Robotic transthoracic diaphragmatic hernia repair

摘要

Central MessageRobotic transthoracic repair is a useful approach for diaphragmatic hernia repair in the presence of a hostile abdomen.See Commentaries on pages 581 and 582. Robotic transthoracic repair is a useful approach for diaphragmatic hernia repair in the presence of a hostile abdomen. See Commentaries on pages 581 and 582. Diaphragmatic hernias are rare entities that can be congenital, traumatic, or iatrogenic.1Kim J.K. Desai A. Kunac A. Merchant A.M. Lovoulos C. Robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture.Surg J (N Y). 2020; 6: e164-e166Crossref PubMed Google Scholar Transthoracic hernia repairs are most often performed via open thoracotomy, with few reports of robotic-assisted approaches.1Kim J.K. Desai A. Kunac A. Merchant A.M. Lovoulos C. Robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture.Surg J (N Y). 2020; 6: e164-e166Crossref PubMed Google Scholar, 2Counts S.J. Saffarzadeh A.G. Blasberg J.D. Kim A.W. Robotic transthoracic primary repair of a diaphragmatic hernia and reduction of an intrathoracic liver.Innovations (Phila). 2018; 13: 54-55Crossref PubMed Scopus (3) Google Scholar, 3Campbell S. Kipnis S. Robotic repair of an incarcerated right-sided diaphragmatic hernia after liver resection.https://www.ctsnet.org/article/robotic-repair-incarcerated-right-sided-diaphragmatic-hernia-after-liver-resectionDate accessed: June 9, 2021Google Scholar We report a case that illustrates our technique of transthoracic diaphragmatic hernia repair with mesh using the da Vinci Xi robotic platform in the presence of an extremely hostile abdomen. The Memorial Sloan Kettering Cancer Center institutional review board approved the submission, as this does not constitute human subjects research and the project does not involve identifiable patient information (#16-1631, October 27, 2020). The patient gave informed written consent for the publication of the study data. A 41-year-old woman with stage IV high-grade serous ovarian carcinoma was referred to our clinic. The disease involved bilateral diaphragms, the posterior aspect of the liver, the inferior vena cava, and Morison's pouch. Additional findings were diffuse peritoneal carcinomatosis and large bilateral ovarian masses, disease along the bladder and uterosacral ligaments, and cancerous nodules on the surface of a 4-cm segment of colon. She underwent radical total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, bilateral diaphragmatic stripping, appendectomy, and total peritoneal stripping. On 6-month computed tomography of the chest, abdomen, and pelvis, a new giant left diaphragmatic hernia was noted with distended stomach in the left chest, for which she was referred to thoracic surgery for repair (Figure 1). We used the da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, Calif) with a 0-degree camera to minimize pressure on the intercostal nerve. Before incision, an esophagogastroscopy was performed, and the stomach was decompressed. Placement of an orogastric tube ensured continued gastric decompression and facilitated visualization during the operation. Port placement is shown in Figure 2. The camera was introduced in the sixth intercostal space at the posterior axillary line. Targeting of the platform was performed to the hernia defect. The AirSeal system (CONMED, Utica, NY) was introduced at the eighth intercostal space as anterior as possible for smoke evacuation and insufflation. A monopolar spatula was inserted through an 8-mm port at the sixth interspace at the anterior axillary line, and fenestrated bipolar forceps with bipolar cautery were placed through an 8-mm port at the seventh intercostal space posterior to the tip of the scapula. We used 3 arms and an assistant port for our dissection; however, the addition of a fourth retracting arm posteriorly near the diaphragm can facilitate dissection and exposure. The patient was placed in reverse Trendelenburg position at 30 d