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This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

BackgroundIntrapericardial diaphragmatic hernia (IPDH), defined as prolapse of the abdominal viscera into the pericardium, is a rare clinical condition. This case illustrates the possibility of IPDH after esophagectomy with antethoracic alimentary reconstruction, although such hernias are extremely rare. IPDH often presents with symptoms of bowel obstruction such as abdominal discomfort or vomiting. If not properly treated, life-threatening necrosis and/or perforation of the herniated contents may occur.Case presentationA 68-year-old Japanese man underwent subtotal esophagectomy with three-field lymph node dissection for treatment of esophageal cancer. Completion gastrectomy with perigastric lymph node dissection was also performed because the patient had previously undergone distal partial gastrectomy for treatment of gastric cancer. The alimentary continuity was reconstructed using the pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. The patient was readmitted to our hospital because of abdominal discomfort and vomiting 6 months after the esophagectomy. A diagnosis of IPDH after esophagectomy was made. The patient was treated by primary closure of the diaphragmatic defect using vertical mattress sutures and additional reinforcement of the closing defect using a graft harvested from the rectus abdominis posterior sheath. The postoperative course was uneventful, and he was discharged on the seventh day after hernia repair.ConclusionsThis patient’s clinical course provides two important clinical suggestions. First, we must be aware of the possibility of iatrogenic IPHD after esophagectomy with antethoracic alimentary reconstruction. Second, a graft from the rectus abdominis posterior sheath is beneficial in the treatment of IPDH.

Aim Robotic surgery using the da Vinci system has markedly increased worldwide. However, robotic inguinal hernia repair remains unpopular outside the United States. We introduced and evaluated a robotic transabdominal preperitoneal repair (R‐TAPP) technique for inguinal hernia in our hospital. Methods First, we designed a task protocol according to the surgical results of 388 laparoscopic TAPP (L‐TAPP) procedures performed during the 4 years prior to introducing R‐TAPP. Our task protocol included several time limitations during a step‐wise procedure: creating the peritoneal flap (<60 minutes), mesh placement with fixation (<30 minutes), and peritoneal suture closure (<30 minutes) under experienced supervision. We investigated the preliminary clinical results of R‐TAPP performed by a single operator between December 2018 and January 2020. Results We identified 27 lesions in 20 patients (unilateral in 13 and bilateral in seven). According to the Japan Hernia Society Classification, our cohort included eight type I, five type II, and seven bilateral hernias (nine type I, four type II, and one type IV). The median operation time was 124 minutes (range, 81‐164 minutes), and the median console operation time was 85 minutes (range, 50‐132). The median time required for the peritoneal incision was 30 minutes (range, 18‐54 minutes), that for mesh placement (including tucking) was 13 minutes (range, 7‐27 minutes), and that for peritoneal suturing was 9 minutes (range, 3‐20 minutes). Conclusion Our preliminary results suggest that our task protocol for R‐TAPP is feasible. However, refinement of our task protocol is essential for standardization.

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