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With the rising number of MBS and their revisions, rare complications may start to increase as well. Iatrogenic diaphragmatic hernia following metabolic and bariatric surgery (MBS) is extremely rare but potentially fatal. Its recognition is often delayed due to vague clinical presentations.
Purpose
We report a case of strangulated diaphragmatic hernia after Roux-en-Y gastric bypass (RYGB) and gastro-gastric fistula dismantling, highlighting diagnostic and surgical pitfalls, and lessons for bariatric surgeons.
Methods
We describe the presentation, diagnostic work-up, and surgical management of a diaphragmatic hernia after RYGB.
Results
The patient had a smooth postoperative recovery but then developed pleural effusion requiring tapping. She had recovered fully with normal follow-up clinically and radiologically.
Conclusion
This case highlights the importance of attention to such rare but life-threatening consequences after MBS. Precise use of energy devices intraoperatively, especially in revisional cases, is mandatory. A high index of suspicion for vague abdominal symptoms and tailored surgical strategies are essential.
• Iatrogenic diaphragmatic hernias are scarce, underreported, and might end up in a potentially fatal condition.
• Energy devices are usually implicated in inadvertently injuring the diaphragm intraoperatively.
• Surgical repair is the only accepted intervention for symptomatic diaphragmatic hernia, but indications for asymptomatic diaphragmatic hernia remain unclear.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Bariatric surgeries are now regarded as the primary sustainable management option for patients with obesity when medical interventions fail, and they are widely performed nowadays [1]. With the rising number of gastric bypass surgeries, rare complications will start to come to the surface, like diaphragmatic hernias, for instance.
Acquired diaphragmatic hernias usually result from trauma, such as blunt or penetrating injuries to the abdomen or chest. However, they can rarely be caused by surgical interventions, particularly upper GI surgeries, and also MBS due to unintended diaphragm damage with energy devices [2].
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CT scan of the chest is the gold standard for diagnosis because the early symptoms may resemble the chronic pain and colic that usually accompany gastric bypass surgery, or even nonspecific symptoms like dyspnea and shortness of breath [3].
Management of these types of hernia is essentially surgical, preceded by resuscitation, because they usually remain silent till presenting with intestinal obstruction [4].
Iatrogenic diaphragmatic hernias following bariatric surgeries are exceedingly rare, with only three case reports documented in the literature and no large-scale studies conducted to date, to the best of our knowledge [5‐7].
Case Presentation
We present the case of a 36-year-old female with an unremarkable medical history who underwent Roux-en-Y gastric bypass (RYGB) 9 years prior to presentation for the management of morbid obesity. She achieved a good clinical response, losing almost 90% of her excess weight.
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Six years after the bypass, she began to experience episodes of reflux and weight regain. Following investigations, a gastro-gastric fistula was diagnosed and successfully dismantled laparoscopically.
One year later, the patient began to report recurrent episodes of vague abdominal pain. Investigations revealed calculous gallbladder disease. The pain was attributed to gallstones and to chronic pain that may occur after RYGB. The patient presented acutely with sudden, severe abdominal pain that radiated to the back; upon examination, she was found to be tachycardic, normotensive, and afebrile, with abdominal tenderness mainly in the left hypochondrium.
She was admitted to the hospital, resuscitated, and investigations were conducted.
Laboratory tests revealed no significant findings apart from mild anemia and an elevated C-reactive protein (CRP) of 38 mg/L. A computed tomography (CT) scan of the abdomen and pelvis showed a hollow organ herniating into the left hemithorax, compressing the left lung with no intra-abdominal or thoracic collections (Fig. 1). After counseling the patient, the decision was made to proceed with laparoscopic exploration.
Fig. 1
CT chest and abdomen showing herniation of a hollow organ through a small diaphragmatic opening
We started the procedure with careful adhesiolysis. At this time, part of the transverse colon was found to be herniating through a diaphragmatic defect (Fig. 2) in the left posterior hemidiaphragm near the hiatal opening. This most likely resulted from inadvertent injury of the diaphragm by an ultrasonic shear on monopolar electrocautery during the second surgery that passed unnoticed.
Fig. 2
Reduction of the gangrenous colon from the diaphragmatic tear
The colon was edematous, and retraction was challenging, so the diaphragmatic opening was widened to facilitate its reduction.
Upon exploring the left hemithorax, the left lung was collapsed, and toxic fluid was in the left hemithorax. (Fig. 3). We began by suctioning and lavaging the toxic fluid, followed by selective cannulation of the left lung by the anesthetist until it was completely inflated.
Resection of the strangulated segment of the transverse colon was performed, followed by creating an isoperistaltic colo-colic anastomosis using endo-staplers.
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The defect was closed by running sutures with V-Loc™ 180 Absorbable Sutures (Medtronic, Minneapolis, MN, USA) and reinforced with non-absorbable Polypropylene sutures. A concomitant hiatus hernia was detected and repaired with a cruroplasty and esophagopexy using Ethibond™ (Ethicon, Somerville, NJ, USA) (Fig. 4).
Postoperatively, she had a smooth recovery, and she was discharged home after 4 days of admission, until the fourth postoperative week, when she began to complain of difficulty breathing and left-sided pleuritic chest pain. Examination revealed limited air entry to the left lung, with no signs of sepsis or vital instability.
CT chest revealed left thoracic effusion completely occluding the left lung; upon consulting cardiothoracic surgeons, they decided to go for tapping instead of inserting a chest drain. Tapping was done twice, followed by a remarkable improvement of chest condition and complete inflation of the left lung in follow-up imaging. She subsequently experienced an uneventful postoperative recovery, as documented in follow-up visits.
Discussion
This case report highlights a rare but crucial topic of iatrogenic diaphragmatic hernia. While the incidence of diaphragmatic hernias is low, those following bariatric surgeries are exceedingly rare.
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This case underlines the importance of early diagnosis and proper surgical intervention, which can avoid unnecessary morbidities and mortality.
In this case, the patient had chronic vague symptoms of epigastric pain, but what grabbed attention was the sudden onset of severe abdominal pain with tachycardia, raising suspicion of a more serious underlying condition. The CT scan confirmed the diagnosis of the herniated colon in the left hemithorax.
Intraoperatively, finding a herniating, strangulated colon was consistent with the preoperative clinical and radiological findings.
As well known, diaphragmatic tears should be closed with non-absorbable sutures. Still, due to the lack of availability of non-absorbable barbed sutures and difficulty in closing the defect with braided sutures due to the dynamic nature of the diaphragm, we used absorbable barbed suture first, which was reinforced with non-absorbable propylene sutures; both were running continuous sutures.
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In our belief, this will not be different from any diagrammatic hernia resulting from trauma or any other type of surgery.
The patient developed left-sided pleural effusion in week 4 postoperatively. This could be due to an inflammatory response following diaphragmatic repair and thoracic lavage, or it might be reactive hydrothorax from lung re-expansion. After consultation with the cardiothoracic team, they decided to go for tapping instead of inserting a chest drain. According to them, there was no active pathology to allow the chest to recollect, and there was no evidence of infection or hemodynamic instability. They tapped twice, achieving a successful outcome. This approach prevented complications like tube displacement or subcutaneous emphysema.
The probable etiology of the diaphragmatic tear is mostly unrecognized thermal injury from previous surgeries. This aligns with literature stating that energy devices such as electrocautery and ultrasonic coagulation shears are implicated in inadvertently injuring the diaphragm intraoperatively. The interval between primary surgery and hernia development varies [8].
Surgical repair is necessary for symptomatic diaphragmatic hernia, but the indications for asymptomatic diaphragmatic hernia remain unclear. Significant morbidity and even mortality are associated with delayed diagnosis due to the rarity of this condition [9].
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After a thorough search, we found that only nine cases of iatrogenic diaphragmatic hernias after bariatric surgeries are reported in the literature, which are listed in Table 1 [10‐18]. All the reported cases were either after Roux-en-Y Gastric Bypass (RYGB) or adjustable gastric band.
Table 1
Nine cases of iatrogenic diaphragmatic hernias after bariatric surgeries are reported in the literature
Author’s name
Journal
Year of publication
Initial procedure
Garcia et al.
Cureus
2022
RYGB
Abu-Jaish et al.
Bariatric Times
2016
RYGB
Alfa-Wali et al.
International Journal of Surgery
2013
RYGB
Borg et al.
Surgery for Obesity and Related Diseases
2011
RYGB
Arsalane et al.
Obesity Surgery
2005
RYGB
Dukhno et al.
International Surgery Journal
2006
Band
Boyce et al.
Journal of Surgical Case Reports
2008
Band
Batumsky et al.
Obesity Surgery
2015
Band
Fraga et al.
International Surgery Journal
2020
Band
Limitations
⚬ A single case presentation cannot be generalized.
⚬ Short-term follow-up.
Conclusion
Iatrogenic diaphragmatic hernia is a rare and potentially fatal condition. Diagnosis can be challenging due to the vague presentation, which may be attributed to more common conditions. Early diagnosis and proper surgical intervention can help to avoid morbidities, if not mortality.
Careful handling of energy devices near the diaphragm, along with awareness of the potential for iatrogenic diaphragmatic hernia after bariatric surgeries, is necessary to avoid this potentially fatal condition.
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Declarations
Ethics Approval
All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Informed Consent
The patient provided written informed consent and is available if requested.
Competing interests
The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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