Repair of an iatrogenic posterolateral diaphragmatic hernia after pedicled omentoplasty for chronic empyema in an immunocompromised patient: taking down the omentum or not?—A case report

Abstract

Iatrogenic diaphragmatic hernias (IDHs) are rare, but the incidence is potentially rising due to the increased implementation of laparoscopy. In case of complications i.e. perforation, bleeding, and/or incarceration, urgent exploration is mandated. However, treatment algorithms lack. We present a case of a 49-year old immunocompromised male patient who developed an IDH with gastric herniation 1 year after performing a pedicled thoracic omentoplasty in the treatment of a recurrent pleurocutaneous fistula. An emergency laparoscopy with 3-trocar approach was performed and the stomach could successfully be reduced.In order to preserve the existing omentoplasty a gastropexy was performed to cover the large diaphragmatic defect (5 cm × 5 cm). Though, due to persisting postural pain, laparoscopic reintervention with detachment of the gastropexy and omentoplasty took place 6 weeks postoperatively. Diaphragmatic repair was executed using a polypropylene mesh. Further postoperative course was uneventful. One year postoperatively neither chronic pain nor signs of hernia recurrence or empyema are noted. In the repair of IDH caused by a pedicled omentoplasty a laparoscopic approach with mesh repair might be preferred considering previous thoracic surgery and/or infections, overview of the abdominal cavity and diaphragm, and visualization of the pedicle.Nevertheless, the need to preserve the omentoplasty in immunocompromised and other patients should be further investigated, as repair after detachment is technically less complex.