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

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.
References
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hernia seen as a late complication of laparoscopic
cholecystectomy. Surg Endosc 1999; 13: 817-818.
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9. Yamashita J, Kuwata K, Miyamoto Y, et al. Two
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JOURNAL OF THE ROYAL MEDICAL SERVICES
Vol. 17 Supp No. 1 February 2010