Exploratory Laparotomy for Bowel Obstruction with Primary Repair of Two Diaphragmatic Hernias

Introduction

A diaphragmatic hernia (DH) is characterized by protrusion of abdominal organs into the chest cavity through an opening in the diaphragm. Congenital diaphragmatic hernias occur in 0.045% of births.¹ A sliding or paraesophageal hernia is the most prevalent type, characterized by its occurrence near the esophageal hiatus. Typically present since birth, it can also develop later in life, occasionally arising as a result of severe trauma or iatrogenic injury. Less often, congenital DHs protrude through posterolateral or substernal diaphragmatic defects, referred to as Bochdalek and Morgagni hernias, respectively.

DH can remain asymptomatic and is commonly detected as an incidental finding during evaluation for other medical issues. Hiatal hernias differ from abdominal wall hernias in that they are influenced by the constant motion of the diaphragm, which exerts continuous friction and pressure changes on the esophagus and the stomach. As a result, hiatal hernias have a higher likelihood of recurrence following surgical correction in comparison to abdominal hernias. Right-sided hernias may enclose the liver, the right kidney, or fat, whereas hernias on the left can allow intestines, spleen, the left liver lobe, pancreas, the left kidney, or fat to enter the chest cavity.² Additionally, some patients present with bowel obstruction as a complication of DH, although incarceration and strangulation are rather rare.³ In general, late presentation of congenital diaphragmatic hernia is reported to occur in 5–25% of all cases. Bowel obstruction is a relatively rare complication of DH in adults.⁴

Case Overview

The patient, a 46-year-old female, has been dealing with frequent bloating and epigastric discomfort for the past 2 years. Recently, over the last 3 days, her condition worsened as she began to experience constipation, nausea and bilious vomiting, heartburn, and a vague mesogastric pain. This escalation in symptoms led to her arrival at the emergency department, where she was diagnosed with a rare and challenging surgical condition. Her small intestine and colon had entered the chest through a diaphragmatic hernia (DH), resulting in an obstruction. Interestingly, the patient reported switching to a high fiber diet for weight loss recently, which could have potentially triggered the sudden exacerbation of her symptoms.

The case was further complicated by the patient's medical history spanning multiple surgeries, including Roux-en-Y gastric bypass (RYGB) for weight-loss, previous diaphragmatic hernia repair, and several abdominoplasties. An emergency exploratory laparotomy via supraumbilical midline incision was initiated to safely access the abdominal cavity. Two DHs were identified, one containing the small intestine, positioned more anteriorly and toward the left side of the sternum, and the other containing the transverse colon, positioned toward the right side. During the exploration and reduction of the small bowel and colon, the surgical team faced several challenges. The organs were fused over the liver, and a previous hernioplasty stitch and the mesh further complicated reduction. Although reducing the small bowel was relatively straightforward, the hernia sac holding the colon had several adhesions. Following the reduction of the colon, a primary pledgeted repair of the diaphragm securing the sutures to the upper abdomen and the chest wall was attempted. The use of pledgets to reinforce hiatal sutures is considered safe and may be associated with a lower early recurrence. The pledgets are placed to prevent the tension and further tearing of the diaphragmatic muscle. A recent study evaluating the outcomes of using pledgeted sutures for hiatal closure demonstrated that recurrence rate following surgery was 6.8% (3/44 patients) at 3 months and 10.8% (4/37 patients) at 1 year, with notably only one patient experiencing symptoms.⁵

A careful examination of the abdominal organs and mesenteric vessels was then performed. The small bowel and colon appeared healthy and well-perfused with no signs of abnormalities. Thorough hemostasis was achieved, and the midline incision was sutured in a standard fashion.

This exploratory laparotomy with primary repair addressed the patient's bowel obstruction resulting from the DHs, requiring careful navigation through the intricacies posed by her past medical history and the complexity of her diaphragm’s altered anatomy.