Diaphragmatic hernias

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Diaphragmatic   hernias

Authors
F Becmeur
Keywords
pediatrics,operation
Media type
Duration
07'00''
Publication
2001-11
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Nov 2001;1(11).
URL: http://www.websurg.com/doi-vd01en1108e.htm

Diaphragmatic   hernias

1. Case presentation 00'14''
How to treat delayed diaphragmatic hernias by thoracoscopy? One of our first cases was an incarcerated hernia in a 9-month-old girl. There is a mediastinum shift and an enlarged stomach. A gastric tube allowed to improve the ventilatory distress. The child is lying in a lateral position as for a thoracotomy. Please note the pleural catheter, which will be very useful in the first 24 hours after surgery. The surgeon is in front of the patient’s head and TV is on the back. The optical probe will be just under the scapula. One trocar for an instrument will be on the middle axillary line through the 5th or 6th space. The other trocar will be behind the scapula through the 4th space. We will begin with the optical trocar and because we don’t have a double-lumen tube for ventilation, we need to insufflate the pleural cavity with CO2. The aim is to collapse the lung. We can discover the collapsed lung, the empty stomach and the spleen. The 1st difficulty in a hernia without any sac is to push back the abdominal organs, especially for the spleen, which is very fragile. We’ll look at the external side of the Bochdalek hole and try to open the hole. This is the stomach. The operative field is very narrow and because of the very narrow space between 2 ribs in little infants, this girl was weighing less than 10 kilos. The mobility of the instruments is very restricted. As soon as the spleen and stomach have been removed from the pleural cavity, it’s easy to describe the Bochdalek hole and to look for a diaphragmatic muscle on the back side of the hernia. In this case, the hole is not important and the defect can be easily closed. It’s a new case with the left kidney. The insufflation allows to reduce the hernia with a sac. The hole is very large without any posterior muscle. We use Ethibond 2/0. The needle holder is 5mm. In case it is 3mm, it could be broken and then, there will remain a little hole, which will be filled by a medial plug as for inguinal hernias, and then we’ll fix a Mersilene mesh with a stapler. I operated this boy 2 years ago and he’s doing very well with a normal chest X-ray. In this case, we can see a hernia with a sac and very little extralobar sequestration in front of the thoracic canal. We can see the spleen and the stomach behind the sac. We remove the sequestration. The posterior diaphragmatic muscle is very thin and short in this case but it’s possible to close easily the hernia. This is a Morgagni hernia. A laparoscopic approach seems to be the best procedure. We can see the colon in the hernia, on the right side, the pleura and the right lung, and on the left side, the pericardium. The colon must be pulled back in the abdomen; Then the omentum and for this case a part of the left liver. If possible, the sac is removed; the muscular wedges are sutured. A Mersilene mesh is added. For this 7-month-old infant, we found a colon in the hernia. The sac has been removed and the hole is easily closed.