A 4-month-old girl showing severe heart failure was referred to our hospital. Echocardiography revealed remarkable dilatation of the left ventricle, severe mitral regurgitation, and a low left ventricular ejection fraction (15%), and she was diagnosed with dilated cardiomyopathy (DCM). She received temporary LVAD implantation (ROTA flow), followed by exchange to a BHE device. At the implantation of the LVAD, the pericardium and diaphragm were dissected from the anterior chest wall using LigaSureTM (Medtronic, Minneapolis, MN, USA).
At 7 months of age (body weight, 5 kg), she received a surgical consult for intermittent emesis and irritability. Her abdomen was soft, and gurgle was heard at the left chest. Plain X-ray showed suspected intestinal loops in her left thorax (Fig. 1a). Plain chest and abdominal computed tomography confirmed the diagnosis of diaphragmatic hernia with herniation of the small intestine (Fig. 1b). The laboratory findings were normal. Ultrasonography revealed intestinal tracts with maintained blood flow in the left thorax. In the absence of findings of bowel ischemia, an operation was performed electively after decompressing the intestinal tract. Her anticoagulant management was maintained with aspirin, dipyridamole, and warfarin preoperatively. Prior to the operation, the effect of warfarin was reversed with lyophilized human prothrombin complex concentrate (Kcentra®; CSL Behring, King of Prussia, PA, USA).
Since a transperitoneal approach was not possible due to the blood pump and cannulae just above the abdomen (Fig. 2a), thoracoscopic repair was performed. She was placed in the right lateral decubitus position, and BHE cannulae (inflow and outflow) were fixed to her abdomen (Fig. 2b). Three 5-mm trocars were placed at the midaxillary line at the 7th intercostal space (ICS), the posterior axillary line at the 8th ICS, and the posterior axillary line at the 10th ICS. Artificial pneumothorax (5 mmHg) using carbon dioxide was established. Following manual reduction of the herniated small intestine using a 5-mm laparoscopic blunt-tip dissector (ETHICON, Bridgewater, NJ, USA), the diaphragmatic defect (3 × 2 cm) was identified just lateral to the cannula (Fig. 3). Although the lateral rim was substantial, the medial and ventral rims were fragile. First, one thread was applied and ligated. Pulling this thread allowed us to find the rim of the orifice and peritoneum. We took care that all stitches pass through the peritoneum in both sides of the defect. The most medial thread partially passed the pericardium (Fig. 4). The most ventral knot was ligated subcutaneously with the aid of a 19-G needle (Lapa-her-closure®; Hakko, Chikuma, Japan), which has a wire loop to hold and release a thread (Fig. 5). Finally, the defect was closed with 7 interrupted sutures using 2-0 non-absorbable suture materials (Fig. 6). A 10-Fr chest tube was placed through the most caudal incision. Intraoperative bleeding was 1 ml.
Her postoperative course was uneventful, and she is waiting for heart transplantation.