Robotic Repair of an Incarcerated Right-Sided Diaphragmatic Hernia After Liver Resection

In this video, the authors demonstrate the robotic repair of an incarcerated right-sided diaphragmatic hernia containing transverse colon after liver resection. Noncongenital right-sided diaphragmatic hernias are most often due to blunt or penetrating trauma; however, they are also a known complication of liver resection and transplantation, occurring in 2-3% of patients. Right-sided diaphragmatic hernias have a high risk of incarceration and strangulation, and thus should be repaired in all patients who are operative candidates, regardless of symptoms.

This patient was a 43-year-old woman who was three years s/p large hepatic adenoma resection. She presented to ED with several months of abdominal discomfort and diarrhea, acutely worsening over the last several days.  At presentation, her pain was 8/10, constant and diffuse, and she had nausea. Her vitals were stable in the ED, and her abdomen was soft, nondistended, and tender in the right upper quadrant without rebound or guarding. She had a chevron incision scar. A CT of the abdomen and pelvis showed a right-sided diaphragmatic hernia near the adenoma resection site containing transverse colon.

The patient was taken for a robotic repair of the hernia. A 12 mm Hassan trocar was placed in the right upper quadrant under direct visualization, followed by three 8 mm robotic trocars, two in the left abdomen and one in the epigastric area. Adhesions were lysed, and the diaphragmatic hernia was visualized. Using a Cadière and a scissor attached to monopolar electrocautery, the anterior portion of the hernia sac was dissected. The transverse colon and omentum were incarcerated and unable to be reduced. To aid in reduction, the diaphragm was opened anteriorly with harmonic scalpel. A diamond flex liver retractor was placed through the assistant port to help elevate the diaphragm. After the diaphragm was adequately opened, the hernia contents were able to be reduced back into the abdomen. A secondary defect was noted containing omentum. The diaphragm was closed primarily with a 2-0 PDS v-loc suture, starting anteriorly to assist in visualization by elevating the defect. Imbricated bites were taken to increase strength. Once the defect was closed, the liver retractor was moved inferiorly. The diaphragm repair was reinforced with an 8 cm x 5 cm Allomax mesh and secured circumferentially with the same 2-0PDS vloc suture. Mesh was used due to the young age of the patient and multiple diaphragm defects, and biologic mesh was used because of the incarcerated transverse colon. The trocars were removed and port sites closed in the usual fashion. The patient was started on a diet postoperative day one and discharged home postoperative day two.

Reference

Esposito F, Lim C, Salloum C, Osseis M, Lahat E, Compagnon P, et al.  Diaphragmatic hernia following liver resection: case series and review of the literature. Ann Hepatobiliary Pancreat Sur. 2017;21(3):114-121.

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