Laparoscopic repair of giant diaphragmatic hernia after minimal invasive esophagectomy: a case report and review of the literature

Abstract

: The incidence of esophageal cancer (EC) is rapidly increasing, as well as the overall survival of patients affected by it, given the improvement in its multimodal treatment. Minimally invasive esophagectomy (MIE) is the cornerstone to reach this goal, but the alteration of the anatomy that comes along with the surgery leads to an increased risk of diaphragmatic hernia (DH). This latter is a rare but highly morbid complication of MIE, which is expected to become more and more relevant. A 61-year-old man undergone to MIE for cancer, with uneventful immediate post-operative course, presented to our observation, 8 years after the procedure, with unspecific abdominal pain and vomiting. The CT scan showed a giant DH involving the small bowel and the transverse colon, which ascended in the thoracic cavity through a large defect of the left hemi diaphragm. A laparoscopic transabdominal repair, with direct suture of the diaphragm pillars, was performed. We did not record any immediate or long term post-operative complications, but a recurrence at 2 years CT scan follow-up. We treated the recurrent DH with an open repair employing a dual mesh placed on the left hemi diaphragm. No post-operative complications or further recurrences have been recorded. DH may be a life threatening early or long term post-esophagectomy complication. Nowadays, still little is known on its risk factors, and it has a nuanced clinical presentation, which frequently brings to a delayed diagnosis. Moreover, to the best of our knowledge a general consensus is lacking on the most appropriate attitude or technique to adopt in front of this uncommon disease. Our personal experience shows the efficacity and safety of a surgical approach, with direct suture, in a symptomatic post-MIE.