Acquired diaphragmatic hernia after hepatectomy and liver transplantation in adults and children: A case series and literature review

Abstract

Acquired diaphragmatic hernia is a rare complication following liver surgery in adult and pediatric patients. This study aims to describe main features occurring in adult and pediatric patients after liver surgery and report an up-date review of the literature. Methods: All adult and pediatric patients who were diagnosed with postoperative acquired diaphragmatic hernia in Lyon and Marseille University Hospitals were included in this study. Diagnosis, clinical, radiologic, and therapeutic data were analysed retrospectively from medical papers and/or electronic records. Results: Thirteen adults with a median age of 50 years (range, 30-67 years) and 5 children aged 2.4 years (range, 0.9-4 years) were diagnosed with acquired diaphragmatic hernia after a median time of 65.1 (range, 1.8-244.7) and 2 (range, 0.33-10.9) months, respectively, following surgeries (5 live-donor right hepatectomies, 5 right and 1 left hepatectomies for tumors and cysts, and 2 whole liver transplantations in adults; and 5 liver transplantations with left lateral section in children). Eleven patients presented digestive and/or thoracic symptoms whereas seven were asymptomatic and diagnosed by routine imaging follow-up. All patients were re-operated with a median delay of 2.4 months (range, 0-25.3 months) for adults and 1 day (range, 0-2 days) for children. Two recurrences resulted in a secondary surgical repair. Conclusions: Acquired diaphragmatic hernia is a rare and potentially serious event after liver surgery. Recognition and surgical repair of this particular complication should be considered in the setting of unexplained abdominal and/or thoracic symptoms. Preventive measures should be taken intraoperatively.

A rare complication of pediatric liver transplantation: Post‐transplant diaphragmatic hernia

“…In our series, laparotomy was the preferred approach for all patients. However, it is noteworthy that other surgical approaches such as thoracotomy or thoracoscopy have also been discussed in the literature 7,8 . In particular, thoracoscopy offers several potential benefits including smaller incisions, reduced postoperative pain, faster recovery, and shorter hospital stays when compared to traditional open surgery 7 .…”

“…1,4 Several factors, including the size and location of the hernia, the contents of the hernia, and the choice of closure technique are critical considerations in the management of acquired PTDH. 3,4,7,8 Surgical repair remains the primary treatment modality for those cases. In our series, laparotomy was the preferred approach for all patients.…”

“…However, it is noteworthy that other surgical approaches such as thoracotomy or thoracoscopy have also been discussed in the literature. 7,8 In particular, thoracoscopy offers several potential benefits including smaller incisions, reduced postoperative pain, faster recovery, and shorter hospital stays when compared to traditional open surgery. 7 Nevertheless, it is important to bear in mind the potential abdominal complications of LT such as biliary leakage or stricture and adhesive complications.…”

Development of diaphragmatic hernia following hepatectomy

“…This may potentially cause devascularization, delayed healing, and even perforation. 9 As delayed diagnosis is associated with herniation of abdominal organs and increased strangulation risk, laparoscopy, thoracoscopy, or open surgical exploration may be required for diagnosis in patients with unclear diagnosis. When a diaphragm injury is diagnosed, even if it is asymptomatic, surgical repair of DH is recommended to prevent more serious complications that may develop.…”

“…This area can be more sensitive to thermal injury caused by cautery used during right liver mobilization. This may potentially cause devascularization, delayed healing, and even perforation 9 …”