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

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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Vol. 17 Supp No. 1 February 2010