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Abstract

Postoperative iatrogenic diaphragmatic hernia after thoracoscopic lobectomy is extremely rare. We present a 55-year-old female patient who developed an iatrogenic diaphragmatic hernia with gastric perforation several months after VATS (video-assisted thoracic surgery) left upper lobectomy with systematic lymphadenectomy. During the readmission, urgent laparotomy was performed. Intraoperatively, the choledochoscopy was introduced into left thoracic cavity through the diaphragmatic defect for dissecting the secondary inflammatory adhesions and achieving satisfactory hemostasis. It appears to be an efficient and feasible approach for the patients who have been diagnosed as delayed diaphragmatic hernia concomitant with remarkable intra-abdominal findings and have a history of thoracic surgery. We consider that delayedonset diaphragmatic hernia should be suspected in patients complaining of nausea or vomiting after VATS procedure, although it is very rare. Figure 1B). The diagnosis of diaphragmatic hernia with gastric perforation was confirmed by barium swallow ( Figure 1C). Therefore, urgent laparotomy was scheduled. Intraoperatively, the stomach was incarcerated in the chest through the diaphragmatic defect (Figure 2A). The thoracic cavity was also inspected closely under the choledochoscopy which was inserted through the diaphragmatic defect. Due to the secondary inflammation of perforation, the adhesion which located between the lesser curvature of stomach and thorax was carefully dissected. Meanwhile, the thoracic hemostasis was verified using by ultrasonic activated scissor under the choledochoscopy ( Figure 2B). Subsequently, the stomach was gently reduced into the abdominal cavity. On account of gastric gangrene and secondary perforation, partial stomach was needed to be resected and nasojejunal tube was placed as well. Thereafter, the diaphragmatic defect was repaired with non-absorbable interrupted sutures. The postoperative recovery of the second surgery was uneventfully. Up to present, the patient was still well and no evidence of cancer recurrence was detected. DiscussionIatrogenic diaphragmatic hernia is a rare complication of thoracic and abdominal surgery (5). The low incidence of iatrogenic diaphragmatic hernia might be the result of a high misdiagnosis rate. Though the rare occurrence of J Thorac Dis 2016;8(6):E399-E402 jtd.amegroups.com iatrogenic diaphragmatic hernia, the mortality following emergency surgery for strangulated or perforated bowel or stomach rises to between 20% and 80% (6). To our knowledge, no document was found to describing the delayed complication several months after VATS left upper lobe (LUL) lobectomy. In this case, the left lower lobe (LLL) was completely adhered to diaphragm and the adhesions had been dissected with ultrasonic scissor in the first surgery. After reviewing the initial surgical procedure which may lead to diaphragmatic hernia, we suppose that a weak point (or an imperceptible perforation) in the diaphragm might have been provoked by the ultrasoni...

Delayed Iatrogenic Diaphragmatic Hernia after Left Lower Lobectomy

“…To date, reports related to iatrogenic diaphragmatic hernia after pulmonary resection are extremely rare. To our knowledge, no such reports have been published in Korea, and even worldwide, only 1 case report was published by Pan et al [ 3 ] in 2016.…”

“…The approach should be carefully selected, considering the advantages and disadvantages of each possibility. Although we used the VATS approach, another case report used the abdominal approach with a choledochoscope [ 3 ]. Although it is difficult to consider one approach to be superior to the other, we believe that the thoracic approach is more advantageous in cases where a long duration has passed after the thoracic procedure, for the following reasons: (1) the thoracic approach is more advantageous than the transabdominal approach for dissecting adhesions; (2) the thoracotomy wound that was used in the pulmonary resection can be used again; and (3) the blood flow in the herniated stomach in the thoracic cavity might be reduced in comparison with the normal stomach, making it more vulnerable to injuries during reduction, and the thoracic approach allows more direct and gentle manipulation of the stomach.…”

First demonstration of imaging cosmic muons in a two-phase Liquid Argon TPC using an EMCCD camera and a THGEM

“…Presently scientific CMOS cameras that can reach up to 1 million frames/sec are available, however due to their high noise they are lacking the sensitivity required for this application. For example, we have tested the Photron FASTCAM Mini UX100 [24] which can capture up to 800,000 frames/sec with no successful results. However, CMOS technologies 2015 JINST 10 P10004 are advancing very quickly and are likely to improve in terms of quantum efficiency and readout noise in coming years.…”

FMOe: Preprocessing and visualizing package of the fragment molecular orbital method for Molecular Operating Environment and its applications in covalent ligand and metalloprotein analyses

“…In this instance, it is necessary to obtain information such as the atoms and formal charges of each fragment and the BDAs or BAAs for each divided covalent bond. Several graphical user interface (GUI) programs [14][15][16][17] are available for each solver to assist in such a complicated procedure.…”