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How I Do It: Robotic Diaphragmatic Hernia Repair
Anne O'Shea, MD, Dianela Perdomo, MD, Klara Schwarzova, MD, Stephen Yang, MD.
Johns Hopkins, Baltimore, MD, USA.
BACKGROUND: There are limited descriptions of robotic transthoracic diaphragmatic hernia repairs available in the literature. Given the versatility of the robot and the superior visibility afforded by the robotic camera, robotic repair is safe and reproducible.
METHODS: We present a video case of a robotic transthoracic diaphragmatic hernia repair performed in a patient who developed an acquired hernia following abdominal surgery that was not amenable to primary repair.
RESULTS: A 49 year-old-female with a history of Stage IIIB dedifferentiated liposarcoma located in the left retroperitoneum underwent a radical resection of her tumor en bloc with surrounding structures. Her surgery included a distal pancreatectomy and splenectomy, partial gastrectomy, partial colectomy, radical left nephrectomy, and resection of a portion of the left diaphragm with primary repair. She recovered well from the operation and completed adjuvant chemotherapy without issue. Surveillance imaging was obtained demonstrating no cancer recurrence; however, the patient was incidentally noted to have a small bowel-containing diaphragmatic hernia for which she was referred to thoracic surgery for consideration of a transthoracic repair given her significant previous abdominal surgery. She was taken to the operating room electively. Using the DaVinci Xi system (Intuitive Surgical, Sunnyvale, CA) we were able to identify the hernia, excise the hernia sac, and reduce the small bowel intra-abdominally. Owing to her previous diaphragm resection and primary repair, the patients defect though small was unable to be closed primarily without tension. A small piece of XenMatrix biologic graft (BD, Franklin Lakes, NJ) was placed sub-diaphragmatically and secured in place with interrupted, pledgeted, mattress sutures using non-absorbable, barbed suture. The patient made an uneventful recovery and upon outpatient follow-up has no complaints and no evidence of recurrence on plain films.
CONCLUSIONS: Our video presentation demonstrates the safety and effectiveness of robotic transthoracic diaphragmatic hernia repair. It is an important alternative to open thoracotomy in patients with hostile or frozen abdomens. In cases in which the diaphragm cannot be closed primarily, mesh can be secured to close the defect.
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