Reduced port laparoscopic repair of Bochdalek hernia in an adult: A first report
Our patient was a 57-year-old woman, with history of difficulty in swallowing, and retching, which was sudden in nature. She had nausea and vomiting of about 2 week duration, with no abdominal pain. There was no history of abdominal or thoracic trauma. Her medical history included tubal ligation and bronchial asthma. She consulted a surgeon, was treated symptomatically and referred to our hospital. A chest radiograph revealed the herniated stomach well above the left diaphragm. Computed tomography (CT), abdomen, [] showed a herniated volvulus of stomach via the foramen of Bochdalek (left posterolateral diaphragmatic hernia), which was confirmed by upper gastrointestinal endoscopy. She was initially treated for acute bronchitis with bronchodilators, antibiotics and pulmonary care, followed by surgery.\nUnder general anaesthesia, the patient was positioned supine, with legs abducted and flexed as in Lloyd Davies position. The surgeon stood between the legs with the camera person to his left. The scrub nurse stood to the right of the surgeon. The single monitor was situated at the head end of the patient.\nA Karl Storz high definition camera was used with a xenon light source. A transumbilical vertical incision was made for a distance of 2 cm. Flaps were undermined just below the skin to create a space for the trocars. 10 mm trocar was inserted using direct vision method followed by CO2 insufflation and a long bariatric telescope with 45 degree angle. Two trocars of 5 mm with threads (Apple trocars) were inserted by the side of the primary trocar using the same single incision. This was the initial single incision by multi trocar method. The liver was retracted by insertion of Nathanson's liver retraction subcostally without any trocars by a single 5 mm incision. More than half the stomach had herniated through the posterolateral defect situated lateral to the left crus of the diaphragm.\nThe table was tilted to 15 degree head up to expose the viscera well. Using bowel forceps, the stomach was reduced with difficulty, after releasing the dense omental adhesions with ACE harmonic scalpel. After complete reduction of the stomach, a nasogastric tube was passed by the anaesthetist to empty the stomach. Initial attempt to insert the nasogastric tube was futile as the herniated stomach did not allow passage of the tube into it. The sac in the mediastinum was large and this was carefully reduced and excised fully by blunt and sharp dissection. A small left pneumothorax was made inadvertently. As the hemodynamic equilibrium was maintained, no chest tube was inserted.\nAfter excision of the sac, the defect was found to measure 4×4 cm []. This was situated just lateral to the left crus. This defect was repaired by suturing the diaphragm to the left crus using intracorporeal sutures with left and right needle holders. 2-0 ethibond sutures were used with atraumatic curved needles. Only straight conventional laparoscopic hand instruments were used. The sutures appeared to be adequate for the repair and there was no tension of the tissues after suturing []. As the defect was only 4 cm, sutures were under no tension and the repair appeared satisfactory, no expensive mesh was found necessary to reinforce this well done repair. Throughout surgery, the laparoscopic hand instruments were the standard straight instruments including long bariatric hand instruments. Sometimes, using a long bariatric handle on one hand and a standard handle on the hand were useful to prevent a clash of hands. No curved special instruments were necessary for dissection or suturing. Long bariatric laparscope was useful, as it kept the camera person's hands well clear of the operating site. A 45 degree of vision by the long telescope provided more than necessary vision for the surgery, including suturing without need for expensive flexible laparoscopes.\nThe stomach was then sutured to the anterior abdominal wall to create an anterior gastropexy using interrupted 2-0 ethibond sutures. An intraoperative gastroscopy was done with flexible Olympus gastroscope to ensure that there were no perforations and to confirm there was no gastric pathology. Hemostasis was verified and the abdomen was closed after withdrawal of all instruments, ports and evacuation of the CO2 pneumoperitoneum, with no drainage. Post operatively, the patient made an uneventful recovery. Oral intake was recommenced on the first post operative day, and the patient was discharged after 48 hours. Patient remained remarkably pain free after surgery despite the magnitude of the surgery.