Delayed Bochdalek diaphragmatic hernia in children: thoracoscopic and laparoscopic approach

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Delayed Bochdalek diaphragmatic hernia in children: thoracoscopic and laparoscopic approach

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Type de vidéo

Vidéo chirurgicale

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05'00''

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2006-01

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WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1896.htm

Delayed Bochdalek diaphragmatic hernia in children: thoracoscopic and laparoscopic approach

1. Thoracoscopic approach 00'07''

Posterior lateral Bochdalek-type diaphragmatic hernia A thoracoscopic approach is being used on the hernia site on the present case. The child is placed in lateral decubitus. A first trocar which is a 5mm optical is positioned just underneath the tip of the scapula. Two operating trocars are placed in a triangular pattern. Slow low-pressure carbon dioxide insufflation provides some working space in the left pleural cavity. Exploration helps to identify that the lung is collapsed. The organs found up in the thorax region include the colon, most of the small bowel, the stomach and the spleen. The small bowel and the colon are easily reduced through the foramen of Bochdalek back into the abdominal cavity. This is then followed by the stomach. However, the major difficulty remains: the reintroduction of the spleen. Despite best efforts, this takes some time to do. However, in due course, it is successfully performed. In this case, the hernia is quite small in size and it is easily sutured with non-absorbable 2/0 Ethibond thread.

2. Thoracoscopic and laparoscopic approach 02'22''

When reduction of the hernia content cannot be performed thoracoscopically, a laparoscopic approach in addition must be used. In this case, thoracoscopy permits a mere observation of a partially atelectatic lung parenchyma with a great quantity of herniated organs in the thoracic cavity. The diaphragmatic opening cannot be identified, and hence we have to switch to a laparoscopic approach. Two trocars, one optical and one operating trocar are placed in the left hypochondrium. Hernia reduction is achieved through soft traction of the organs and progressively the peritoneal cavity fills up and visibility becomes poorer. The edges of the diaphragmatic opening are visualized. All omental attachments are removed and the opening is sutured thoracoscopically. We can gain more space in the thoracic cavity because the lung is collapsed by the CO2 insufflation in the pleural cavity. Drainage of the thoracic cavity may be used. However, mere exsufflation of the pleural cavity performed under the guidance of the anesthetist is often sufficient.