Case report Surg Endosc (1999) 13: 817–818

© Springer-Verlag New York Inc. 1999

Diaphragmatic hernia seen as a late complication of laparoscopic cholecystectomy P. A. Armstrong, S. F. Miller, G. R. Brown Department of Surgery, Wright State University School of Medicine, Miami Valley Hospital, One Wyoming Street, Suite 7000 CHE, Dayton, OH 45409, USA Received: 22 July 1998/Accepted: 13 October 1998

Abstract. Laparoscopic surgery has emerged as the standard of care for the elective operative management of symptomatic gallbladder disease. The surgical literature is now beginning to accumulate sufficient case numbers that more clearly define the associated morbidity of this type of surgery. This article reports an instance of iatrogenic injury to the right muscular hemidiaphragm and subsequent hernia after laparoscopic cholecystectomy. Key words: Laparoscopic cholecystectomy — Diaphragmatic injury — Gallbladder

Symptomatic gallbladder disease is now generally managed with laparoscopic surgery. However, surgery always entails some risk of morbidity. Complications have been reported in 5% of laparoscopic cholesystectomy [3]. Of 1,535 patients treated at our hospital over a 5-year period, a single patient was readmitted with a diaphragmatic hernia following such surgery, presumed to be an iatrogenic injury. Herein we report the details of that case. Case report A 53-year-old woman presented with epigastric pain consistent with biliary colic. Evaluation began with an upper gastrointestinal contrast study, which demonstrated a small duodenal diverticulum but no other unusual findings. Abdominal ultrasound confirmed cholelithiasis and suggested a prominent pancreatic body and tail. This finding prompted us to perform a computerized tomography scan (CT) of the abdomen. The CT scan showed no pancreatic or other visceral abnormalities. Views through the lower lung fields and diaphragm revealed no hernia. Preoperative chest radiograph also showed no unusual findings. The patient underwent laparoscopic cholecystectomy. No unusual findings, events, or complications were documented at the time of surgery. The patient was discharged home in good condition on the 1st postoperative day.

Correspondence to: P. A. Armstrong

Six weeks postoperatively, the patient began to experience persistent right-sided pain. The pain was intermittent with sharp exacerbations. There were no apparent aggravating or alleviating factors. Conservative therapy with antacids, H-2 blockers, and nonsteroidal antiinflammatory agents provided no relief. The patient was reevaluated by her surgeon, but no clear etiology for the pain was identified. Evaluation by both psychiatric and pain clinics provided no relief. Eventually, a repeat CT scan was performed. This scan revealed a small right hemidiaphragm defect and an apparent hernia of fatty tissue (Fig. 1). A thoracic surgery consult was obtained. The patient underwent a right thoracotomy. At surgery, a small right posterolateral defect in the right muscular hemidiaphragm was found. The hernia contained fatty tissue, a finding that was confirmed by pathology review. The incarcerated tissue was excised and the defect was closed. The patient recovered uneventfully. She has remained asymptomatic over a 3-year period.

Discussion Diaphragmatic hernias can be either congenital or acquired. There are three congenital types—posterolateral (Bochdalek’s), subcostosternal (Morgagni’s), and esophageal hiatal. Acquired diaphragmatic hernias are generally the result of blunt or penetrating thoracoabdominal trauma, or iatrogenic injury. Late diagnosis of acquired diaphragmatic hernias is a frequent occurrence, especially when they are associated with small penetrating wounds. In the absence of strangulated or obstructed viscera, chronic pain with or without mild respiratory changes may be the only presenting complaint. Chest radiograph is the best screening examination, but only 50% of patients show an abnormality [1]. An even lower percentage of abnormal findings could be expected with injury to the right hemidiaphragm. Carter et al. described a group of findings on chest radiograph that should raise a high suspicion for diaphragmatic injury. These findings include: (a) visceral herniation, (b) obscuration of diaphragmatic shadow, (c) pleural fluid, and (d) irregularity of the contour of the diaphragm [2]. CT scan, magnetic resonance imaging, ultrasonography, radioisotope scintigraphy, and contrast studies may also aid in making the diagnosis.

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Fig. 1 CT scan demonstrating hernia tissue in right posterior lung window.

More invasive investigation might include laparoscopy or thoracoscopy evaluation. The approach for repair of diaphragmatic hernia may be either transabdominal or transthoracic. If the diagnosis has been delayed and there are no acute abdominal concerns, repair is probably best accomplished by a transthoracic route. This approach avoids a potentially difficult previously operated field and allows dissection of any intrathoracic adhesions. Acute injuries are best repaired from an abdominal approach. Complications occur in 5% of patients undergoing laparoscopic cholecystectomy. Serious complications requiring surgical intervention occur in 1% of all patients with complications. Major bile duct injury, bile leak, bowel injury, and bleeding comprise the majority of complications leading to reoperation [3]. Deizel et al. reviewed 77,604 cases of complications associated with laparoscopic cholecystectomy from over 4,292 hospitals and did not identify any diaphragmatic injuries or hernias [4]. We found no instance of postoperative diaphragmatic hernia following laparoscopic

cholecystectomy in the literature. We also reviewed the hospital records of 1,535 patients who had undergone laparoscopic cholecystectomy at our 772-bed tertiary care center between January 1991 and June 1996. No intraoperative injury to the diaphragm was documented in this group. Except for the case reported here, none of these patients were readmitted to our hospital with a diagnosis of diaphragmatic hernia following laparoscopic surgery. In retrospect, the injury may have occurred in one of three ways. First, a grasping instrument may have perforated the diaphragm while traction was being applied during dissection. Second, electrocautery may have caused thermal injury to the diaphragm. Finally, the suction instrument may have caused the injury while irrigation fluid was being evacuated from the right gutter or over the dome of the liver. The possibility of a propatent diaphragmatic defect might also be considered. Regardless of the mechanism, this case underscores the importance of precise dissection and careful handling of the instruments during laparoscopic surgery. A final “laparoscopic look” at the field of operation is also recommended before the abdomen is closed.

References 1. Asenio JA, Demetrios D, Rodriguez A (1996) Injury to the diaphragm. In: Felciano DV, Moore EE, Mattox KL (eds). Trauma. 3rd ed. Appleton & Lange, Stamford, CT, pp 461–485 2. Carter BN, Giuseffi J, Felson B (1951) Traumatic diaphragmatic hernia. Ann of Thorac Surg 65: 56–59 3. Dezeil DJ (1994) Complications of cholecystectomy: incidence, clinical manifestations and diagnosis. Surg Clin North Am 74: 809–822 4. Dezeil DJ, Millikan KW, Economou SG, Wherry DC, Champion HR (1993) Complications of laproscopic cholecystectomy: results of a national survey of 4,292 hospitals and analysis of 77,604 cases. Am J Surg 165: 9–14 5. Ochsner MG, Rozycki GS, Lucente F, Doolas A, Ko ST, Airan MC (1993) Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma 34: 704–710