Congenital diaphragmatic hernia is a congenital disease caused by unilateral or bilateral diaphragm defect, which leads to abdominal internal organs hernia into the thoracic cavity. The incidence of congenital malformations is 1/2000∼1/5000,often complicated with other congenital malformations, easy to occur on the left[1,2]. Thoracic and abdominal hiatus hernia after neonatal period is called delayed diaphragmatic hernia in children. Often due to shortness of breath, vomiting, abdominal pain and other symptoms, it is easy to be misdiagnosed as pulmonary cysts, pneumothorax,lobar pneumonia,enteritis,etc.,delayed treatment,serious life-threatening.We report a case of delayed small hernia sac orifice with left diaphragmatic hernia.After sufficient preoperative preparation, the patient underwent laparoscopic-assisted remediation of left diaphragmatic hernia contents and diaphragmatic repaired, with a satisfactory clinical result.Case presentation
A 7-month-old girl was admitted to hospital with repeated vomiting for 1 day. 1 day before admission, the patient had no obvious inducement of recurrent vomiting. The vomiting was yellow-green. The volume of vomiting was about 10 ml/time, 5 times/day. Abdominal color Doppler ultrasonography showed that left diaphragmatic hernia was possible, thoracic and upper abdominal CT scan suggested:(1)left diaphragm showed hypoclarity and mixed density shadow in left middle and lower thoracic cavity, considering left diaphragmatic hernia (hernia contents were intestinal canal, spleen, pancreas possibility); (2) left pulmonary inflammation and compression swelling were not altered completely, the volume of left lower lobe was reduced, and the lung dysplasia was not completely excluded;(3)gastric dilatation and displacement(Fig. 1). On admission, her blood pressure was 126/72 mmHg,pulse rate 120 beats per minute, and respiratory rate 48 per minute.She was febrile with temperature of 37.6 °C. Her reaction was still acceptable, breathing was slightly short, left thorax was full, breathing movement was slightly weaker than right, left breathing sound was slightly weaker than right.Chest auscultation was thick, phlegm sounds and moist rales were not heard, though cardiac sounds were normal. Abdominal evaluation was soft and nontender.
The patient had been growing well, received routine physical examinations and blood workup, and biochemical tests showed each index was normal. After admission, oxygen, gastrointestinal decompression, anti-infection and other treatments were given. Chest and abdominal radiographs showed multiple patchy and saccular shadows in the left thoracic cavity, blurred left diaphragm and left costal diaphragm angle. These findings were suspicious for CDH(Fig. 2). Upper gastrointestinal radiography also considered left diaphragmatic hernia. Because the hernia entered the thoracic viscera and squeezed the heart and lungs, causing a similar tension pneumothorax state. If the compression was not removed immediately, the child would die soon. Therefore, once diagnosed, the abdominal viscera should be returned as soon as possible to reduce the thoracic pressure, thereby improving the respiratory and circulatory functions.
After sufficient preoperative preparation, the patient underwent laparoscopic-assisted remediation of left diaphragmatic hernia contents and diaphragmatic repaired. After anesthesia, Trocar was sutured and fixed after thoracic cavity was confirmed by endoscopy.Inform anesthesiologists before pressurization that it might affect anesthesia. Pressure to 12 mmHg was about 1.5-2 minutes. During this period, the end-expiratory partial pressure of carbon dioxide could not be measured (waveform was straight), balloon pressure resistance was large, even could not be pressed, oxygen saturation gradually dropped to 50%-60%. When thoracic cavity was observed by endoscopy again, only a few intestinal tubes were admitted, and a large number of intestinal tubes were still located on the left side. In the lateral thoracic cavity, the colour of the thoracic intestinal tube was slightly purple. Due to the accumulation of intestinal tubes in the thoracic cavity, the defect of diaphragm was not clearly displayed. Many attempts were made to push the intestinal tubes into the abdominal cavity, and no significant progress was made in the return. Consider a smaller hernia sac(Fig. 3). The herniated intestinal tract was entrapped for a long time and could not be returned by thoracoscopy. Laparoscopic-assisted repair of left diaphragmatic hernia was performed. Oxygen inhalation, anti-infection and intravenous nutrition support were given after operation. Chest radiograph showed that the diaphragm was smooth on both sides, the angle of costal diaphragm was sharp, and there was no obvious pathological change in heart and lung on post-operative day two(Fig. 4). A small amount of liquid diet was ordered. On the third post-operative day, closed thoracic drainage tube was clamped and removed on the fifth day.The patient was discharged eight days after her operation.