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Repair of a Diaphragmatic Injury During Hand Assisted Laparoscopic Nephrectomy Using an Onlay Patch of Polypropylene and Polyglactin Mesh
0022-5347/02/1676-2512/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 2512–2513, June 2002 Printed in U.S.A.
Urologists at Work REPAIR OF A DIAPHRAGMATIC INJURY DURING HAND ASSISTED LAPAROSCOPIC NEPHRECTOMY USING AN ONLAY PATCH OF POLYPROPYLENE AND POLYGLACTIN MESH CHRIS M. GONZALEZ, ROBERT A. BATLER, MICHAEL FELDMAN, JONATHON N. RUBENSTEIN, ROBERT B. NADLER AND RICHARD A. SCHOOR From the Veterans Administration Lakeside Division and Northwestern University Department of Urology, Chicago, Illinois
ABSTRACT
Purpose: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. Materials and Methods: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 ⫻ 2 piece of polypropylene mesh to a 2 ⫻ 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. Results: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. Conclusions: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing. KEY WORDS: kidney, nephrectomy, laparoscopy, intraoperative complications, surgical mesh
Hand assisted laparoscopic radical nephrectomy represents an effective, minimally invasive treatment option in patients with clinical stage T1 disease and in select patients with stage T2 renal cell carcinoma.1, 2 Coincident with the increasing number of hand assisted laparoscopic nephrectomies performed each year is the development of complications unique to urologists performing laparoscopic surgery. Little data exist in the literature on the management of diaphragmatic injury that occurs during laparoscopic radical nephrectomy.3 We describe the use of a patch of polypropylene and polyglactin mesh for repairing a small diaphragmatic injury occurring during hand assisted laparoscopic nephrectomy. To our knowledge we report the first case in the literature of the successful use of a dual layer mesh patch for laparoscopic repair of an intraoperative diaphragmatic injury.
muscular leaflet of the right hemidiaphragm just behind and yet not involving the lateral lobe of the liver. Lung parenchyma was not visualized and there was no bloody efflux from the site of the injury. The patient remained hemodynamically stable with no evidence of respiratory compromise, and so hand assisted laparoscopic radical nephrectomy was
CASE REPORT
A 57-year-old male with a history of coronary artery disease and hypertension presented with gross hematuria. Computerized tomography revealed a 6.8 cm. contrast enhancing upper pole right renal mass. Metastatic evaluation demonstrated no evidence of distant disease. The patient underwent hand assisted laparoscopic right radical nephrectomy. The renal mass was adherent to the diaphragm in the posterior plane. After dissection of this area a 1 cm. diaphragmatic injury was noted. The injury was located over the Accepted for publication January 4, 2002.
FIG. 1. Extracorporeal development of dual layer mesh of polypropylene and polyglactin introduced into peritoneal cavity through hand assistance device. 2512
REPAIR OF DIAPHRAGMATIC INJURY DURING NEPHRECTOMY
completed. After the specimen was removed a dual layer patch of polypropylene and polyglactin mesh was used to repair the diaphragmatic injury. MATERIALS AND METHODS
A dual layer of polypropylene and polyglactin mesh was created extracorporeally by suturing a 2 ⫻ 2 cm. patch of polyglactin mesh to a 2 ⫻ 2 cm. patch of polypropylene mesh with 4, 4-zero polyglactin sutures (fig. 1). This dual layer mesh patch was then positioned manually over the diaphragmatic rent through the hand assistance device with the edges of the patch secured to the diaphragm using a Pro-Tak stapler (United States Surgical Co., Norwalk, Connecticut) (fig. 2). The dual layer mesh patch was positioned, so that the polyglactin mesh side was exposed to the peritoneal cavity. Although simple aspiration of the pneumothorax after desufflation may have sufficed, a 16Fr chest tube was placed at surgery. RESULTS
Total operative time was 3.5 hours with an estimated blood loss of 100 cc. Placement of the dual layer patch over the diaphragmatic rent extended the procedure by 25 minutes. Pneumothorax was not identified on chest radiography postoperatively. Minimal serosanguinous drainage was evacuated from the chest tube and it was successfully removed 36 hours after surgery. The patient received 30 mg. ketorolac pushed intravenously every 6 hours for the first 24 hours postoperatively and was then changed to acetaminophen orally. He was discharged home 72 hours after the procedure. Pathological evaluation of the renal mass revealed stage pT2N0Mx Fuhrman grade 3 clear cell carcinoma. At 14 months postoperatively the patient remained disease-free on radiography with no pulmonary or gastrointestinal sequelae. DISCUSSION
Laparoscopic repair of a traumatic diaphragmatic rupture, herniation or laceration has been previously described.4 – 6
2513
Recently Potter et al reported using an endoscopic stitching device for primary repair of a 3 cm. diaphragmatic injury during laparoscopic radical nephrectomy, although repair durability is unknown since postoperative followup was not mentioned.3 Previous data indicate that the approach of laparoscopic primary closure of diaphragmatic defects with nonabsorbable suture provides durable repair comparable to that of open repair.5 Our technique represents a simple, tension-free, time efficient (25 minutes) management strategy for a diaphragmatic injury that occurred during right hand assisted laparoscopic radical nephrectomy. Animal data corroborates the efficacy and strength of laparoscopic mesh patch repair for diaphragmatic lacerations (less than 2 cm.) compared with other laparoscopic or open stapling or suture techniques.7 We designed a dual layer patch of nonabsorbable polypropylene and absorbable polyglactin mesh since the use of absorbable mesh alone for diaphragmatic defect repair remains unproven.8 The dual mesh patch adheres to the known principles of diaphragmatic injury repair, including tension-free, airtight repair using nonabsorbable mesh. Furthermore, the risk of small bowel erosion into the nonabsorbable mesh layer was circumvented through intraperitoneal placement of the polyglactin mesh side of the patch. To our knowledge we report the first known intraoperative laparoscopic repair of a small diaphragmatic injury with a dual layer patch of absorbable and nonabsorbable mesh during radical nephrectomy. Our choice of this repair was based on the availability and ease of fashioning a dual layer of mesh suitable for stapling over the diaphragmatic laceration, while adhering to known surgical principles of diaphragmatic injury repair. Our patient continues to have no clinical or radiographic sequelae due to this injury more than 1 year after surgery. CONCLUSIONS
The technique of stapling a dual layer patch over the diaphragmatic injury has the advantages of manual and tactile sensation through the hand assistance device, provides tension-free repair and avoids laparoscopic suturing. Further data are needed regarding this repair and its ease using a pure laparoscopic approach. Nevertheless, the apparent simplicity of this technique to close diaphragmatic injuries provides another useful tool in the armamentarium of beginning and advanced laparoscopists. REFERENCES
FIG. 2. Dual layer mesh is secured to diaphragmatic rent with laparoscopic stapler. Polyglactin side of dual layer mesh is placed within peritoneal cavity.
1. Sosa, R. E., Seiba, M. and Shichman, S.: Hand-assisted laparoscopic surgery. Semin Laparosc Surg, 7: 185, 2000 2. Fadden, P. T. and Nakada, S. Y.: Hand-assisted laparoscopic renal surgery. Urol Clin North Am, 28: 167, 2001 3. Potter, S. R., Kavoussi, L. R. and Jackman, S. V.: Management of diaphragmatic injury during laparoscopic nephrectomy. J Urol, 165: 1203, 2001 4. Smith, R. S., Fry, W. R., Morabito, D. J., Koehler, R. H. and Organ, C. H., Jr.: Therapeutic laparoscopy in trauma. Am J Surg, 170: 632, 1995 5. Cougard, P., Goudet, P., Arnal, E. and Ferrand, F.: Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position. Ann Chir, 125: 238, 2000 6. Meyer, G., Huttl, T. P., Hatz, R. A. and Schildberg, F. W.: Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc, 14: 1010, 2000 7. Kozar, R. A., Kaplan, L. J., Cipolla, J., Meija, J. and Haber, M. M.: Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res, 97: 164, 2001 8. Ramadwar, R. H., Carachi, R. and Young, D. G.: Collagencoated, Vicryl mesh is not a suitable material for repair of diaphragmatic defects. J Pediatr Surg, 32: 1708, 1997
Vol. 167, 2512–2513, June 2002 Printed in U.S.A.
Urologists at Work REPAIR OF A DIAPHRAGMATIC INJURY DURING HAND ASSISTED LAPAROSCOPIC NEPHRECTOMY USING AN ONLAY PATCH OF POLYPROPYLENE AND POLYGLACTIN MESH CHRIS M. GONZALEZ, ROBERT A. BATLER, MICHAEL FELDMAN, JONATHON N. RUBENSTEIN, ROBERT B. NADLER AND RICHARD A. SCHOOR From the Veterans Administration Lakeside Division and Northwestern University Department of Urology, Chicago, Illinois
ABSTRACT
Purpose: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. Materials and Methods: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 ⫻ 2 piece of polypropylene mesh to a 2 ⫻ 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. Results: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. Conclusions: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing. KEY WORDS: kidney, nephrectomy, laparoscopy, intraoperative complications, surgical mesh
Hand assisted laparoscopic radical nephrectomy represents an effective, minimally invasive treatment option in patients with clinical stage T1 disease and in select patients with stage T2 renal cell carcinoma.1, 2 Coincident with the increasing number of hand assisted laparoscopic nephrectomies performed each year is the development of complications unique to urologists performing laparoscopic surgery. Little data exist in the literature on the management of diaphragmatic injury that occurs during laparoscopic radical nephrectomy.3 We describe the use of a patch of polypropylene and polyglactin mesh for repairing a small diaphragmatic injury occurring during hand assisted laparoscopic nephrectomy. To our knowledge we report the first case in the literature of the successful use of a dual layer mesh patch for laparoscopic repair of an intraoperative diaphragmatic injury.
muscular leaflet of the right hemidiaphragm just behind and yet not involving the lateral lobe of the liver. Lung parenchyma was not visualized and there was no bloody efflux from the site of the injury. The patient remained hemodynamically stable with no evidence of respiratory compromise, and so hand assisted laparoscopic radical nephrectomy was
CASE REPORT
A 57-year-old male with a history of coronary artery disease and hypertension presented with gross hematuria. Computerized tomography revealed a 6.8 cm. contrast enhancing upper pole right renal mass. Metastatic evaluation demonstrated no evidence of distant disease. The patient underwent hand assisted laparoscopic right radical nephrectomy. The renal mass was adherent to the diaphragm in the posterior plane. After dissection of this area a 1 cm. diaphragmatic injury was noted. The injury was located over the Accepted for publication January 4, 2002.
FIG. 1. Extracorporeal development of dual layer mesh of polypropylene and polyglactin introduced into peritoneal cavity through hand assistance device. 2512
REPAIR OF DIAPHRAGMATIC INJURY DURING NEPHRECTOMY
completed. After the specimen was removed a dual layer patch of polypropylene and polyglactin mesh was used to repair the diaphragmatic injury. MATERIALS AND METHODS
A dual layer of polypropylene and polyglactin mesh was created extracorporeally by suturing a 2 ⫻ 2 cm. patch of polyglactin mesh to a 2 ⫻ 2 cm. patch of polypropylene mesh with 4, 4-zero polyglactin sutures (fig. 1). This dual layer mesh patch was then positioned manually over the diaphragmatic rent through the hand assistance device with the edges of the patch secured to the diaphragm using a Pro-Tak stapler (United States Surgical Co., Norwalk, Connecticut) (fig. 2). The dual layer mesh patch was positioned, so that the polyglactin mesh side was exposed to the peritoneal cavity. Although simple aspiration of the pneumothorax after desufflation may have sufficed, a 16Fr chest tube was placed at surgery. RESULTS
Total operative time was 3.5 hours with an estimated blood loss of 100 cc. Placement of the dual layer patch over the diaphragmatic rent extended the procedure by 25 minutes. Pneumothorax was not identified on chest radiography postoperatively. Minimal serosanguinous drainage was evacuated from the chest tube and it was successfully removed 36 hours after surgery. The patient received 30 mg. ketorolac pushed intravenously every 6 hours for the first 24 hours postoperatively and was then changed to acetaminophen orally. He was discharged home 72 hours after the procedure. Pathological evaluation of the renal mass revealed stage pT2N0Mx Fuhrman grade 3 clear cell carcinoma. At 14 months postoperatively the patient remained disease-free on radiography with no pulmonary or gastrointestinal sequelae. DISCUSSION
Laparoscopic repair of a traumatic diaphragmatic rupture, herniation or laceration has been previously described.4 – 6
2513
Recently Potter et al reported using an endoscopic stitching device for primary repair of a 3 cm. diaphragmatic injury during laparoscopic radical nephrectomy, although repair durability is unknown since postoperative followup was not mentioned.3 Previous data indicate that the approach of laparoscopic primary closure of diaphragmatic defects with nonabsorbable suture provides durable repair comparable to that of open repair.5 Our technique represents a simple, tension-free, time efficient (25 minutes) management strategy for a diaphragmatic injury that occurred during right hand assisted laparoscopic radical nephrectomy. Animal data corroborates the efficacy and strength of laparoscopic mesh patch repair for diaphragmatic lacerations (less than 2 cm.) compared with other laparoscopic or open stapling or suture techniques.7 We designed a dual layer patch of nonabsorbable polypropylene and absorbable polyglactin mesh since the use of absorbable mesh alone for diaphragmatic defect repair remains unproven.8 The dual mesh patch adheres to the known principles of diaphragmatic injury repair, including tension-free, airtight repair using nonabsorbable mesh. Furthermore, the risk of small bowel erosion into the nonabsorbable mesh layer was circumvented through intraperitoneal placement of the polyglactin mesh side of the patch. To our knowledge we report the first known intraoperative laparoscopic repair of a small diaphragmatic injury with a dual layer patch of absorbable and nonabsorbable mesh during radical nephrectomy. Our choice of this repair was based on the availability and ease of fashioning a dual layer of mesh suitable for stapling over the diaphragmatic laceration, while adhering to known surgical principles of diaphragmatic injury repair. Our patient continues to have no clinical or radiographic sequelae due to this injury more than 1 year after surgery. CONCLUSIONS
The technique of stapling a dual layer patch over the diaphragmatic injury has the advantages of manual and tactile sensation through the hand assistance device, provides tension-free repair and avoids laparoscopic suturing. Further data are needed regarding this repair and its ease using a pure laparoscopic approach. Nevertheless, the apparent simplicity of this technique to close diaphragmatic injuries provides another useful tool in the armamentarium of beginning and advanced laparoscopists. REFERENCES
FIG. 2. Dual layer mesh is secured to diaphragmatic rent with laparoscopic stapler. Polyglactin side of dual layer mesh is placed within peritoneal cavity.
1. Sosa, R. E., Seiba, M. and Shichman, S.: Hand-assisted laparoscopic surgery. Semin Laparosc Surg, 7: 185, 2000 2. Fadden, P. T. and Nakada, S. Y.: Hand-assisted laparoscopic renal surgery. Urol Clin North Am, 28: 167, 2001 3. Potter, S. R., Kavoussi, L. R. and Jackman, S. V.: Management of diaphragmatic injury during laparoscopic nephrectomy. J Urol, 165: 1203, 2001 4. Smith, R. S., Fry, W. R., Morabito, D. J., Koehler, R. H. and Organ, C. H., Jr.: Therapeutic laparoscopy in trauma. Am J Surg, 170: 632, 1995 5. Cougard, P., Goudet, P., Arnal, E. and Ferrand, F.: Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position. Ann Chir, 125: 238, 2000 6. Meyer, G., Huttl, T. P., Hatz, R. A. and Schildberg, F. W.: Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc, 14: 1010, 2000 7. Kozar, R. A., Kaplan, L. J., Cipolla, J., Meija, J. and Haber, M. M.: Laparoscopic repair of traumatic diaphragmatic injuries. J Surg Res, 97: 164, 2001 8. Ramadwar, R. H., Carachi, R. and Young, D. G.: Collagencoated, Vicryl mesh is not a suitable material for repair of diaphragmatic defects. J Pediatr Surg, 32: 1708, 1997