Fig. 4

Surgical findings of case 4. a Thinned diaphragm and cystic lesions were detected at the central tendon of the diaphragm. No pores or bubbles due to laparoscopic pneumoperitoneum were observed on the diaphragm on the thoracic side. b Laparoscopic view of the diaphragmatic fistulas. Two small fissures with a diameter of 1 mm were detected on the abdominal side; we soaked the dye containing indigo carmine into the pores in the peritoneal cavity. c Two lesions with blue staining were noted on the diaphragm from the thoracic side. d Each lesion was closed with a 4–0 non-absorbable monofilament and Teflon pledget, with single U suture. Furthermore, the lesions were covered with a sheet of absorbable polyglycolic acid felt and sprayed with fibrin glue on the thoracic side