V10-05: Tension Pneumothorax from Occult Diaphragmatic Hernia During Robotic Pyeloplasty - Step-By-Step Management
Diaphragmatic hernia is a rare condition, and may be undiagnosed preoperatively. In transperitoneal procedures such as Robot-Assisted Laparoscopic Pyeloplasty (RALP), a diaphragmatic hernia allows intraperitoneal pressure to communicate freely with the pleural space, which mimics the physiology of a tension pneumothorax. Thus, recognition and treatment of this condition is critical.
We present the case of a 9-year-old boy with a history of heterotaxy and repaired congenital cardiac disease who presented with a symptomatic right ureteropelvic junction obstruction. At the time of infant cardiac surgery his mediastinum and right pleural space were drained with infracostal exit of the right chest tube. These had been removed 48 hours postoperatively.
8 years later, the patient underwent RALP with transperitoneal approach. On insufflation, elevated end-tidal carbon dioxide and increased peak inspiratory pressure heralded the possibility of thoracic communication of insufflated gas. A diaphragmatic hernia was identified. Immediate management is discussed and demonstrated, including placement of a chest tube under thoracoscopic guidance. This minimizes risk of injury to the lung parenchyma while rapidly correcting mediastinal shift. The diaphragmatic hernia was repaired using free-hand laparoscopy and the majority of the existing ports. Passage of an additional instrument near the costal margin greatly facilitated closure by placing the laparoscopic fulcrum closer to the area being repaired. Interrupted and figure-of-eight braided non-absorbable suture repaired the defect. The chest tube was removed at the case terminus, and a post-removal film demonstrated no pneumothorax. The patient did not have an oxygen requirement or chest morbidity and was discharged 22 hours postoperatively.
In patients with a history of infracostally exiting chest tubes, diaphragmatic hernia may result with immediate life-threatening physiologic consequence when the abdomen is later insufflated. Early recognition and urgent chest drainage are critical. A transperitoneal approach to diaphragmatic closure is feasible with no postoperative thoracic morbidity. As pyeloplasty presents unusual positioning for diaphragmatic surgery, placement of additional laparoscopic ports assists closure.