Diaphragmatic hernia is a rare complication after hepatectomy, with some case reports having been published and only two case series of treatment outcomes [3, 4]. Normally, the liver serves as a block against herniation of abdominal contents into the right thorax and, therefore, diaphragmatic hernia rarely occurs on the right side in persons without surgical history . The clinical manifestation of diaphragmatic hernia can differ widely, depending on the side of involvement of the herniated organs. All DH that develop following right hepatectomy are right-sided [3, 4] which, in our case, included symptoms resulting from the entrapment of the ileus. Francesco et al. reported an incidence rate of postoperative DH following right-sided hepatectomy of 2.3% (3/131), with the DH development with a median delay of 14 months in their case series .
The risk factors for DH after hepatectomy include (1) undetected direct injury or thermal injury by electrocautery to the diaphragm during mobilization of the liver; (2) a fragile thin musculature in the congenitally weak area of the posterior diaphragm, between the costal and lumbar portions of the diaphragm; and (3) the pressure gradient between the abdominal and thoracic cavities. The defect may enlarge progressively, resulting from the constant diaphragmatic motion or the adhesions that form after surgery, with the inflamed postoperative scar tissue exerting traction on the diaphragm . In addition, Scott et al. reported right hepatectomy for liver transplantation to carry the greatest risk for DH because of the right diaphragmatic attachments to the liver, which cover a relatively large surface area and are substantially more adherent than on the left side of the diaphragm and, therefore, increase the risk of inadvertent injury during liver mobilization . The patient in our case report had undergone hepatectomy with a diaphragm incision and intra-operative direct repair, and then the defect of the DH was observed to be clearly separated from the suture area during the first laparotomy performed. Similarly, at the time of our DH repair, the defect was confirmed as being different from the suture area. In our patient, although the cause of DH was still unclear, thermal injury by electrocautery might have weakened the diaphragm during the previous procedure.
DH repair can be performed by laparotomy, laparoscopy, or thoracoscopy, with the approach selected based on the preference of a surgeon, the anatomical location of the defect, and the degree of sub-diaphragmatic adhesions. Tabrizian et al. reported that a thoracic approach might be the best approach when dealing with recurrence after an abdominal repair . In our case, we selected a laparoscopic approach as it provided a better approach than thoracotomy for instrument and bowel manipulation, as well as being deemed to be more appropriate based on the expectation of adhesions in the thoracic due to prior thoracotomy. Moreover, the approach allowed us to separate the adhesion of the herniated bowel to the right of the diaphragm and to subsequently repair the damaged pleural lining using a laparoscopic transdiaphragmatic route.
Our review of the literature in PubMed, using “diaphragmatic hernia” and “hepatectomy” or “liver surgery” or “liver resection” as keywords, identified only two cases of DH after hepatectomy with both being repaired by laparoscopic procedure [4, 8]. We did not find reports of laparoscopic surgery for recurrent DH after hepatectomy. Therefore, our case is important in demonstrating the effectiveness of laparoscopic surgery for repair of a diaphragmatic defect, providing a sufficient working space and an increased field of view.
With regard to the repair of the defect itself, some authors have reported on the use of prosthetic material as reinforcement, whereas other authors preferred simple suturing of the defect. However, it is generally agreed that defects larger than 20–30 cm2 do require use of a prosthesis . Different types of mesh can be used for DH repair, including polypropylene, composite, or biological mesh, with a polypropylene mesh being most commonly used. Although polypropylene mesh is more expensive than other types of mesh, it is preferred due to the low associated rate of infection . In our case, the diaphragmatic defect was sufficiently small, allowing us to proceed with a direct suture repair and, thereby, avoiding adverse events associated with using a mesh.
In conclusion, in this rare case of recurrence of DH following hepatectomy for trauma, laparoscopic surgery was found to be effective for the diagnosis and repair of a DH.