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Case Reports
. 2020:67:169-172.
doi: 10.1016/j.ijscr.2020.01.044. Epub 2020 Feb 6.

Iatrogenic diaphragmatic hernia as a late complication of laparoscopic excisional biopsy of peritoneal nodules: A case report

Kyoichi Hashimoto  1 , Kazutaka Obama  2 , Shigeru Tsunoda  3 , Shigeo Hisamori  4 , Tatsuto Nishigori  5 , Masazumi Sakaguchi  6 , Yoko Ueda  7 , Nozomu Nakanishi  8 , Yoshiharu Sakai  9
Affiliations
Case Reports

Iatrogenic diaphragmatic hernia as a late complication of laparoscopic excisional biopsy of peritoneal nodules: A case report

Kyoichi Hashimoto et al. Int J Surg Case Rep. 2020.

Abstract

Introduction: Iatrogenic diaphragmatic hernias have been reported as a rare complication of abdominal surgery, and only a few reports have suggested minimal intraoperative injury to the diaphragm as a cause.

Presentation of case: We report a rare case of delayed diaphragmatic hernia caused by laparoscopic excisional biopsy of a peritoneal lesion on the diaphragmatic peritoneum. A 70-year-old woman with gastric gastrointestinal stromal tumor underwent laparoscopic partial gastrectomy and excisional biopsy for white nodules on the left diaphragmatic peritoneum using laparoscopic scissors. Slight bleeding that occurred after excisional biopsy was stopped using a soft-coagulation system. Six months after her first surgery, a left diaphragmatic defect and transverse colon migration into the thoracic cavity were detected on computed tomography. The patient subsequently underwent laparoscopic diaphragmatic hernia repair. The site at which the diaphragm defect occurred was consistent with the site of excisional biopsy. The defect was closed with interrupted suturing using non-absorbable threads, following which a composite mesh was applied above the suture site for reinforcement.

Discussion: This is the first report of an iatrogenic diaphragmatic hernia after diagnostic laparoscopy for peritoneal excision biopsy of the diaphragmatic surface. In the present case, the coagulation procedure for hemostasis after peritoneal resection was considered to be the cause of the diaphragmatic hernia. The heat generated by soft coagulation might have unexpectedly reached and damaged the deep areas of the diaphragmatic muscle.

Conclusion: Surgeons performing laparoscopic excisional biopsy of the diaphragmatic peritoneum should consider the potential risk for iatrogenic diaphragmatic hernias.

Keywords: Diagnostic laparoscopy; Iatrogenic diaphragmatic hernia; Soft coagulation.

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Conflict of interest statement

Declaration of Competing Interest No potential conflicts of interest exist.

Figures

Fig. 1
Fig. 1
Images of the diaphragmatic peritoneal surface during the first surgery. (A) Three white nodules were found on the diaphragmatic peritoneal surface and were excised for the diagnosis of peritoneal metastasis. (B) Hemostasis after nodule excision.
Fig. 2
Fig. 2
Coronal computed tomography images showing the left diaphragm after the first laparoscopy. (A) At 2 months, the diaphragm seemed intact. (B) At 6 months, a left diaphragmatic hernia was observed. (C) At 9 months, incarcerated splenic flexure of the colon was observed.
Fig. 3
Fig. 3
Intraoperative images of the herniation repair during the second surgery. (A) The incarcerated colon. (B) A defect measuring 2 × 2 cm on the left diaphragm. (C) Diaphragmatic hernia repair with a composite mesh.
See this image and copyright information in PMC

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