Full text of DOI:10.1007/BF03215863

World J. Surg. 25, 1150–1154, 2001
DOI: 10.1007/s00268-001-0097-1
WOR LD
Journal of
SURGERY
©
2001 by the Soci e´ t e´
Internationale de Chirurgie
Lateral Approach to Laparoscopic Repair of Left Diaphragmatic Ruptures
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Pierre Goudet, M.D., Nicolas Cheynel, M.D., Lo ¨ı c Ferrand, M.D., Fr ´e d ´e rique Peschaud, M.D.,
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Jean-Philippe Steinmetz, M.D., Bernard Letourneau, M.D., Jean-Paul Isnardon, M.D.,
Marie-Th ´e r `e se Noirot, M.D., Laurencia Poli, M.D., Marc Freysz, M.D., Patrick Cougard, M.D.
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Service de Chirurgie Visc ´e rale et Urgences, H oˆ pital G ´e n ´e ral, 3 Rue du Faubourg-Raines, BP 1519, 21033 Dijon C ´e dex, France
Service de Chirurgie G ´e n e´ rale, Centre Hospitalier de Clamecy, 14 Route de Beaugy, 58503 Clamecy C ´e dex, France
Department d’Anesth ´e sie et de R ´e animation, H oˆ pital G ´e n ´e ral, 3 Rue du Faubourg-Raines, BP 1519, 21033 Dijon C ´e dex, France
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Abstract. Video-assisted repairs of traumatic diaphragmatic ruptures nique. The second aim was to determine indications and contra-
have been described where thoracoscopy or laparoscopy in the supine
position were used. This study aims to validate a new lateral laparoscopic
approach for left diaphragmatic repairs. Six consecutive patients were
indications in case of immediate or delayed surgery.
operated on for left diaphragmatic rupture using a lateral approach
Population and Method
(Gagner’s position). A series of 362 consecutive patients presenting with
abdominal or thoracic trauma with or without diaphragmatic rupture
over a 2-year period were reviewed retrospectively. Contraindications for
immediate or delayed lateral laparoscopic approach were studied. The
lateral approach provided complete visibility of the subdiaphragmatic
Patients Operated on by Lateral Laparoscopy
From June 1994 to February 1999, six patients aged 16 to 68 and
space, easy reduction of herniated organs, easy thoracic inspection and presenting with a left diaphragmatic rupture were operated on
cleaning, the use of low peritoneal pressure, full range of instrumental using a video-assisted technique. Clinical, anesthetic, and surgical
motion, and rapid diaphragmatic repair. No operative mortality or mor-
descriptions of the six patients are detailed in Tables 1, 2, and 3.
They were operated on using a left lateral transperitoneal ap-
proach (Fig. 1). No patient was operated on within the first 6
bidity was noted. Altogether, 14% to 50% of the patients with diaphrag-
matic ruptures were candidates for immediate lateral laparoscopic repair.
Associated spleen injury in 50% of the cases was the main contraindica-
tion. The lateral laparoscopic approach provides better exposure of the hours after the accident so we could assess the feasibility of the
diaphragm on the left side and facilitates the diaphragmatic repair
especially with a large herniation. Immediate repair is possible in selected
new, highly restrictive contraindications for video-assisted tech-
cases (14–50%). There is no contraindication in case of delayed diagnosis.
technique in the safest conditions. Because this approach was
niques were used: unstable hemodynamic status; head trauma/
spinal cord injury; moderate or abundant hemoperitoneum; ret-
roperitoneal hematoma; lung or mediastinal lesion; splenic, liver,
There is a growing interest in the use of thoracoscopy for the or renal injury (hematoma or rupture); perforated viscus (stom-
diagnosis and treatment of diaphragmatic ruptures and penetrat- ach, small bowel, colon); any fracture requiring immediate oper-
ing injuries to the thorax [1–10]. Thoracoscopy enables one to ation (femoral, pelvic ring, spine bone fracture); any thoracic or
fully explore the entire diaphragmatic surface regardless of side. neurosurgery. A helicoidal thoracoabdominal computed tomog-
Nevertheless, thoracoscopy does not give access to the abdominal raphy (CT) scan was used to rule out associated visceral lesions.
cavity and necessitates selective lung intubation, which is not No operative mortality or morbidity was related to the diaphrag-
always well tolerated in case of recent trauma. Laparoscopy is a matic repair (i.e., pulmonary morbidity, abdominal wall infection
possible alternative. Its diagnostic role has been increasingly rec- or hematoma, trocar incisional hernia).
ognized in case of trauma, but its role in the surgical repair of
abdominal organs is still anecdotal. Suturing a diaphragmatic
rupture or a bowel laceration and autotransfusing a hemoperito-
neum have been described [8, 11]. Since 1995 we have used
Retrospective Analysis of Thoracic and Abdominal Trauma
Patients
video-assisted techniques to repair left diaphragmatic ruptures.
Using the laparoscopic lateral approach for adrenenalectomy, we
noted the large exposure of the diaphragm provided by this
technique. Six consecutive patients with a left rupture were then
operated on successfully.
From January 1, 1995 to December 31, 1996 a total of 362
consecutive patients were referred to our institution for thoracic/
abdominal trauma, with or without associated penetrating injury.
The mean age was 38.6 Ϯ 9.0 years. Most of the patients were
male (n ϭ 259, 71.5%). Altogether, 43% (n ϭ 155) were thoracic
trauma patients, 25% were abdominal trauma patients (n ϭ 90),
and 32% had both abdominal and thoracic trauma (n ϭ 117). The
30-day mortality was 10.5% (n ϭ 38). A diaphragmatic rupture
The first aim of this study was to describe the surgical tech-
Correspondence to: P. Goudet, M.D.

Goudet et al.: Left Diaphragmatic Rupture
1151
Table 1. Clinical data.
Elapsed
time after
accident
Weight Age
Method of
diagnosis
Patient Gender (kg)
(years) Past medical history
Method of trauma
Associated lesions
A.B.
Male
65
68
16
Smoking, chronic
bronchitis
CXR, CT
Car accident: driver None
10 Days
3 Days
A.M.
Female 50
None
CXR, NG tube, CT Car accident: front
passenger
Head trauma
Pelvic bone fracture
Left ankle fracture
J.R.
M.D.
Male
Male
85
80
60
55
Epilepsy (seizure)
Asthma, Paget’s disease CT
CT
Car accident: driver Right ankle fracture
Car accident: driver Left ribs fractured
Left hemothorax
4 Days
6 Hours
Left pneumothorax
A.G.
E.B.
Male
Male
85
80
59
38
None
CXR, NG tube, CT Car accident: driver Left hemothorax
6 Hours
Right forearm fracture
Smoking
CXR, CT
Car accident: driver Left ribs fractured
24 Hours
Left hemothorax
Left pneumothorax
Bilateral lung contusion
Right forearm fracture
CXR: chest radiography; NG: nasogastric; CT: computed tomography.
Table 2. Anesthesiologic data.
ware, Los Angeles, CA, USA). The level of significance was set at
a 5% level.
Insufflation
pressure
(mbar)
Mean blood
pressure
Anesthetic
agents
EtCO2
SpO2
Patient
A.B.
(mmHg)
(mmHg) (%)
Results
Thiopental
Sufentanyl
Vecuronium
Isoflurane
Propofol
Sufentanyl
Atracurium
Isoflurane
22–28
110/70
110/70
100/70
100/60
120/80
120/80
30–35
31–45
30–37
22–35
34–42
37–45
Ն 98
Ն 98
Ն 98
Ն 98
Ն 98
Ն 98
Population Operated on by Video-assisted Techniques
The same technique was used in all cases. The patients were
positioned as described by Gagner for adrenalectomy and sple-
nectomy (Fig. 1) [12, 13]. The four trocars were inserted 1 cm
below the costal brim, and 10 mmHg pneumoperitoneum was
maintained throughout the procedure. The herniated viscus were
pulled back in the abdomen (Fig. 2); and the mediastinum and
lung were checked.
Aspiration and lavage cleaned the pleural space. A 28F thoracic
tube was placed under clear vision. The hiatal ring was reconsti-
tuted using an “X” stitch of 0 silk when required (4/6), and the
remainder of the rupture was closed using running stitches (En-
dostitch No. 0; United States Surgical Corporation, Norwalk, CT,
USA) (Fig. 3). At each stitch, a clip blocked the suture. The
abdomen was exsufflated, and no drain was left in place in the
abdomen.
A.M.
J.R.
20–30
Thiopental 18–21
Sufentanyl
Rocuronium
Isoflurane
Thiopental
Sufentanyl
Rocuronium
Isoflurane
Thiopental Not recorded
Sufentanyl
Rocuronium
Desflurane
M.D.
A.G.
E.B.
15–35
Midazolam 22–39
Fentanyl
Rocuronium
Retrospective Study Results
EtCO : end-tidal CO pressure in exsufflated gas; SpO : transcuta-
2
2
2
neous pulsatile oxygen saturation.
Fourteen diaphragmatic ruptures occured in 362 trauma patients
(3.9%). They were situated on the left side in 10 cases (71.4%)
was found in 3.9% of the cases (14/362). Blunt trauma was always and on the right side in 4 (28.6%).
responsible for the ruptures in this study. Using the former con-
Using previously defined exclusion criteria, 25.9% of the pa-
traindications, we selected a group of patients who would have tients without diaphragmatic rupture (90/348) and 14.3% of the
been able to undergo a lateral video-assisted diaphragmatic repair patients with diaphragmatic rupture (2/14) would have been suit-
safely as soon as possible after admission.
able candidates for a lateral laparoscopic approach. Associated
spleen injuries, hemothorax, and pneumothorax were found more
frequently in the group with diaphragmatic rupture (Table 4).
Among the 14 diaphragmatic rupture cases, there were 3
Statistical Analysis
(21.4%) unstable hemodynamic conditions, 7 (50%) spleen inju-
The BMDP software was used to select groups and to perform the ries with moderate or severe hemoperitoneum, 2 (14.3%) liver
2
comparisons of categorical data with the suitable tests (␹ tests, injuries, 1 (7.1%) lung injury necessitating a thoracotomy, 1
with or without Yates correction; bilateral Fisher exact tests) (2D (7.1%) renal injury with retroperitoneal hematoma, and 6
and 4F programs of Biological Models for Data Processing soft- (42.9%) head trauma/spinal cord injuries; two patients (14.3%)

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World J. Surg. Vol. 25, No. 9, September 2001
Table 3. Surgical data and follow-up.
Operating
Follow-
Patient
A.B.
time
Herniated organs
Site of the rupture
Type of suture
up
1 hour 50 min
Stomach, splenic flexure
8 cm Radial from the esophageal
ring to the phrenic center
Silk suture on the esophageal
ring ϩ Endostitch 0
running stitches
Silk suture on the esophageal
ring ϩ Endostitch 0
running stitches
Silk suture on the esophageal
ring ϩ Endostitch 0
running stitches
Silk suture on the esophageal
ring ϩ Endostitch 0
running stitches
6 Months
A.M.
J.R.
1 hour 30 min
1 hour
Stomach, great omentum, colon
Stomach
12 cm Radial from the
esophageal ring to the phrenic
center
1 Year
10 cm Radial from the
esophageal ring to the phrenic
center
6 Months
3 Months
M.D.
1 hour 30 min
Stomach, spleen
10 cm Posterior transversal
A.G.
E.B.
3 hours
Stomach, splenic flexure
Stomach
12 cm Radial from the back to
the phrenic center
8 cm Radial from the back
toward the phrenic center
Silk suture ϩ Endostitch 0
running stitches
Endostitch 0 running stitches
10 Days
1 hour 30 min
2 Months
required an orthopedic operation immediately. No bowel perfo- Any fluid can be aspirated and any clot removed. The pericardium
ration was founded from CT scan examination.
is inspected, looking for a rupture [27]. A thoracic tube is posi-
tioned under clear vision. Use of an Endostitch No. 0 facilitates the
repair with running stitches of nonabsorbable sutures. No pulmo-
nary complication occurred, confirming the already known advan-
Discussion
In European countries, diaphragmatic ruptures are usually caused tage of the laparoscopic approach over laparotomy. We did not
by blunt trauma during car accidents. Deceleration induces ab- repair any right diaphragmatic rupture. The right side is usually
dominal hyperpressure and may damage the diaphragmatic mus- less concerned than the left one (29% in this series). We think that
cle [14, 15]. Penetrating injuries caused by stab wounds or gun- the same technique is feasible because the right lateral approach
shots seem less frequent than in North America [16]. These data is regularly used for adrenalectomy. A case of laparoscopic repair
are confirmed among the 14 patients with a diaphragmatic rup- of right diaphragmatic rupture has been described with the patient
ture admitted during a 2-year period at our institution. The length lying in the supine position [25].
of the ruptures (around 10 cm) enabled the bowel or the spleen to
pass into the thorax easily.
As far as we know, few cases have been repaired via laparos-
copy or thoracoscopy immediately after trauma [4, 10]. According
Laparotomy is the usual route for checking all the intraabdomi- to our retrospective results and using highly restrictive exclusion
nal organs that may be injured. In the same way, laparoscopy is criteria, only 14% of patients with diaphragmatic rupture would
regularly used to evaluate abdominal trauma [11, 17–23]. Lapa- have been good candidates for laparoscopic immediate repair.
roscopy reduces the number of unnecessary laparotomies, but its The larger incidence of spleen injuries associated with diaphrag-
use to repair a diaphragmatic rupture has seldom been mentioned matic ruptures (50%) highlights the specific hemorragic risk and
in the literature [24, 25]. In contrast, short diaphragmatic ruptures confirms that the laparoscopic lateral approach must be used
have often been managed through thoracoscopy, especially when carefully in emergency situations. After a learning curve period, a
herniation into the thorax is moderate [2, 3, 5, 8–10]. Laparo- less conservative attitude is possible. Some patients with intra-
scopic repairs in the supine position have already been carried out splenic, intrahepatic, and retroperitoneal hematomas or with mi-
successfully [24, 25], although the diaphragmatic surface is not nor lung or renal injuries are good candidates for the videoscopic
completely visible, especially its posterior margin. Thorough in- lateral approach. Minor head trauma patients with normal CT
spection of the spleen and the subdiaphragmatic space is not scans are candidates as well. Two recent patients with associated
possible [7]. Gazzaniga et al. recommended tilting the table to the spleen hematoma and pelvic ring fracture were operated on but
right during the procedure [18]. Park et al. perform splenectomy are not presented because of the lack of follow-up. Another
using the laparoscopic lateral approach [13]. This position enables recent patient with an operation on the right side prompts us to
the surgeon to explore the subdiaphragmatic space easily with a develop this operation bilaterally.
lower pressure because the last ribs act as a roof. Moreover
Nevertheless, no more than 50% of patients are manageable
intraabdominal organs are not pushed into the thorax. The pneu- laparoscopically because spleen injuries with active bleeding re-
moperitoneum pressure does not exceed 10 mmHg at the begin- main a contraindication. Conversely, this technique may be used
ning of the procedure and can be decreased as soon as the in case of delayed diagnosis when the diaphragmatic rupture may
diaphragmatic surface is well exposed. The side effects of intra- be considered an isolated lesion.
abdominal hyperpressure on intracranial pressure are minimized
[
26]. Moreover, the spleen, stomach, colon, and liver are drawn
R ´e sum ´e
out from the operative field with minimal forceps traction. The
immediate subcostal conversion on the trocar line is possible in Fond du probl `e me: La r ´e paration vid ´e o-assist ´e e des ruptures
case of emergency. The mediastinal and thoracic inspection is traumatiques du diaphragme est d ´e j `a bien d ´e crite. L’intervention
carried out at the same time through the diaphragmatic rupture. a lieu en d ´e cubitus dorsal soit par thoracoscopie soit par

Goudet et al.: Left Diaphragmatic Rupture
1153
Fig. 1. Gagner’s lateral position.
Fig. 2. Reduction of herniated organs. The procedure is facilitated by the low insufflation pressure (Ͻ 10 mmHg).
Fig. 3. Running stitches with use of the Endostitch device.
laparoscopie. L’objectif de cette ´e tude a ´e t ´e de valider une rupture diaphragmatique pendant une periode de deux ans. Les
nouvelle approche lat ´e rale laparoscopique pour la r ´e paration des contre-indications `a une r ´e paration lat ´e rale laparoscopique
ruptures diaphragmatiques gauches. Population et m ´e thodes: (1) imm ´e diate ou retard ´e es ont ´e t ´e ´e tudi ´e es. R ´e sultats: (1)
Six patients cons ´e cutifs ont ´e t ´e op ´e r ´e s pour rupture L’approche lat ´e rale permet: une visibilit ´e compl `e te de I’espace
diaphragmatique gauche par I’approche lat ´e rale (position de sous-diaphragmatique, une r ´e duction ais ´e e des organes herni e´ s, la
Gagner). (2) On a revu 362 dossiers cons e´ cutifs de patients ayant possibilit ´e d’inspection et de toilette thoraciques faciles,
eu un traumatisme abdominal et/ou thoracique avec ou sans I’utilisation d’une pression intra-abdominale basse, un champs

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World J. Surg. Vol. 25, No. 9, September 2001
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Resumen
1
Antecedentes: Se sabe, que las rupturas traum a´ ticas del
diafragma pueden ser tratadas mediante viedo-cirugia.
Normalmente se utiliza la toracoscopia o la laparoscopia en
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lateral para la reparaci o´ n de las rupturas diafragm ´a ticas
izquierdas. Casuistica y M ´e todos: (1) Seis pacientes con rupturas
del hemidiafragma izquierdo fueron intervenidos mediante
abordaje lateral (en posici o´ n de Gagner). (2) Se revisaron
retrospectivamente 362 pacientes con traumatismo abdominal y/o
tor ´a cico con o sin ruptura diafragm ´a tica tratados en un periodo
de dos a n˜ os. Se estudiaron las indicaciones y contraindicaciones
del tratamiento precoz
Resultados: (1) El abordaje lateral permite una completa
visualizaci o´ n del espacio subdiafragm ´a tico, facilita la reducci o´ n de
los o´ rganos herniados, siendo la inspecci o´ n tor ´a cica m ´a sf ´a cil y 21. Sackier, J.M., Berci, G., Paz-Partlow, M.: Elective diagnostic laparos-
m ´a s clara; la presi o´ n intrabdominal (neumoperitoneo) necesaria
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1
1
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1
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1
9. Gomel, V.: Laparoscopy in general surgery. Am. J. Surg. 131:319, 1976
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o diferido por via laparosc o´ pica.
2
copy. Am. J. Surg. 161:326, 1991
2
2
2
2
2. Berci, G., Sackier, J.M., Paz-Partlow, M.: Emergency laparoscopy.
es menor y la movilidad de los instrumentos id o´ nea, permitiendo
una r ´a pida reparaci o´ n del defecto diafragm ´a tico. No se registr o´
morbi-mortalidad alguna. (2) Entrel 15 y el 50% de pacientes con
ruptura diafragm ´a tica fueron tratados precozmente mediante
abordaje lateral laparosc o´ pico. La contraindicaci o´ n mayor, en el
Am. J. Surg. 161:332, 1991
3. Livingston, D.H., Tortella, B.J., Blackwood, J.: The role of laparos-
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matiques du diaphragme: a propos de deux cas. J. Coelio. Chin. 21:59,
1997
5
0% de los casos, fue la ruptura concomitante del bazo.
Conclusiones: El abordaje lateral laparosc o´ pico permite una
mejor exposici o´ n del hemidiafragma izquierdo y facilita la 26. Bloomfield, G.L., Ridings, P.C., Blocher, C.R., Marmarou, A., Sug-
erman, H.J.: Effects of intra-abdominal pressure upon cranial and
reparaci o´ n diafragm ´a tica, sobre todo en casos de grandes hernias.
cerebral perfusion pressure before and after volume expansion.
La reparaci o´ n precoz es posible en el 14 al 50% de casos
J. Trauma 40:936, 1996
seleccionados. La intervenci o´ n no est ´a contraindicada en
pacientes diagnosticados tardiamente.
2
7. Shah, R., Sabanathan, S., Mearns, A.J., Choudhury, A.K.: Traumatic
rupture of the diaphragm. Ann. Thorac. Surg. 60:1444, 1995