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We report the case of a 32-year-old man who developed a giant diaphragmatic hernia following the removal of a left ventricular assist device 4 years prior due to improved cardiac function. Chest radiography revealed an intrathoracic prolapse of the gastrointestinal tract. The patient was diagnosed with a diaphragmatic hernia and a laparoscopy-assisted repair was performed. A 12 × 8 cm hernia was found intraoperatively on the left diaphragm, and a large portion of the gastrointestinal tract had prolapsed into the thoracic cavity. We attempted to repair the ventromedial defect using mesh; however, it was found to be insufficient. Therefore, we used a left rectus abdominis myocutaneous flap to fill the defect and sutured it to the mesh. A myocutaneous flap could be a useful strategy in cases where complete closure with mesh is difficult.

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Laparoscopic intraperitoneal onlay mesh repair is favoured for diaphragmatic hernias due to better outcomes. However, fixation devices pose risks, including cardiac tamponade. A man underwent laparoscopic repair for a large diaphragmatic hernia. One week later, he presented with chest discomfort which was initially attributed to postoperative pain. Subsequently, patient represented with worsening of chest pain and tachycardia. CT requested to rule out pulmonary embolism revealed a large pericardial effusion. Urgent drainage via apical approach resolved tamponade. The case highlights the challenges in managing pericardial effusions post-laparoscopy in the presence of diaphragmatic mesh and stresses multidisciplinary collaboration. Literature review highlights risks associated with fixation devices. Suggestions include limiting their use near vital structures. Key learning point of this case report is to raise awareness of cardiac tamponade following diaphragmatic hernia repair. Limited evidence necessitates cautious use of fixation devices, emphasising patient safety.

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BACKGROUND: Thoracic endometriosis syndrome gives rise to various clinical and radiological manifestations. We reviewed the records of patients operated for intrathoracic migration of abdominal viscera through a diaphragmatic hernia secondary to thoracic endometriosis. METHODS: We retrospectively reviewed the single-center prospective collected database of all patients operated for thoracic endometriosis during the twenty years. All cases in which an abdominal organ was found to be herniated into the thoracic cavity were retrieved. Clinical and pathological data are presented and analyzed. RESULTS: Twenty women of median age 36 (range 25-58) years were operated for endometriosis-related diaphragmatic hernia. The hernia was diagnosed concomitantly with endometriosis-related pneumothorax in 13 cases and during the exploration of catamenial thoracic pain in seven cases. There were 18 cases on the right side and two cases on the left side. The median diameter of the hernia was 8 cm (2.5-20 cm). In seventeen cases, the hernia was repaired by direct suture, and in three cases a heterologous prosthesis was positioned. At follow-up, two patients had an episode of recurrent pneumothorax. CONCLUSIONS: Diaphragmatic hernia should be ruled out in the presence of endometriosis-related pneumothorax or catamenial thoracic pain. Surgery is indicated to make a pathological diagnosis, restore anatomy, and prevent recurrence in patients presenting with pneumothorax.

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BACKGROUND: Post-hepatectomy diaphragmatic hernia is the second most common cause of acquired diaphragmatic hernia. This study aims to review the literature on this complication's incidence, treatment and prognosis. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed for all studies related to acquired diaphragmatic hernias after hepatectomy. RESULTS: We included 28 studies in our final analysis, comprising 11,368 hepatectomies. The incidence of post-hepatectomy diaphragmatic hernia was 0.75% (n = 86). The most frequent type of hepatectomy performed was right hepatectomy (79%, n = 68), and the indications for liver resection were a liver donation for living donor transplantation (n = 40), malignant liver tumors (n = 13), and benign tumors (n = 11). The mean onset between liver resection and the diagnosis of diaphragmatic hernia was 25.7 months (range, 1-72 months), and the hernia was located on the right diaphragm in 77 patients (89.5%). Pain was the most common presenting symptom (n = 52, 60.4%), while six patients were asymptomatic (6.9%). Primary repair by direct suture was the most frequently performed technique (88.3%, n = 76). Six patients experienced recurrence (6.9%), and three died before diaphragmatic hernia repair (3.5%). CONCLUSION: Diaphragmatic hernia is a rare complication occurring mainly after right liver resection. Repair should be performed once detected, given the not-negligible associated mortality in the emergency setting.

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64-Year-old male patient with hepatocellular carcinoma (HCC), liver cirrhosis, chronic hepatitis C infection, and glottic cancer presented with acute progressive abdominal pain and palpable mass in right upper quadrant of the abdomen. Despite treatment with hyoscine and tramadol, the symptoms persisted. He had received three sessions of Transcatheter arterial chemoembolization (TACE) and two sessions of microwave ablation (MWA) for HCC treatment, with the last session being TACE 11 months prior. Plain film abdomen showed bowel gas pattern in the right hemithorax compatible with bowel obstruction. CT imaging revealed a right diaphragmatic hernia containing closed loop small bowel obstruction. An emergency exploratory laparotomy was performed. The patient improved and was discharged. There was no recurrence of diaphragmatic hernia or abdominal mass or pain at the 6-month follow-up visit. We herein demonstrate a catastrophic complication of TACE by using an IPA and MWA which leads to right diaphragmatic hernia.

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Cases of adult liver transplant recipients with a postoperative right-side acquired diaphragmatic hernia are extremely rare. In this report, we describe an adult case of right-side acquired diaphragmatic hernia 15 years after living donor liver transplant. A 27-year-old woman was diagnosed with pancreatic insulinoma with multiple metastases in the liver. To treat the liver failure, she underwent left lobe living donor liver transplant and distal pancreatectomy with splenectomy 3 years after the transcatheter arterial chemoembolization. As a result of the liver abscesses that reached the diaphragm, the delicate diaphragm was injured, which required repair during the transplant surgery. At the age of 46 years, she developed a cough and intermittent abdominal pain. One month later, she went to another hospital's emergency room with complaints of epigastric pain. The computed tomography scan revealed colon and small intestine prolapse into the right thoracic cavity. She was referred to our hospital and underwent surgery the next day. Two adjacent right diaphragm defects were successfully sutured with nonabsorbable sutures. The patient was discharged on postoperative day 11.

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Acquired diaphragmatic hernia in children is rare. Even less often, this disease occurs after liver transplantation for biliary atresia. In our case, diaphragmatic hernia was acquired, since the patient underwent repeated chest X-ray examinations including CT prior to liver transplantation. There were no signs of hernia. Clinical manifestations of diaphragmatic hernia were absent throughout 9 months after liver transplantation and manifested acutely with combination of symptoms of respiratory failure and intestinal obstruction. Surgical treatment was performed after emergency consultation with attending doctor.

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La hernia diafragmática (HD) es la protrusión de los tejidos abdominales a la cavidad torácica secundaria a un defecto en el diafragma. Tras una revisión de la bibliografía, únicamente se han identificado 44 referencias al respecto, donde se describen 35 casos de HD secundarias a tratamientos percutáneos con radiofrecuencia (RF). En su gran mayoría son secundarias a lesiones por carcinoma hepatocelular en los segmentos V y VIII. No obstante, hasta la fecha, este es el primer caso comunicado de HD tras RF para el tratamiento de una metástasis hepática por carcinoma colorrectal. Las complicaciones secundarias a las HD son muy diversas. El principal factor de riesgo para ello es su contenido; así se describen casos incarceración de colon e intestino delgado. Igualmente, se describen casos asintomáticos en los que la HD ha sido un hallazgo en el seguimiento de los pacientes. El mecanismo fisiopatológico no está del todo esclarecido, pero se especula con la posibilidad de un daño térmico locorregional. Dado que la mayoría de las comunicaciones corresponden a casos sintomáticos y/o tratados, probablemente la incidencia esté infraestimada. No obstante, debido al advenimiento de los tratamientos percutáneos, esta complicación podría verse comunicada en mayor número en los próximos años. Respecto a los tratamientos descritos, en la mayoría de los casos se ha optado por una herniorrafia primaria, con una vía de abordaje abierta o laparoscópica a discreción del cirujano. No se dispone de evidencia que apoye ninguna actitud al respecto, si bien parece claro que el tratamiento quirúrgico es el único definitivo y el de elección en caso de complicación. Sin embargo, en pacientes asintomáticos en quienes la HD sea un hallazgo radiológico de control, el manejo quizá deba guiarse por el estado general del paciente, así como los riesgos potenciales de complicación (contenido, diámetro del orificio herniario…). (AU)

A diaphragmatic hernia is the protrusion of abdominal tissues into the thoracic cavity secondary to a defect in the diaphragm. Reviewing the literature, we found only 44 references to diaphragmatic hernia secondary to percutaneous radiofrequency treatment. The vast majority of these cases were secondary to the treatment of hepatocellular carcinoma in segments V and VIII. Nevertheless, to date, this is the first reported case of diaphragmatic hernia after radiofrequency ablation of a liver metastasis from colorectal cancer. Complications secondary to diaphragmatic hernias are very diverse. The principal risk factor for complications is the contents of the hernia; when small bowel or colon segments protrude in the thoracic cavity, they can become incarcerated. Asymptomatic cases have also been reported in which the diaphragmatic hernia was discovered during follow-up. The pathophysiological mechanism is not totally clear, but it is thought that these diaphragmatic hernias might be caused by locoregional thermal damage. Given that most communications correspond to asymptomatic and/or treated cases, it is likely that the incidence is underestimated. However, due to the advent of percutaneous treatments, this complication might be reported more often in the future. Most cases are treated with primary herniorrhaphy, done with a laparoscopic or open approach at the surgeon's discretion; no evidence supports the use of one approach over the other. Nevertheless, it seems clear that surgery is the only definitive treatment, as well as the treatment of choice if complications develop. However, in asymptomatic patients in whom a diaphragmatic hernia is discovered in follow-up imaging studies, management should probably be guided by the patient's overall condition, taking into account the potential risks of complications (contents, diameter of the opening into the thoracic cavity …). (AU)

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OBJECTIVE: Diaphragmatic herniation is a rare complication following esophagectomy, associated with risks of aspiration pneumonia, bowel obstruction, and strangulation. Repair can be challenging due to the presence of the gastric conduit. We performed this systematic review and meta-analysis to determine the incidence and risk factors associated with diaphragmatic herniation following esophagectomy, the timing and mode of presentation, and outcomes of repair. METHODS: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was performed using four major databases. A meta-analysis of diaphragmatic herniation incidence following esophagectomies with a minimally invasive abdominal (MIA) approach compared with open esophagectomies was conducted. Qualitative analysis was performed for tumor location, associated symptoms, time to presentation, and outcomes of postdiaphragmatic herniation repair. RESULTS: This systematic review consisted of 17,052 patients from 32 studies. The risk of diaphragmatic herniation was 2.74 times higher in MIA esophagectomy compared with open esophagectomy, with pooled incidence of 6.0% versus 3.2%, respectively. Diaphragmatic herniation was more commonly seen following surgery for distal esophageal tumors. Majority of patients (64%) were symptomatic at diagnosis. Presentation within 30 days of operation occurred in 21% of cases and is twice as likely to require emergent repair with increased surgical morbidity. Early diaphragmatic herniation recurrence and cardiorespiratory complications are common sequelae following hernia repair. CONCLUSIONS: In the era of MIA esophagectomy, one has to be cognizant of the increased risk of diaphragmatic herniation and its sequelae. Failure to recognize early diaphragmatic herniation can result in catastrophic consequences. Increased vigilance and decreased threshold for imaging during this period is warranted.

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Trauma and abdominal surgery that involves the diaphragm and pericardium rarely ends up in post-operative visceral herniation into the pericardial cavity. Urgent intervention is crucial to restore the cardiac output and prevent bowel strangulation. A case of a patient with intrapericardial hernia following nephrectomy for renal cell carcinoma and en block resection of an IVC neoplasmatic thrombus via transdiaphragmatic approach is presented.

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BACKGROUND: Both diaphragmatic hernia and thoracic gastropericardial fistula rarely occur simultaneously in patients with radical esophagectomy. CASE PRESENTATION: A 72-year-old man presented to our hospital with 1 day of nausea, vomiting and acute left chest pain. He had radical esophagectomy (Sweet approach) for esophageal cancer 18 years ago. Computed tomography (CT) of the chest revealed diaphragmatic hernias and air collection within the pericardial space. While an operation of diaphragmatic hernia repair was decisively performed to prevent further serious complications, unusually, a thoracic gastropericardial fistula was also found unusually. CONCLUSION: Diaphragmatic hernia and thoracic gastropericardial fistula may occasionally coexist in patients with esophagectomy. Upper GI radiograph with a water-soluble contrast agent is a better diagnostic tool than CT in visualizing the fistula.

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Despite its relative underutilization in the primary management of aortoiliac occlusive disease, thoracofemoral bypass is an attractive extra-anatomic surgical option in select patients. Thoracofemoral bypass classically entails passing a graft from the left chest into the retroperitoneal space through a small opening created in the diaphragm. While theoretically possible that this maneuver may predispose to a peri-graft diaphragmatic hernia, currently there are no cases of this complication reported in the literature, nor has its surgical repair been described. This case illustrates the rare complication of symptomatic diaphragmatic hernia following a thoracobifemoral bypass.

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An iatrogenic diaphragmatic hernia after major hepatic resection is a rare complication. Incarceration of the abdominal organ through a diaphragmatic defect can have a fatal prognosis. Here, we report a case of incarcerated diaphragmatic hernia after right hepatectomy, which was diagnosed only after the autopsy. The deceased, who had right hepatectomy 1 year previously, complained of severe chest pain, and 4 days later was found dead. Localized decomposition in his chest and abdomen suggested a late complication of the surgery because the location was consistent with the prior surgical area. In the autopsy, there was a small defect in his right diaphragm, resulting in the herniation and incarceration of the small intestine. Gross and microscopic findings of the herniated small intestine were consistent with ischemic enteritis. Different from our case, most of the previously reported cases showed a good prognosis after surgical repair, except one lethal one. Even though its overall incidence is very low, an incarcerated diaphragmatic hernia is one of the critical complications of major hepatic resection. The clinicians should warn the patients to avoid preventable morbidity and mortality. Reviewing this fatal complication would be also helpful for forensic pathologists and death investigators.

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Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation. A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home. CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.

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INTRODUCTION: Postoperative diaphragmatic hernia (DH) is a rare but potentially life-threatening complication following pediatric liver transplantation (LT). In the current literature, a total of 49 such hernias have been reported in 17 case series. We present eight additional cases, three of which reoccurred after surgical correction, and review the current literature with a focus on recurrence. MATERIALS AND METHODS: The study sample included children (<18 years of age) who underwent LT between June 2013 and June 2020 at five large transplant centers and who subsequently presented with DH. During the study period, a total of 907 LT was performed. Eight DH were recognized, and risk factors were analyzed. RESULTS: For the eight children with DH, the mean age at LT was 28.0 (5-132) months. All patients with a DH received left lateral segment split grafts except one, who received a full left lobe. The mean weight at time of LT was 11.8 (6.6-34) kg. Two patients had a primary abdominal muscle closure, and six had a temporary silastic mesh closure. All eight children presented with a right posterolateral DH. The small bowel was herniated in the majority of cases. Symptoms reported included nausea, vomiting, and respiratory distress. Two patients were asymptomatic, and discovery was incidental. All patients underwent prompt primary surgical repair. Three DH hernias (37.5%) recurred despite successful surgical correction. CONCLUSION: DH following liver transplant with technical variant grafts may be underreported and is prone to recur despite surgical correction. A better understanding of the pathophysiology and more thorough reporting may help increase awareness. Early detection and prompt surgical management are the cornerstones of a successful outcome.

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