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LAPAROSCOPIC SLEEVE GASTRECTOMY IN A PATIENT WITH AGENESIS OF THE LEFT HEMIDIAPHRAGM

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Laparoscopic Sleeve Gastrectomy in a Patient with Agenesis of the Left Hemidiaphragm

 

Chandra Hassan, Luis F. Gonzalez Ciccarelli, Mario Masrur, MD1, Roberto Bustos, Antonio Gangemi, Francesco M. Bianco,  Pablo Quadri, Lisa Sanchez-Johnsen, PhD, Pier Cristoforo Giulianotti

Division of General, Minimally Invasive and Robotic Surgery, Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA

Introduction

 •Diaphragm agenesis (DA) is the most severe form of diaphragmatic defect and a rare occurrence in adults (1).

•Incidence of 1:250,000 births (1)

•Associated with lung & cardiac anomalies (1). 

 Case Presentation

 •58-year-old female, BMI of 40 kg/m2 .

 •Seeking bariatric surgery after reporting lifelong history of obesity.

 •Pre-surgical evaluation fluoroscopy and chest x-ray showed elevation of the left hemi-diaphragm concurrent with a type II para-esophageal hernia of the stomach

 •The patient elected to undergo a laparoscopic sleeve gastrectomy and a repair of para-esophageal hernia.

 

Surgical Procedure

•A diagnostic laparoscopy was performed with no visualization of a para-esophageal hernia.
•An incidental finding of a complete absence of the left hemi-diaphragm with an open communication between the abdomen and the left thorax was diagnosed.
•The stomach was mostly intrathoracic extending into the apex of the left chest.
•The pylorus was identified 10 cm to the left of the falciform ligament.
•Visualization and dissection of the short gastric was extremely difficult due to the thoracic location of the spleen.
•Creation of pneumoperitoneum caused supraventricular tachycardia due to the pressure on the heart.
•There was no attempt to repair the defect due to the patient’s age, asymptomatic history and complexity of the repair.
•Standard sleeve gastrectomy was performed using a 40 French Bougie. Intraoperative air-leak test was negative.
•Operative time was 116 minutes with an estimated blood loss of 5 ml. 

 Post-Operative Outcome

 •A postoperative fluoroscopy showed no evidence of contrast extravasation. 

 •The patient was discharged tolerating a liquid diet on postoperative day one. 

 •Postoperative course was uncomplicated. 

 •At one month follow up, the patient was doing well.


Conclusions

 

•Elective laparoscopic sleeve gastrectomy in a patient with asymptomatic and incidental left hemi-diaphragm agenesis was safe and feasible.

 •The diagnosis of asymptomatic DA remains challenging despite the thorough pre-operative diagnostic work up for bariatric surgery.

 •Additional case studies in this area are needed to determine the reproducibility of our findings and the most appropriate work up to successfully diagnose DA prior to elective bariatric surgery.

 

References

1. Morosanu C et al. Prenatal diagnosis of unilateral agenesis of diaphragm and associated anomalies. Indian J PatholMicrobiol 2016;59:251-2


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