Robotic reconstruction of a left hemi-diaphragm defect with double mesh in a patient with trisomy 21

Abstract

Robotic reconstructions of large diaphragmatic defects with mesh reconstructions are rare in the literature. We present a case of a complicated diaphragmatic defect, in an adult with trisomy 21, which was successfully repaired robotically with double mesh reinforcement. The meshes were sutured together via a separate suture in the middle to avoid fluid accumulation between them. The patient recovered quickly and uneventfully. On follow-up, he reported no pain, and his performance score improved dramatically. We present this complicated reconstruction in this specific patient, who we think benefitted from avoiding a thoraco-abdominal incision, demonstrating the merits of persevering with a robotic approach.

Robotic surgery is increasingly utilized in the treatment of multiple pathologies [1–3].

INTRODUCTION

Robotic surgery is increasingly utilized in the treatment of multiple pathologies [1–3]. Although robotic surgery of the diaphragm is not new, reports of robotic repairs of complex congenital diaphragmatic hernias are rare. We report a thoracic robotic approach repair of a massive and complex left hemi-diaphragm defect in an adult with trisomy 21.

CASE PRESENTATION

A 47-year-old man with trisomy 21 was referred with worsening breathlessness. His performance score was 2 and his body mass index (BMI) was 42.

He had a history of a laparotomy for bowel atresia in infancy, when a diaphragmatic defect was noted. Subsequently, he had repair of an abdominal incisional hernia.

Imaging showed herniation of most abdominal contents in the left thorax through a large left hemi-diaphragm defect (Fig. 1A, B). His forced expiratory volume in 1 s was 0.89 l (32%).

Figure 1:

Preoperative imaging. (A) Axial and (B) coronal computed tomography showing the abdominal contents inside the chest.

An open approach was feared because of his issues related to compliance. A thoracic approach was decided to avoid abdominal adhesions.

The patient was positioned in a right lateral position. To reduce abdominal contents, a Veress needle was inserted in the third intercostal space midclavicular line for CO₂ insufflation. We used 1 x 12-mm and 3 x 8-mm ports (Fig. 2A). The DaVinci X system (Intuitive Surgical, Sunnyvale, CA, USA), was docked from the legs, slightly posteriorly. Multilevel intercostal blocks and local anaesthesia were used.

Figure 2:

(A) Port placement on a reconstruction of the patient’s rib cage. (B) Chest x-ray taken on postoperative day 1.

The hernia was dissected from the posterior chest wall initially; then, dissection continued towards the aorta and the spine. Dissection continued laterally under the diaphragmatic muscle fibre remnants and then to the anterior aspect of the hernia (Video 1). The hernia sac was dissected free from the abdominal adhesions by also dissecting it inside the abdomen then reducing it into the abdomen. A Parietex 15- x 15-cm mesh (Medtronic, Dublin, Ireland) was sutured into the opening with No. 0 V-Loc non-absorbable suture (Covidien, Medtronic). Posteriorly it was sutured to the psoas muscle. A second mesh (dual-mesh Prolene) was similarly fashioned on top of the first mesh, under the fear of failure because of the long-standing defect and the patient’s high BMI. To avoid seroma between the meshes, a suture was placed in the centre of the second mesh, “tacking it” down to the first.

A 24 Fr drain was left inside the chest. The overall surgical duration (docking, console time and closure) was 210 min; the blood loss was 200 ml. No intraoperative events were encountered.

A nasogastric tube to decompress the stomach and a urinary catheter for urine output and intra-abdominal pressure monitoring were inserted.

The patient was transferred to the high dependency unit. He was mobilized on the same day, requiring only oral analgesia for his pain.

His chest drain, nasogastric tube and catheter were removed the next day (Fig. 2B).

He was discharged home on day 4 after an uneventful recovery.

One year after surgery, the patient was discharged because no issues were reported.

DISCUSSION

We present a case of a massive deteriorating left diaphragmatic defect in an adult with trisomy 21 who was treated successfully with robotic dual mesh reconstruction with uneventful recovery and subsequent improvement of his quality of life. Apart from the reduction of the abdominal contents, we attribute his improvement to avoiding an open procedure. Robotic approaches should be considered even in complicated diaphragmatic defect cases.

Because of the previous extensive abdominal surgery, it was considered that a thoracic approach would be more appropriate. The use of the Veress needle provided the extra space needed to introduce the ports in an acceptable place and avoid damage to the abdominal contents.

We chose to use 2 meshes due to the long-standing issue and his increased BMI [4]. To avoid accumulation of fluid/seroma between the meshes, a single suture was placed in the middle of the meshes to “tack” them together. There was no sign of any issues postoperatively. It appeared that there were no issues from the meshes, nor did any pleural fluid collect.

CONCLUSION

We present the case of double robotic mesh reconstruction of a complicated massive left hemi-diaphragm defect that caused abdominal herniation into the chest in an adult male patient with trisomy 21. The patient underwent the procedure uneventfully and was discharged home quickly with minimal pain and without complications, demonstrating the benefits of persevering with a robotic approach.

Funding

This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Conflict of interest: none declared.

DATA AVAILABILITY

No new data were generated or analysed in support of this research