Conventional mesh repair of a giant iatrogenic bilateral diaphragmatic hernia with an enterothorax
The reported patient is a 65-year-old male. During a vocal cord operation 10 years before, there was an accidental intralaryngeal gas explosion that required several subsequent tracheal reconstructions. Consequently, a huge bilateral diaphragmatic hernia developed over the years.\nAs the patient was suffering from progredient dyspnea, a computed tomography was performed, which showed a complete enterothorax (); therefore, an operative approach was indicated. The upper abdomen was incised by transverse laparotomy revealing a large package of small intestine ventrally disappearing on both sides of the chest (). The adhesions were divided and the parts of the colon and jejunum that were dislocated in the chest were repositioned into the abdomen. Some parts were partially strangulated but still in good shape. The stomach, however, was in the correct anatomical location. After repositioning and resection of the hernial sac, the hernial gap could hardly be adapted (). The diaphragm was very weak, which suggested that a direct closure would be too fragile. For this reason, a large flap of PERMACOL™ (original size: 18 cm ×28 cm ×1.5 cm; Covidien Ltd, Dublin, Ireland) was trimmed to fit so that it covered both sides of the dorsal diaphragm and the ventral part of the flap overlapped with the abdominal wall incision (). The flap was fixed all around with VICRYL™ 0 sutures (Johnson & Johnson, New Brunswick, NJ, USA; ). As a pneumothorax on the right side was provoked by the manipulation, thoracic drainage was applied. The abdominal wall was occluded involving the ventral edge of the PERMACOL™ flap to provide for more stability.\nThe postoperative course was uneventful apart from paroxysmal atrial fibrillation and the patient was released from hospital 16 days after operation.\nThe postoperative follow-up after 3 and 6 months including a computed tomography scan did not reveal any pathologies.