根治性腎切除術後發生之橫膈疝：病例報告暨文獻回顧

蕭伯任^{1, 2}、宋文瑋^{1, 2}

¹中山醫學大學附設醫學泌尿科；²中山醫學大學醫學研究所

Diaphragmatic Hernia after Radical Nephrectomy: A Case Report and Literature Review

Po-Ren Hsiao^{1, 2}、Wen-Wei Sung ^{1, 2}

¹Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan;² Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan

Introduction

Post-nephrectomy diaphragmatic hernia is an extremely rare condition. Iatrogenic diaphragmatic hernias are most common among acquired diaphragmatic hernias, often following abdominal surgeries. Hereby we reported a case presenting with left diaphragmatic hernia immediately after a complicated radical nephrectomy. 

Case Presentation

This is a 69-year-old male with left renal mass incidentally noted by ultrasound. Abdominal computed tomography (CT) revealed a hypervascular tumor 11.6 cm with renal vein invasion over left kidney, considering renal cell carcinoma. The patient consequently underwent laparoscopic radical nephrectomy, and the operation shifted to open surgery intraoperatively owing to massive bleeding over right hilum and tumor vessels. The operation time was 8 hours and 45 minutes, and estimated blood loss was 5000 ml. Pathology discovered papillary renal cell carcinoma, pT3a, with renal vein thrombosis.

 After extubation, chest radiograph showed distended stomach with elevated left diaphragm and tracheal right deviation. (Fig. 1) Left diaphragmatic hernia was confirmed by chest CT. (Fig. 2 and 3) Thoracic surgeons were consulted for surgical repair, which was conducted on post-nephrectomy day 3. Intraoperative findings were laceration wound about 15cm × 10cm over left posterior diaphragm, with hernia contents including stomach, spleen, omentum, and transverse colon. Follow-up chest radiograph showed no diaphragmatic hernia, and the patient was extubated successfully. He is in good health with no significant sequelae 3 months postoperatively.

Discussion and Review

There is a low incidence of iatrogenic diaphragmatic hernias. In a comprehensive review of the literature, only 10 were post-nephrectomy in 37 cases. The mechanism seems a direct or thermal injuries of the diaphragm fibers that creates a weak point or a punctiform perforation, aggravating by the positive pressures in the chest due to intubation. Diaphragm with weak walls, increase in abdominal pressure or post-operative adhesions can exert traction at the diaphragmatic level and thus cause hernias. The majority of diaphragmatic hernias happened in the left side, probably because of the protective effect of the liver. In this care, preoperative chest CT discovered a focal defect of left hemidiaphragm with small herniation, and this might be the weak point leading to the diaphragmatic hernia. Symptoms can vary widely, and diagnosis can be challenging due to the non-specific early symptoms, including abdominal pain, respiratory distress, nausea, vomiting, and bowel obstruction. Delayed diagnosis could be days to years postoperatively. Surgical intervention is typically required for symptomatic cases, and early diagnosis and treatment are crucial to prevent potentially life-threatening complications.