eP527 - "Colonic Herniation Through Diaphragmatic Defect: A Rare Complication of Laparoscopic Endometrial Implant Excision"

Purpose/Background: Diaphragmatic hernias can be caused either by developmental failure of the posterolateral foramina to fuse properly or by traumatic injury of the diaphragm. An infrequent etiology is iatrogenic in nature. Among these diaphragmatic abnormalities, diaphragmatic endometriosis represents a rare form of endometriosis that manifests with respiratory symptoms like dyspnea and pneumothorax (PTX). Failure of medical therapy necessitates surgical intervention for symptomatic control. The utilization of energy, particularly near the diaphragm, can result in diaphragmatic defects, rendering it susceptible to subsequent complications such as herniation, incarceration, or strangulation. Typically, the liver plays a protective role by acting as a barrier to hinder the herniation of abdominal organs. In this report, we present a distinctive case involving a young female who presented with a strangulated colon due to a right-sided diaphragmatic hernia following laparoscopic removal of endometrial implants.Methods/Interventions: A 38-year-old female with a history of endometriosis complicated by catamenial pneumothorax requiring right partial lung resection with chronic PTX, laparoscopic excision of endometrial implants in 2007 presented with abdominal pain, nausea, vomiting, and intolerance to oral intake for 4 days. Her labs were notable for lactate 2 mmol/L, and a white cell count of 8.5 B/L. The abdominal exam was significant for diffuse abdominal tenderness and distension but no guarding or rebound tenderness. Computed tomography of the abdomen and pelvis demonstrated pneumoperitoneum in the upper abdomen and dilated loops of the small bowel with a transition point in the right lower quadrant concerning adhesive disease (Figure 1).Results/Outcomes: She underwent exploratory laparotomy and was found to have two adjacent right diaphragmatic hernias for a total defect size of 5 x 5 cm with strangulated right colon with perforation in the right hemithorax (Figure 2). Hernia contents were reduced, the right hemicolectomy was completed, and a 32 Fr chest tube was placed in the right chest. Hernia was closed primarily using 2-0 Prolene™ suture and was reinforced with biologic mesh. The patient was admitted to the intensive care unit post-operatively. The chest tube was removed on postoperative day five and the patient was discharged home on postoperative day seven on an extended antibiotic course.Conclusion/

Discussion: While infrequent, it is imperative to exercise caution when utilizing energy near the diaphragm to avert potentially catastrophic outcomes. Once identified, management is contingent on intraoperative findings, and repairing the hernia defect is of paramount importance to forestall the recurrence of complications."CT scan findings of air fluid levels in the chest

Axial Cut
Intra-operative findings of multiple Right sided Diaphragmatic Hernia Defects

Intra-operative findings"