Strangulated iatrogenic diaphragmatic hernia

Hazem BEN AMEUR |

La tunisie chirurgicale - ; Vol

Resumé

Les principales étiologies de la hernie diaphragmatique sont des malformations congénitales et la rupture traumatique. Les causes iatrogènes sont moins fréquentes. Leur diagnostic est souvent tardif, parfois à l’occasion d’un étranglement du contenu herniaire. Nous rapportons le cas d’un homme de 39 ans opéré un an auparavant d’une tumeur rénale droite pour laquelle il a eu une néphrectomie droite élargie, et admis pour un syndrome occlusif. La radiographie de thorax a montré des clartés digestives dans l’hémithorax droit. Le scanner thoraco-abdominal a révélé une rupture du diaphragme avec l’issu du colon dans l’hémithorax droit ; le colon proximal était très dilaté avec un niveau hydro-aérique. Le patient a été opéré en urgence. Il y avait une large hernie diaphragmatique droite contenant du colon nécrosé. Le reste du colon droit, de siège intra-abdominal, était aussi nécrosé du fait d’une importante distension. Après réduction de la hernie, une colectomie droite avec anastomose iléo-colique a été réalisée ainsi qu’un drainage thoracique et la fermeture du défect diaphragmatique par des points séparés au fil non résorbable. Les suites post-opératoires étaient simples.

Mots Clés

diaphragme, hernie, nephrectomie

Introduction :

Diaphragmatic hernia has usually congenital or traumatic origin. Iatrogenic causes are less common. Their diagnosis is often delayed, sometimes for a strangulation of the hernia contents.

Article

A 39-year-old male with a past medical history of a right radical nephrectomy for renal cell carcinoma one year ago, was admitted to the hospital because of abdominal pain, vomiting and constipation. On examination, there was an abdominal distension predominantly of the right hemi-abdomen without signs of peritoneal irritation. Abdominal plain film objectified air-fluid levels. Chest X-ray showed digestive air on the right hemithorax (figure 1). Thoracoabdominal CT scan revealed a diaphragmatic rupture with transposition of the colon into the right hemithorax ; the right colon, which remained in intra-abdominal location, was very dilated with air-fluid level (figure 2). The patient was operated urgently via a large right subcostal incision extended to the left. On the intraoperative exploration, the cœcum was greatly distended with infarction ; hepatic flexure and transverse colon were incarcerated in the chest through a 7-cm posterior right diaphragmatic defect with evidence of infarction also. There was no evidence of colic perforation. After hernia reduction, a right colectomy with immediate ileocolic anastomosis was performed, a chest tube was inserted in right pleural cavity and the diaphragmatic defect was closed using an interrupted non-absorbable sutures. The postoperative course was uneventful.

Discussion

An accidental diaphragmatic injury may occur during thoracic or abdominal surgery. Apart from gastroesophageal surgery in which there is direct trauma to the hiatus (fundoplication [1], gastric band for morbid obesity [2], esophagectomy [3]), nephrectomy was the main abdominal intervention of occurrence of this injury [4, 5]. Diaphragmatic injury was also reported after microwave-assisted laparoscopic hepatectomy [6], cholecystectomy [7] and coronary artery bypass surgery [8].If it is not diagnosed intraoperatively, diaphragmatic injury may lead to the formation of a diaphragmatic hernia with migration of abdominal viscera into the thorax. On the right side, it is often the liver which passes into chest, more rarely the colon [9]. In our case, radical nephrectomy has promoted the passage of the colon behind the liver and then into the chest. Symptoms are not specific (vomiting, abdominal or thoracic pain), which is causing the delay in diagnosis (1 year in our case, range from 6 months to 5 years in the literature [4, 5]). The strangulation of hernia contents constitutes a rare but potentially dangerous complication because of the risk of gastrointestinal perforation. In our case, there is evidence of infarction in both colon herniated into the chest than proximal colon but without perforation. The diagnosis of diaphragmatic hernia is based on imaging. Chest X-ray can show digestive air, as illustrated in our case [9]. Thoracoabdominal CT scan may show the tear especially on the frontal and sagittal plan reconstructions and precise kind of the hernia contents and their vitality. The iatrogenic etiology must be evoked in the absence of other causes, especially congenital and traumatic ones, and with a history of surgery involving the viscera near the diaphragm. The treatment is surgical. Thoracotomy is more appropriate for right diaphragmatic hernia due to the interposition of the liver [10]. However, in our case, significant distension of the colon both at the chest than at the abdomen made us prefer laparotomy to ensure intestinal vitality and to eventually resect ischemic portions, which was actually conducted. The diaphragmatic tear is usually repaired by non-resorbable sutures or by interposition of prosthesis in cases of large defect [10].

Conclusion

The iatrogenic diaphragmatic hernia is sometimes revealed by an acute bowel obstruction secondary to incarceration of digestive structures in the chest. The diagnosis should be evoked in the presence of a history of thoracic or abdominal surgery near the diaphragm. The CT scan confirmed the diagnosis in most cases. Surgery is the treatment of choice. Prevention remains crucial by the intraoperative detection and repair of diaphragmatic injury.

 

Références

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