- Email: [email protected]
Iatrogenic diaphragmatic hernia due to laparoscopic gastric banding
Surgery for Obesity and Related Diseases 2 (2006) 61– 63
Case report
Iatrogenic diaphragmatic hernia due to laparoscopic gastric banding Oleg Dukhno, M.D.,* Jochanan Peiser, M.D., M.P.H., Isaac Levy, M.D., F.A.C.S., Amnon Ovnat, M.D. Department of Surgery B, Soroka University Medical Center, Goldman Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Manuscript received August 28, 2005; revised October 24, 2005; accepted November 1, 2005
Abstract:
A patient developed a huge diaphragmatic hernia following laparoscopic gastric banding. Almost the entire stomach was incarcerated within the left chest. Segmental necrosis of the greater curvature of the stomach necessitated partial gastrectomy. The postoperative course was uneventful. The etiology, diagnosis and treatment of this previously undescribed complication of laparoscopic gastric banding are addressed in relation to the present case. © 2006 American Society for Bariatric Surgery. All rights reserved.
Key words:
Laparoscopic gastric banding; Diaphragmatic hernia
Introduction The etiology of diaphragmatic hernias is divided into congenital and acquired. One of the causes of later is traumatic form. Fall from height, motor vehicle accidents as well as penetrating wounds of the chest and abdomen are but some of the mechanisms which can result in the occurrence of a traumatic diaphragmatic hernia. However,rarely,these hernias are a result of an iatrogenic error during surgery. Traumatic hernias are not true hernias since no peritoneal sac is present. [1] We have accumulated a great deal of experience in laparoscopic gastric banding (LGB) for bariatric surgery. In our first 250 cases the operative technique that we used for placement of the band circumferentially around the proximal stomach included perigastric dissection to create a tunnel next to the stomach wall. [2,3] Because there was a significant rate of band slippage we subsequently adopted a modification of this technique, using the pars flaccida approach, in which access to posterior aspect of gastroesophageal junction is gained via the right crus [3,4,5] and the upper stomach is encircled circumferentially. This tech-
*Address for correspondence: Oleg Dukhno, M.D., Department of Surgery B, Soroka University Medical Center, Beer-Sheva, Israel 84101, Tel: 972-8-6400346; Fax: 972-8-6239930. E-mail:[email protected]
nique requires minimal gastric dissection, maintains normal gastric anatomy and avoids disruption of the lesser sac. [5] A crucial step in LGB is the blind creation of a retrogastric tunnel, through which the band is positioned. The instrument (“goldfinger”-Obtech® Medical GA.Switzerland) used to create this tunnel may be passed, inadvertently, into the left chest causing the band to incorporate part of the left diaphragm together with the stomach. We present a case in which an iatrogenic tear of the left diaphragm caused a huge diaphragmatic hernia with incarceration of the stomach and necrosis of part of the greater curvature. Case Report A 23 year old female was admitted to the hospital because of abdominal pain, vomiting and dyspnea. She had undergone LGB three months earlier. Her pre-operative BMI was 41 kg/m2. Following surgery the band was inflated through the port three times under fluoroscopy, the last time 10 days prior to the present admission. The patient lost 15 kg, and her BMI on the day of admission was 33.1 kg/m2. On examination at admission the temperature was 38.6 °C, the pulse rate was 140 and the patient was dyspneic. There was evidence of peritoneal irritation, primarily in the epigastrium. A CT scan revealed a huge diaphragmatic
1550-7289/06/$ – see front matter © 2006 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.11.007
62
O. Dukhno et al. / Surgery for Obesity and Related Diseases 2 (2006) 61– 63
Fig 1. Chest x-rays showing the stomach in the left pleural cavity causing mediastinal deviation to the opposite site and compression of the left lung.
hernia with most of the stomach located in the left chest (Figs. 1-2). The band was in its expected position. The patient underwent explorative laparoscopy, in which a small amount of reactive peritoneal fluid and a huge diaphragmatic hernia were seen. Reduction of the hernia content was performed. At the greater curvature of the stomach a necrotic segment was noted and resected with ATG 45 (Ethicon®, Johnson & Johnson, Cincinnati.USA). Following this resection the tear in the left diaphragm to the left of the hiatus became completely evident. The band passed through this tear, encircling the gastro-esophageal junction and part of the left diaphragm. It was evident that band positioning was the cause of the iatrogenic tear of the left diaphragm. The band was removed and the tear was sutured with nonabsorbable sutures. The postoperative course was uneventful. Discussion Recognized complications of LGB include slippage, pouch formation, erosion, balloon dilatation, disconnection of tubing system, esophagitis, esophageal dilatation and port site infection. [5–10] To our knowledge there is no previous report of a diaphragmatic tear with diaphragmatic hernia occurring during LGB. The crucial part of the LGB procedure is the creation of the retro-gastric tunnel. This part of the procedure is
performed blindly since the retro-gastric area cannot be visualized. In the present case, passage of the band through the left diaphragm produced a small tear, the size of the band circumference. The continuous movement of the diaphragm due to respiration, pumping of the heart and swallowing caused an enlargement of this tear, with concurrent adjustment of the band. At the time of operation we found a 4 cm long tear. Most of the stomach had passed through this tear with ensuing necrosis of part of the greater curvature. The clinical picture was acute onset of epigastric pain and dyspnea. The differential diagnosis included pulmonary emboli and obstructive pouch with herniation of the stomach. [9,10] Pulmonary embolism was considered unlikely because three months had elapsed since the initial operation and obstructive pouch was the primary suspicion. Plain chest and abdominal x-rays disclosed an inflated stomach, which created a mass effect in the left chest with deviation of the mediastinum to the right and a well-positioned band. The final diagnosis was made by helical CT scan with contrast material, which demonstrated the incarcerated stomach within the left chest. We felt that this life threatening complication could be repaired by a laparoscopic procedure. The band had to be removed from its original harmful position. In principle the band could have been re-positioned through a new tunnel that did not include the diaphragm, but we preferred not to do that because it
O. Dukhno et al. / Surgery for Obesity and Related Diseases 2 (2006) 61– 63
63
Fig 2. Three-dimensional CT scan with saggital reconstruction showing the incarcerated stomach with the defect in left diaphragm.
would involve an unsterile operation. In the presence of a necrotic gastric segment that had to be resected, we deemed it safer to remove the band altogether. Although this is a very rare life threatening complications, it has to be recognized and treated appropriately. In the present case we encountered an extremely unusual complication of the LBG procedure, i.e., an incarcerated diaphragmatic hernia with a strangulated stomach, which caused pulmonary distress and deviation of the mediastinum. We believe that this rare condition occurred due to the inappropriate initial placement of the band system through the left crura (creating a false route), and ongoing adjustments of the band system results in an enlargement of the defect. This rare complication can be diagnosed by CT and treated by laparoscopic repair. The post-operative course in our patient was uneventful. References [1] Gueto J, Vazquez-Frias JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Lapars Endosc Percutan Tech 2001;11:209 –12.
[2] Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12: 564 – 8. [3] Cadiere GB, Himpens J, Hainaux B, Gaudissart Q, Favretti S, Segato G. Laparoscopic adjustable gastric banding. Semin Laparosc Surg 2002; 9:105–14. [4] Fielding GA, Allen JW. A stet-by-step guide to placement of the Lap-Band ® adjustable gastric banding system. Am J Surg 2002; 184:26S–30S. [5] O’Brien P, Dixon J, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band ®: a prospective study of medium-term effects on weight, health and quality of live. Obes Surg 2002; 12: 625– 60. [6] Chapman AE, Kiroff G, Game P, et al. Adjustable gastric banding in the treatment of obesity: A systematic literature review. Surgery 2004; 135; 326 –51. [7] Chevallier JM, Zinzindohoue F,Douard R, et al. Complications after laparoscopic adjustable gastric banding for morbid obesity: Experience with 1000 patients over 7 years. Obes Surg 2004; 14:407–14. [8] Abu-Abeid S, Szold A. Laparoscopic management of Lap-Band erosion. Obes Surg 2001; 11: 87–9. [9] Landen S, Majerus B, Delugeau V.Complications of gastric banding presenting to the ED. Am J Emerg Med 2005;23:368 –70. [10] Dargent J. Pouch dilatation and slippage after adjustable gastric banding:Is it still an issue? Obes Surg 2003;13:111–5.
Case report
Iatrogenic diaphragmatic hernia due to laparoscopic gastric banding Oleg Dukhno, M.D.,* Jochanan Peiser, M.D., M.P.H., Isaac Levy, M.D., F.A.C.S., Amnon Ovnat, M.D. Department of Surgery B, Soroka University Medical Center, Goldman Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel Manuscript received August 28, 2005; revised October 24, 2005; accepted November 1, 2005
Abstract:
A patient developed a huge diaphragmatic hernia following laparoscopic gastric banding. Almost the entire stomach was incarcerated within the left chest. Segmental necrosis of the greater curvature of the stomach necessitated partial gastrectomy. The postoperative course was uneventful. The etiology, diagnosis and treatment of this previously undescribed complication of laparoscopic gastric banding are addressed in relation to the present case. © 2006 American Society for Bariatric Surgery. All rights reserved.
Key words:
Laparoscopic gastric banding; Diaphragmatic hernia
Introduction The etiology of diaphragmatic hernias is divided into congenital and acquired. One of the causes of later is traumatic form. Fall from height, motor vehicle accidents as well as penetrating wounds of the chest and abdomen are but some of the mechanisms which can result in the occurrence of a traumatic diaphragmatic hernia. However,rarely,these hernias are a result of an iatrogenic error during surgery. Traumatic hernias are not true hernias since no peritoneal sac is present. [1] We have accumulated a great deal of experience in laparoscopic gastric banding (LGB) for bariatric surgery. In our first 250 cases the operative technique that we used for placement of the band circumferentially around the proximal stomach included perigastric dissection to create a tunnel next to the stomach wall. [2,3] Because there was a significant rate of band slippage we subsequently adopted a modification of this technique, using the pars flaccida approach, in which access to posterior aspect of gastroesophageal junction is gained via the right crus [3,4,5] and the upper stomach is encircled circumferentially. This tech-
*Address for correspondence: Oleg Dukhno, M.D., Department of Surgery B, Soroka University Medical Center, Beer-Sheva, Israel 84101, Tel: 972-8-6400346; Fax: 972-8-6239930. E-mail:[email protected]
nique requires minimal gastric dissection, maintains normal gastric anatomy and avoids disruption of the lesser sac. [5] A crucial step in LGB is the blind creation of a retrogastric tunnel, through which the band is positioned. The instrument (“goldfinger”-Obtech® Medical GA.Switzerland) used to create this tunnel may be passed, inadvertently, into the left chest causing the band to incorporate part of the left diaphragm together with the stomach. We present a case in which an iatrogenic tear of the left diaphragm caused a huge diaphragmatic hernia with incarceration of the stomach and necrosis of part of the greater curvature. Case Report A 23 year old female was admitted to the hospital because of abdominal pain, vomiting and dyspnea. She had undergone LGB three months earlier. Her pre-operative BMI was 41 kg/m2. Following surgery the band was inflated through the port three times under fluoroscopy, the last time 10 days prior to the present admission. The patient lost 15 kg, and her BMI on the day of admission was 33.1 kg/m2. On examination at admission the temperature was 38.6 °C, the pulse rate was 140 and the patient was dyspneic. There was evidence of peritoneal irritation, primarily in the epigastrium. A CT scan revealed a huge diaphragmatic
1550-7289/06/$ – see front matter © 2006 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.11.007
62
O. Dukhno et al. / Surgery for Obesity and Related Diseases 2 (2006) 61– 63
Fig 1. Chest x-rays showing the stomach in the left pleural cavity causing mediastinal deviation to the opposite site and compression of the left lung.
hernia with most of the stomach located in the left chest (Figs. 1-2). The band was in its expected position. The patient underwent explorative laparoscopy, in which a small amount of reactive peritoneal fluid and a huge diaphragmatic hernia were seen. Reduction of the hernia content was performed. At the greater curvature of the stomach a necrotic segment was noted and resected with ATG 45 (Ethicon®, Johnson & Johnson, Cincinnati.USA). Following this resection the tear in the left diaphragm to the left of the hiatus became completely evident. The band passed through this tear, encircling the gastro-esophageal junction and part of the left diaphragm. It was evident that band positioning was the cause of the iatrogenic tear of the left diaphragm. The band was removed and the tear was sutured with nonabsorbable sutures. The postoperative course was uneventful. Discussion Recognized complications of LGB include slippage, pouch formation, erosion, balloon dilatation, disconnection of tubing system, esophagitis, esophageal dilatation and port site infection. [5–10] To our knowledge there is no previous report of a diaphragmatic tear with diaphragmatic hernia occurring during LGB. The crucial part of the LGB procedure is the creation of the retro-gastric tunnel. This part of the procedure is
performed blindly since the retro-gastric area cannot be visualized. In the present case, passage of the band through the left diaphragm produced a small tear, the size of the band circumference. The continuous movement of the diaphragm due to respiration, pumping of the heart and swallowing caused an enlargement of this tear, with concurrent adjustment of the band. At the time of operation we found a 4 cm long tear. Most of the stomach had passed through this tear with ensuing necrosis of part of the greater curvature. The clinical picture was acute onset of epigastric pain and dyspnea. The differential diagnosis included pulmonary emboli and obstructive pouch with herniation of the stomach. [9,10] Pulmonary embolism was considered unlikely because three months had elapsed since the initial operation and obstructive pouch was the primary suspicion. Plain chest and abdominal x-rays disclosed an inflated stomach, which created a mass effect in the left chest with deviation of the mediastinum to the right and a well-positioned band. The final diagnosis was made by helical CT scan with contrast material, which demonstrated the incarcerated stomach within the left chest. We felt that this life threatening complication could be repaired by a laparoscopic procedure. The band had to be removed from its original harmful position. In principle the band could have been re-positioned through a new tunnel that did not include the diaphragm, but we preferred not to do that because it
O. Dukhno et al. / Surgery for Obesity and Related Diseases 2 (2006) 61– 63
63
Fig 2. Three-dimensional CT scan with saggital reconstruction showing the incarcerated stomach with the defect in left diaphragm.
would involve an unsterile operation. In the presence of a necrotic gastric segment that had to be resected, we deemed it safer to remove the band altogether. Although this is a very rare life threatening complications, it has to be recognized and treated appropriately. In the present case we encountered an extremely unusual complication of the LBG procedure, i.e., an incarcerated diaphragmatic hernia with a strangulated stomach, which caused pulmonary distress and deviation of the mediastinum. We believe that this rare condition occurred due to the inappropriate initial placement of the band system through the left crura (creating a false route), and ongoing adjustments of the band system results in an enlargement of the defect. This rare complication can be diagnosed by CT and treated by laparoscopic repair. The post-operative course in our patient was uneventful. References [1] Gueto J, Vazquez-Frias JA, Nevarez R, Poggi L, Zundel N. Laparoscopic repair of traumatic diaphragmatic hernia. Surg Lapars Endosc Percutan Tech 2001;11:209 –12.
[2] Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12: 564 – 8. [3] Cadiere GB, Himpens J, Hainaux B, Gaudissart Q, Favretti S, Segato G. Laparoscopic adjustable gastric banding. Semin Laparosc Surg 2002; 9:105–14. [4] Fielding GA, Allen JW. A stet-by-step guide to placement of the Lap-Band ® adjustable gastric banding system. Am J Surg 2002; 184:26S–30S. [5] O’Brien P, Dixon J, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band ®: a prospective study of medium-term effects on weight, health and quality of live. Obes Surg 2002; 12: 625– 60. [6] Chapman AE, Kiroff G, Game P, et al. Adjustable gastric banding in the treatment of obesity: A systematic literature review. Surgery 2004; 135; 326 –51. [7] Chevallier JM, Zinzindohoue F,Douard R, et al. Complications after laparoscopic adjustable gastric banding for morbid obesity: Experience with 1000 patients over 7 years. Obes Surg 2004; 14:407–14. [8] Abu-Abeid S, Szold A. Laparoscopic management of Lap-Band erosion. Obes Surg 2001; 11: 87–9. [9] Landen S, Majerus B, Delugeau V.Complications of gastric banding presenting to the ED. Am J Emerg Med 2005;23:368 –70. [10] Dargent J. Pouch dilatation and slippage after adjustable gastric banding:Is it still an issue? Obes Surg 2003;13:111–5.