Diaphragmatic repair and/or reconstruction during upper abdominal urological laparoscopy

We present our experience with and the technique of laparoscopic mesh reconstruction or suture repair of intentional resection or intraoperative injury of the diaphragm.

In a 10-year (1997 to 2006) review of 1,850 upper abdominal renal and/or adrenal laparoscopic procedures at our institution 13 patients (0.7%) sustained diaphragmatic entry, including iatrogenic injury in 7 (0.4%), deliberate laparoscopic excision of a portion of the diaphragm in 2 and diaphragmatic incision during transthoracic adrenalectomy in 4. Laparoscopic repair techniques involved primary suture repair in 11 cases and primary reconstruction with a synthetic graft in 2. A rubber catheter and water seal system were used to primarily evacuate the pneumothorax.

Inadvertent diaphragmatic injury in 7 cases occurred during transperitoneal (6) and retroperitoneal (1) laparoscopy, including partial nephrectomy in 4, radical nephrectomy in 2 and adrenalectomy in 1. A diaphragmatic breach occurred due to hook electrocautery in 5 cases, trocar insertion in 1 and liver retraction in 1. Deliberate diaphragmatic excision and mesh reconstruction in 2 cases were performed after en bloc excision of the diaphragm during radical nephrectomy in 1 and during excision of a metastatic diaphragmatic nodule in 1. Four transthoracic transdiaphragmatic adrenalectomies were completed successfully without any intraoperative complications. All cases were completed laparoscopically without open conversion. A chest tube was placed prophylactically in the initial 2 patients undergoing transthoracic transdiaphragmatic adrenalectomy.

Laparoscopic and transthoracic repair/reconstruction of the diaphragm is safe and effective.