VM96 - Robot- Assisted Traumatic Diaphragmatic Hernia Repair and Colectomy

Purpose/Background: A 48 year old male with remote history of a left chest stab wound, presented with transverse colon invasive adenocarcinoma on screening colonoscopy. CEA was negative. Staging imaging was negative for metastatic disease, though notable for a large left diaphragmatic hernia with complete atelectasis of the left lower lobe of the lung due to compression of intra-thoracic abdominal contents. Of note, the colonic mass was located in the left thorax. A combined robotic diaphragmatic hernia repair and partial colectomy was planned with Thoracic Surgery. We describe our experience with a concomitant repair and resection.

Methods/Interventions: Robotic trocars and liver retractor were placed transversely in the mid-abdomen for intra-abdominal access. There were significant adhesions that were lysed with a combination of blunt dissection and bipolar electrocautery, providing access to the thoracic cavity. The hernia defect measured 8 x 10 cm. Dissection continued circumferentially in the chest until no further manipulation of the abdominal contents was possible robotically. The weight of the massive hernia made reduction difficult, thus a left thoracotomy was performed. Additional adhesiolysis and manual reduction was performed. Gore-Tex patch was placed to eliminate the diaphragmatic defect. The left lung was re-inflated and chest tubes were placed. Attention was then turned to the colectomy through an upper midline laparotomy. Significant redundancy in the colon permitted an oncologic resection via an extended right hemicolectomy and tension-free ileocolonic anastomosis with minimal additional mobilization. Post-operatively, he remained intubated for positive pressure ventilation and pulmonary recruitment.

Results/Outcomes: Our patient was extubated on postoperative day two, but subsequently developed pneumonia and required re-intubation on post-operative day 13. Increased recruitment of his left lung after years of chronic atelectasis contributed to his pulmonary complications. He recovered from this well and was discharged home after 20 days. Surgical pathology revealed margin negative pT1N0 invasive adenocarcinoma. He continues to do well clinically with improved exercise tolerance and no recurrence thus far of his colon cancer.

Conclusion/Discussion: Our case is unique, with only one similar case in the literature with combined hernia repair and colonic resection. Interestingly, our patient’s colonic mass was within the hernia requiring a combined colectomy and hernia repair. His displaced anatomy added further complexity and ultimately made a minimally invasive approach not feasible. An open approach was considered initially for both the intra-abdominal and intrathoracic components, however the advantages of minimally invasive surgery (decreased operative times, postoperative pain and hospital length of stay) were pivotal. Remarkably, robotics approaches have also been shown to perform more complex and technically challenging operations compared to laparoscopy. This was crucial for which robotic surgery was an attractive approach for our patient. Despite the conversion to open, the robot was paramount in performing much of the laborious dissection and adhesiolysis required. In conclusion, our case highlights a rare presentation of colonic malignancy within a traumatic diaphragmatic hernia and emphasizes the feasibility of a combined hernia repair with colonic resection.