity indicated a white-colored distortion following the location of peritoneal seeding. Partial resection and repair of the diaphragm were made using the thoracoscopic-assisted approach, followed by laparoscopic hepatectomy. The postoperative course was uneventful, and pathological findings revealed that peritoneal metastases of the diaphragm and surgical margin was negative for cancer. Combined thoraco-laparoscopic resection can cover the drawbacks of each approach and is among the options for minimally invasive surgery for invasive tumor of the diaphragm.

Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes.

OBJECTIVE: Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries. METHODS: A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis. RESULTS: A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted. CONCLUSION: The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.