Modified Thoracoabdominal Approach for the Repair of Massive Diaphragmatic Hernias

Abstract

Various approaches to treat large diaphragmatic hernias in adults are available depending on the extent of herniation, patient stability, and surgeon experience. We present a 2-case series of massive diaphragmatic hernia repairs using a modified thoracoabdominal technique whereby a stabilizing myocutaneous bridge is left between the thoracotomy and laparotomy incisions. This technique maintains excellent exposure, may be accomplished for either right- or left-sided hernias, and spares a portion of unaffected diaphragm.

Adult diaphragmatic hernias are rare entities with a wide variety of surgical approaches—from thoracoabdominal incisions to minimally invasive techniques—depending on patient anatomy and surgeon experience. For the largest of hernias, an open approach with a classic thoracoabdominal incision is often preferred given the excellent visualization and ability to reduce herniated organs fully with access above and below the diaphragm. We present a modified thoracoabdominal incision with a stabilizing myocutaneous bridge between the thoracotomy and laparotomy incisions, thus allowing for improved preservation of body wall and diaphragm integrity while affording excellent exposure. We obtained signed informed consent from the patients to publish this report.

Technique

Patient 1

A 55-year-old man presented with 2 days of acute intractable abdominal pain, nausea, vomiting, and obstipation with no relevant medical history besides a motor vehicle accident 30 years earlier. Computed tomography (CT) demonstrated colon, liver, gallbladder, distended stomach, and several loops of distended small bowel, with multiple transition points, herniating into the right side of the chest (Figures 1A, 1B). Given his ongoing abdominal distention, closed-loop bowel obstruction, and mesenteric edema, the decision was made to proceed with surgery on an emergency basis.

Figure 1.

Patient 1: preoperative (A) coronal and (B) axial computed tomography demonstrating abdominal contents occupying the entire right hemithorax, with the arrow pointing to the cephalad-rotated liver; (C) view of abdominal viscera on entering the chest through thoracotomy (the patient’s head is to the right of the image); (D) midline laparotomy leaving a stabilizing myocutaneous bridge; (E) reduction of abdominal viscera, working in both the chest and abdomen; (F) repaired diaphragm with mesh, with the arrow pointing to hypoplastic right lung; and (G) postoperative computed tomography.

A right thoracoabdominal incision was made, entering the sixth interspace and transecting the costal margin. The liver, small intestine, colon, and omentum were observed in the right side of the thorax without an encapsulating hernia sac (Figure 1C). The abdomen was entered at midline, sparing a segment of skin, rectus, and fascia from the thoracotomy incision to act as a stabilizing myocutaneous bridge (Figure 1D).

Reduction of hernia contents (Figure 1E) required extensive lysis of adhesions and slight enlargement of the central diaphragmatic defect. Minimal remaining diaphragm was observed along the chest wall. The liver remained partially in the chest, abutting a diminutive piece of right lung lower lobe (Figure 1F, arrow). A 30-cm length of small intestine was necrotic and perforated. This was resected with linear staplers, leaving the patient in discontinuity. Given the defect size, two 10- by 15-cm (∼0.6- to 0.7-mm thick) Phasix ST (Becton Dickinson) and one 10- by 20-cm (∼2.5-mm thick) Strattice (AbbVie) biologic meshes were used for the diaphragmatic repair. A bridging mesh was secured circumferentially to the remaining diaphragm and to chest wall when remaining diaphragm could not be identified by using #1 polypropylene (Prolene, Ethicon) sutures in a horizontal mattress configuration. The diaphragm reconstruction was intentionally left high given the chronicity of his hernia and concern for abdominal compartment syndrome (Figure 1G). Two chest tubes were placed, and the abdomen was left open with an AbThera (3M) wound system. On postoperative day 2, the small intestine was put back into continuity by a side-to-side stapled anastomosis, and the abdomen was closed. Four months after discharge, there is no evidence of hernia recurrence or ischemia of the myocutaneous bridge, and the patient has returned to normal daily activities.

Patient 2

A 74-year-old man with a past medical history significant for previous coronary artery bypass grafting, laparoscopic hiatal hernia repair complicated by short-interval recurrence and subsequent open repair 9 years earlier, and laparoscopic incisional hernia repair with mesh placement 7 years earlier presented with nausea, abdominal pain, and obstipation. He was found to have a massive left diaphragmatic hernia with obstructed small bowel and colon in the left side of the chest (Figures 2A, 2B). He was taken urgently to the operating room, and a thoracotomy incision was made in the left seventh interspace (Figure 2C). On chest entry, stomach, colon, and small bowel were encountered. A midline laparotomy was made through the previous mesh (Figure 2D) while leaving a myocutaneous bridge between the laparotomy and thoracotomy incisions. The splenic flexure was gangrenous and was resected with a linear stapler. The stomach and small bowel had questionable ischemia and congestion but otherwise appeared to be grossly viable. Two chest tubes were placed, and the chest and abdomen were temporarily closed with the bowel in discontinuity. The next day, the abdominal viscera appeared improved without bleeding or perforation. Given the laxity present in the diaphragm, a tension-free primary repair was deemed feasible. The diaphragm defect, approximately 10-cm in diameter, was closed with a series of #1 Prolene sutures in a horizontal mattress fashion with Phasix ST mesh pledgets. A 10- by 15-cm Phasix ST overlay mesh was secured circumferentially to the diaphragm with running #0 V-Loc barbed suture (Medtronic). The colon anastomosis was performed in a hand-sewn fashion, and both laparotomy and thoracotomy incisions were closed. Postoperatively, the patient was started on total parenteral nutrition with slow diet progression. He was discharged home on a regular diet and remains without evidence of recurrence or ischemia of the myocutaneous bridge.

Figure 2.

Patient 2: preoperative (A) axial and (B) sagittal computed tomography demonstrating small bowel and colon herniating into the left hemithorax; (C) view of gangrenous colon in the chest through thoracotomy; and (D) reduction of abdominal viscera through thoracotomy and laparotomy incisions, leaving a myocutaneous bridge.

Comment

Diaphragmatic hernias in adults are rare and can arise from congenital, iatrogenic, posttraumatic, or idiopathic causes.¹ Traumatic diaphragmatic ruptures occur in approximately 1% to 5% of major traumas, and delayed presentations, sometimes years after the initial injury, account for 10% to 30% of cases.² Here, the cause was likely posttraumatic (patient 1) and iatrogenic related to previous surgery (patient 2). However, in both cases the size and acute presentation necessitated prompt surgical intervention, irrespective of origin.

Surgical management of diaphragmatic hernias involves a broad range of techniques, including open operation (thoracotomy, laparotomy, or thoracoabdominal incision) and minimally invasive approaches (video-assisted thoracoscopy, laparoscopy, or robotic-assisted surgery in experienced hands).³ Regardless of the approach, fundamental principles include reducing herniated contents, resecting the hernia sac (if present), and achieving a tension-free repair by either primary repair or bridging mesh augmentation. In this modified approach, the curvilinear incision starts cephalad between the medial border of the scapula and spine and then curves down 1 to 2 fingerbreadths below the scapular tip and ends inferiorly toward the middle of the costal margin. Rather than crossing the costal margin, a 4- to 6-cm bridge is left intact, and a separate abdominal incision is made at or going toward the midline. Leaving a stabilizing myocutaneous bridge between the thoracic and abdominal cavities provides excellent exposure, permits access to both cavities, maintains the integrity of the unaffected diaphragm, and is feasible from both right- and left-sided approaches. Use of this technique should be avoided if excessive retraction is needed in both the abdomen and chest or if the abdominal wall is compromised, such as in the setting of soft tissue infection.

Mesh selection in contaminated cases remains a subject of ongoing research. Biologic meshes may reduce infection risk by promoting host tissue incorporation. However, there is controversy regarding biologic vs synthetic mesh durability and real-world risk of mesh infection,⁴ with most studies examining only ventral hernias, which have different physiology and tension profiles compared with large diaphragmatic hernias. A small series reported promising long-term outcomes in diaphragmatic hernia repairs with biologic meshes and achieved success rates of 100% at 4 years without infection or recurrence.⁵ In our cases, the use of biologic mesh facilitated a durable repair while mitigating infection in the setting of bowel necrosis. Overall, this case series highlights an approach leading to the successful repair of 2 extreme cases on the wide spectrum of adult diaphragmatic hernias.