Iatrogenic Left Diaphragmatic Hernia as a Complication of Hydatid ...

IATROGENIC LEFT DIAPHRAGMATIC HERNIA AS A
COMPLICATION OF HYDATID SPLENECTOMY:
A CASE REPORT
Khaled Ajarmeh, MD*, Nasser Qassed, MD*, Amer Amireh, MD*, Zeyad Shuraydeh, MD**,
Mohammad Shabaneh, MD**, Khaled Khraisat, MD**
ABSTRACT
We are presenting the case of a 60-year-old male patient who developed an iatrogenic left diaphragmatic
hernia discovered six weeks after his initial surgery of splenectomy for a huge hydatid cyst of the spleen with
excessive adhesions to the left diaphragm. The patient underwent another surgery to repair the hernia through
a thoracotomy incision. There was no mention of such a complication in the literature, though iatrogenic
diaphragmatic hernia has been associated with other surgical procedures. Our aim from this case presentation
is to be the first to report such a complication and to suggest certain manoeuvres to avoid this preventable
complication which could be applied to both sides of the diaphragm when dealing with a hydatid cyst of the
spleen on the left or liver on the right.
Key words: Diaphragm, Hernia, Hydatid cyst, Iatrogenic.
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Introduction
Iatrogenic diaphragmatic hernia has been reported
to occur after many surgical procedures performed
on the right and left sub-diaphragmatic organs
mainly hepatobiliary, (1) oesophago-gastric (2,3) and
splenic (4) organs, and to some extent as a
complication of cardio-thoracic procedures. (5) And
they were dealt with, either immediately if
discovered on the spot or through late repair if
missed primarily. (6)
The problem with excision of hydatid cysts,
whether they are located on the liver or on the
spleen, is that the cyst wall is usually located on the
surface of organ in close proximity to the diaphragm
and as it grows it starts to adhere to it. The cyst
might perforate the diaphragm and rupture into the
corresponding pleural space or lung. This explains
the difficulty that the surgeons usually face during
the procedure of excision of hydatid cysts from the
liver or spleen. Trying to separate the cyst wall
from the diaphragm intact increases the risk of
injury to the diaphragm.
Case report
A sixty year old male patient presented on the 17 th
of June 2001 to the general surgery clinic of King
Hussein Medical Centre (KHMC) after being
investigated at the outpatient clinics. The patient
complained of pain and discomfort in the left upper
quadrant of his abdomen. Abdominal ultrasound
revealed an 8x9.5cm cyst in his spleen suggestive
of a hydatid cyst which was confirmed by
Computed Tomography Scan of the abdomen (see
Fig. 1). The patient was scheduled for
splenectomy. On 12 th of August 2001 he was
admitted to KHMC and pre-operative
investigations were done. Complete blood count,
PT and PTT, liver and kidney function tests, ECG,
From the Departments of:
*General Surgery, King Hussein Medical Centre (KHMC), Amman-Jordan
** Anesthesia, (KHMC)
Correspondence should be addressed to Dr. K. Ajarmeh, P.O. Box 541249 Amman 11937 Jordan, E-mail: ajarma66@yahoo.com
Manuscript received October 28, 2004. Accepted January 27, 2005
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Fig. 1. CT scan of the abdomen showing the splenic
hydatid cyst with adhesions on the left diaphragm
(posterolaterally)
and chest X-ray were normal (see Fig. 2).
On the 13 th of August 2001 the patient underwent
laparotomy through a left sub-costal incision and the
operative findings were a huge cyst arising from the
spleen with excessive adhesions to the left
diaphragm. The liver and the rest of the intraperitoneal
organs were inspected and found to be
free of any gross pathology.
The surgeon's aim was to resect the spleen with the
cyst without trying to excise or evacuate the cyst
alone, but due to the excessive adhesions faced
during the dissection of the cyst wall from the
diaphragm the cyst was opened and it was
immediately secured and irrigation with 10%
hypertonic saline of the area was performed. The
cyst was completely evacuated and dissection
continued with difficulty, then splenectomy was
completed, irrigation with normal saline was done,
haemostasis was secured, a rubber open drain was
inserted in the left sub-diaphragmatic space, and the
wound was closed.
The patient had an uneventful postoperative
recovery and the drain was removed on the second
postoperative day. He was discharged on the 15 th of
August 2001. After his discharge the patient was
followed up in the general surgery outpatient’s
clinic twice (2 nd & 15 th of September) and on both
occasions he was symptom free apart from a
superficial wound infection managed by daily
dressing for 10 days before it completely healed.
On the 23 rd of Sep 2001 he was referred from a
peripheral hospital where he was admitted for five
days for the complaint of shortness of breath, chest
Fig. 2. Chest X ray of the patient before splenectomy
reported as normal.
pain, fever and chills and was managed as a case of
left sided pneumonia by intravenous antibiotics. He
did not improve and was transferred to KHMC as a
suspected case of sub-diaphragmatic collection for
further investigations and management.
His chest X-ray showed a raised left hemi
diaphragm suggestive of a sub-diaphragmatic
collection with left pleural effusion (see Fig. 3), but
when ultrasound was performed it excluded the
presence of a collection. CT scan indicated the
presence of an iatrogenic left diaphragmatic hernia
(see Fig. 4a and 4b).
On the 3 rd of October 2001 the patient underwent
left thoracotomy, the hernia was found to be through
a lateral defect in the left hemi-diaphragm. It was
reduced and the defect repaired using prolene 0/0
sutures in double layers. A chest tube was inserted
and the wound was closed. Chest X-ray on the
fourth post operative day was clear (see Fig.5). The
chest tube was removed on the same day and the
patient was discharged home on the eighth post
operative day. He was followed by both the general
surgery and thoracic surgery clinics till May 2002
where he was discharged from both clinics.
Most of the cases of iatrogenic diaphragmatic
hernias mentioned in the literature are those missed
at the time of primary procedures which are
diagnosed later when patients start to be
symptomatic with chest pain, and discomfort
associated with dyspnea and possible cough. The
diagnosis is confirmed usually after radiological
investigations. (6) JOURNAL OF THE ROYAL MEDICAL SERVICES
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Fig. 3. Chest X ray of the patient on the second admission showing a raised left hemi-diaphragm.
Fig. 4a. Scout view of the CT scan of the lower chest
and upper abdomen showing a left diaphragmatic hernia
containing stomach and splenic flexure of the colon.
Fig. 4b. Four cuts of the CT scan of lower chest and upper
abdomen. Showing the hernial sac containing the stomach
with air-fluid level.
Fig. 5. Chest X-ray of the patient after the thoracotomy where the chest tube is still in situ. The left hemi-diaphragm is
back to normal.
Discussion
Diaphragmatic hernias are classified according to
cause into congenital and acquired, where the
acquired type is either traumatic or iatrogenic. (7,8)
Late diagnosis of acquired diaphragmatic hernias
is a frequent occurrence, especially when they are
associated with small penetrating wounds.
In the absence of strangulated or obstructed
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Table I. Common procedures complicated by diaphragmatic hernia
Surgical procedure
Laparoscopic splenectomy (4)
Laparoscopic cholecystectomy (1)
Anti-reflux procedures (2,3)
Left nephrectomy (9)
Left Hepatic lobectomy (10)
Oesophagectomy (6)
Coronary artery bypass (5)
Miscellaneous (11)
*Occurrence of iatrogenic hiatal hernia is also reported.
Site of Occurrence
Left
Right
Left*
Left
Right and Left
Left*
Central
Right and left
viscera, chronic pain with or without mild
respiratory changes may be the only presenting
complaint. (6)
Iatrogenic diaphragmatic hernias are not as
common as the traumatic type, and have been
reported several times in the literature as a
complication of different upper abdominal and
cardio-thoracic surgical procedures (see Table I.).
The new era of minimal invasive surgeries i.e.
laparoscopy appears to have has increased the rate
of iatrogenic diaphragmatic hernias slightly though
there are no true statistical figures or studies to
confirm this. (1,4) We could not find a single report
of such a complication following splenic or liver
(which is relatively more common) hydatid cyst
removal surgical procedure. This could be
explained by the rarity of such procedures in the
Western world which is the major contributor to
indexed literature.
Regardless of the cause of the hernia, the
recommendations mentioned in the literature to
avoid such a complication are still the same. They
all stress on the surgeons’ awareness of such a
complication and how to avoid it by meticulous
dissection around the region of the diaphragm and
its crura in esophageal surgeries, and to check for
the integrity of the diaphragm after each upper
abdomen and lower thoracic surgical procedure. (6)
Conclusion
Iatrogenic diaphragmatic injury can be easily
missed by surgeons unless they are aware of such a
complication and take the precautions to avoid it.
Checking for the integrity of the diaphragm after
any upper gastro-intestinal or lower cardio-thoracic
procedures is important. We would recommend, in
cases of liver or spleen hydatid cyst surgeries,
whenever the cyst wall is severely adherent to the
diaphragm and sometimes inseparable from it, to
leave the adherent patch stuck to diaphragm and not
to try to resect it but to resume the dissection around
it. This approach will ensure the integrity of the
diaphragm.
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