Transabdominal Minimally Invasive Repair of a Left Chronic Traumatic Diaphragmatic Hernia.

Although the exact incidence of traumatic diaphragmatic hernia (TDH) is unknown, it can carry significant morbidity if not treated promptly. TDH is thought to be more common in penetrating thoracoabdominal trauma compared to blunt trauma. The left side is thought to be more commonly affected than the right due to the protective effects of the liver on the right hemidiaphragm in trauma. Although large defects are evident on CT imaging and the detection rate is improved with higher resolution CT scanners, smaller ruptures may require laparoscopy for definitive diagnosis if there is a high index of suspicion. In this case report, we present a case of a missed left TDH on CT imaging, with eventual herniation of the omentum and stomach. Although TDH traditionally is approached via thoracotomy or laparotomy, we demonstrate that a transabdominal minimally invasive approach with robot-assisted laparoscopic repair is a viable option, with the potential to reduce the morbidities associated with the open approach.

Infected Mature Teratoma in the Anterior Mediastinum Removed Using the Da Vinci Robotic System.

Mature teratomas have been found to be the most common type of extragonadal primary germ cell tumors found in the anterior mediastinum. Over the past decade, several reports have been published using minimally invasive approaches to remove mediastinal masses. Of these publications, only one reported a teratoma excision from the anterior mediastinum via the Da Vinci Robot. Additionally, there have been few reports regarding teratomas infected with bacteria. This is a case of a 37-year-old man with an incidentally identified Proteus mirabilis infected mature teratoma in the anterior mediastinum that was removed with the Da Vinci Robotic System.

Surgical salvage of acquired lung lesions in extremely premature infants.

Acquired neonatal lung lesions including pneumatoceles, cystic bronchopulmonary dysplasia, and pulmonary interstitial emphysema can cause extrinsic mediastinal compression, which may impair pulmonary and cardiac function. Acquired lung lesions are typically managed medically. Here we report a case series of three extremely premature infants with acquired lung lesions. All three patients underwent aggressive medical management and ultimately required tube thoracostomies. These interventions were unsuccessful and emergency thoracotomies were performed in each case. Two infants with acquired pneumatoceles underwent unroofing of the cystic structure and primary repair of a bronchial defect. The third infant with pulmonary interstitial emphysema, arising from cystic bronchopulmonary dysplasia, required a middle lobectomy for severe and diffuse cystic disease. When medical management fails, tube thoracostomy can be attempted, leaving surgical intervention for refractory cases. Surgical options include oversewing a bronchial defect in the setting of a bronchopleural fistula or lung resection in cases of an isolated expanding lobe.

Abdominal surgery after lung transplantation.

Among 450 patients who underwent lung transplantation (LuT) between April 1994 and April 2009 at a single academic hospital, 75 received surgical consultation, and 52 underwent 65 abdominal operations. Operations included colectomy (17), cholecystectomy (14), exploratory laparotomy (10), ulcer repair (five), hernia repair (four), Nissen fundoplication (four), pancreatic debridement (four), ostomy takedown (two), drainage of intra-abdominal abscess (two), and major vascular procedure, gastrostomy, splenectomy, fascial closure, laparoscopic common bile duct exploration, and small bowel resection (one each). Fourteen patients (27%) died within 30 days of surgery. On univariate analysis, age, race, comorbidities, history of previous abdominal surgery, transplant type, and timing of surgery after transplant were similar between the patients who survived and died. On multivariate analysis, emergent surgery, multiple medical comorbidities, and male gender were predictive of 30-day mortality (P < or = 0.05). Ulcer repair, major vascular procedures, pancreatic surgery, splenectomy, and exploratory laparotomy were associated with > or =50 per cent 30-day mortality. This is the largest series reporting outcomes of abdominal operations after LuT. Elective operations in LuT patients are safe, whereas emergent operations carry an extremely high short-term mortality rate. Aggressive prophylaxis for ulcer disease and early elective intervention for potential surgical problems, such as gallstones and uncomplicated diverticulitis, should be considered.