Robot-assisted repair of diaphragmatic hernias following ventricular assist device implantation

Robot-assisted repair of diaphragmatic hernias following ventricular assist device implantation Use of ventricular assist devices (VADs) is increasingly common, as is the need for surgeons to be familiar with the manage- ment of common complications in this population. Nonetheless, repair of diaphragmatic hernias which commonly develop following VAD implantation remains technically challenging due to intra-abdominal adhesions and the proximity of vital structures. Despite the potential benefits of improved dexterity and visualization, robotic approaches have thus far not been used to address this. We present the first two described cases of robot-assisted repair of diaphragmatic hernias in the setting of prior or current VAD placement. derangements [4]. Laparoscopic repairs of these defects have INTRODUCTION been described, however, the proximity of either LVAD hardware Left ventricular assist devices (LVADs) are increasingly being or a transplanted heart to the surgical field make this approach used to provide durable mechanical circulatory support, either challenging [5]. Although robotic surgery could be expected to as a bridge to transplant or as a destination therapy in select improve this by increasing surgeon dexterity and visualization, to patients. Overall, 1451 LVADs were implanted in 2010, and the thebestofour knowledgethere arenoprior reportsof this prevalence of these devices is projected to increase due to a approach in theliterature[6]. We present herein the first two combination of rising life expectancy and improving technol- reported cases of a robotic approach to repair of LVAD-associated ogy [1]. In light of this expanding utilization, the management diaphragmatic hernias. of patients with LVADs is expected to increase in parallel and it will become more and more important for surgeons to be famil- iar with common complications related to LVAD placement CASE #1 and the management of those complications. A number of intra-abdominal complications from LVAD place- Patient #1 is a 60-year-old male with a history of gastroeso- ment have been well-described, including injury to abdominal phageal reflux disease and ischemic cardiomyopathy. He organs, bowel obstruction and hernia formation [2]. Hernias underwent placement of a Heartmate II LVAD in 2013 before through diaphragmatic defects remain difficult to recognize and undergoing an orthotopic heart transplant (OHT) 2 months manage [3]. While the initial presentation of this process is usu- later. After an initially uncomplicated course, he presented to ally indolent and non-specific, the sequelae can be dramatic, with the emergency department 1 year following transplant with either obstructive symptoms or even significant hemodynamic reflux, epigastric pain and a recent 10-pound weight loss. Prior Received: November 28, 2017. Accepted: January 29, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 M. Ongele et al. Figure 1: Imaging from Case #1. (A) Preoperative X-ray demonstrating loop of bowel in the thoracic cavity. (B) Preoperative CT scan, saggital view of diaphragmatic defect. (C) Preoperative CT scan, coronal view demonstrating colon passing through diaphragmatic defect. (D) Preoperative CT scan, axial view demonstrating intra- pericardial transverse colon. (E) Postoperative X-ray demonstrating reduction of hernia contents. Figure 2: Intraoperative Images from Case #1. (A) Reduction of omentum and transverse colon through hernia defect. (B) Representative image of defect following reduction of intra-abdominal contents; heart border visible to lower left of defect. (C) Following placement of mesh for repair of diaphragmatic hernia. endoscopic evaluations had been normal; however, a chest defect (Fig. 1E). At 1 month, the patient was noted to be toler- X-ray was suggestive of intrathoracic bowel. A subsequent CT ating a regular diet without complaints of any dysphagia or scan demonstrated an intrapericardial hernia containing the reflux. transverse colon (Fig. 1A–D) and the patient was taken to the operating room for a robotic diaphragmatic hernia repair. CASE #2 Intraoperative assessment revealed omentum and trans- verse colon herniating through the left diaphragm defect A 43-year-old male with a past medical history significant for (Fig. 2A). This was reduced manually without difficulty. The non-ischemic cardiomyopathy (NICM) treated with a Heartmate heart was easily seen through the defect (Fig. 2B). The area of II LVAD and a biventricular implantable cardioverter defibrillator the hiatus was evaluated noting a small hiatal hernia. The presented to the emergency department with new-onset change paraesophageal hernia was repaired in standard fashion with in vision, weakness of hands and numbness of upper extrem- Nissen fundoplication. Attention was turned to the diaphragm ities. The patient was admitted for a TIA evaluation. Due to com- defect which was closed using a running 0 permanent V-lock plaints of daily vomiting a barium swallow was ordered, which suture. Subsequently, a 12-cm mesh was underlaid and sewn demonstrated mesenteroaxial gastric volvulus. A subsequent CT circumferentially using 0 permanent V-lock suture (Fig. 2C). scan demonstrated a diaphragmatic hernia (Fig. 3A and B) and Intraoperative endoscopy demonstrated ease of passage through the patient was brought to the operating room for robotic repair the GE junction into the stomach. of the diaphragmatic hernia. The patient’s postoperative course was uneventful. Postoperative A diaphragmatic hernia was noted immediately adjacent to imaging showed apparent resolution of the diaphragmatic the LVAD. The herniated intestinal contents were reduced Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Robot-assisted repair of diaphragmatic hernias 3 Figure 3: Imaging from Case #2. (A and B) Preoperative CT scan demonstrating loop of bowel in the thoracic cavity posterior to the heart and LVAD. (C) Postoperative CT scan, coronal view demonstrating repair of the diaphragmatic defect with mesh overlay. without signs of visceral ischemia. A 20-cm round Parietex patients a major open abdominal operation and a formal lapar- mesh was used to bridge the hernia defect, incorporating the otomy. We have demonstrated that this is a safe, feasible and LVAD device. The mesh was secured to the diaphragm using effective approach when performed by a surgeon with a high running 0-prolene suture. Postoperative course was uneventful degree of robotic skill. and the patient was discharged following therapeutic anticoa- gulation. Postoperative imaging revealed repaired diaphrag- CONFLICT OF INTEREST STATEMENT matic defect without evidence of recurrence (Fig. 3C). The authors have no conflicts of interest to disclose. COMMENTS FUNDING This report documents a novel technique for the management of an uncommon but potentially life-threatening complication None. following LVAD placement or explanation. LVAD implantation requires penetration of the diaphragm by inflow and outflow REFERENCES cannulas at the left lateral and anterior positions, respectively, and hernias can develop at either site. The resultant hernias 1. Birks EJ. A changing trend toward destination therapy: are can be extremely complicated, due to either the immediate we treating the same patients differently? Tex Heart Inst J proximity of hardware seen in Case #2 or the extension of the 2011;38:552–4. herniated contents through the diaphragm into the pericardial 2. Costantini TW, Taylor JH, Beilman GJ. Abdominal complica- space as seen in Case #1. The technical difficultyofsafelyrepair- tions of ventricular assist device placement. Surg Infect (Larchmt) ing these defects is exacerbated by the potential adhesive burden 2005;6:409–18. resulting from intraperitoneal placement of LVAD components. 3. Chatterjee S, Williams NN, Ohara ML, Twomey C, Morris JB, Although those intra-abdominal adhesions may make cannula Acker MA. Diaphragmatic hernias associated with ventricu- defect closure more difficult, limited data suggest that surgical lar assist devices and heart transplantation. Ann Thorac Surg closure at the time of LVAD explanation does decrease the 2004;77:2111–4. risk of hernia formation from 15.9 to 4.3% [3]. 4. Murray J, Demetriades D, Ashton K. Acute tension diaphrag- Although robot-assisted repair of LVAD-associated diaphrag- matic herniation: case report. J Trauma 1997;43:698–700. matic hernias is previously unreported, robotic approaches to 5. Groth SS, Whitson BA, D’Cunha J, Andrade RS, Maddaus MA. both hiatal hernias and esophagectomy are well-described [7]. Diaphragmatic hernias after sequential left ventricular assist Although robot-assisted approaches are likely not necessary device explantation and orthotopic heart transplant: early or appropriate for most cases of diaphragmatic hernias, the results of laparoscopic repair with polytetrafluoroethylene. increased dexterity, improved visualization, and ergonomic ben- J Thorac Cardiovasc Surg 2008;135:38–43. efits of robotic systems may provide a benefit for complex cases. 6. Corcione F, Esposito C, Cuccurullo D, Settembre A, Miranda These cases represent two such complicated cases which are N, Amato F, et al. Advantages and limits of robot-assisted nonetheless representative of the issues that can be expected in laparoscopic surgery: preliminary experience. Surg Endosc this population. In both cases large hernias within re-operative 2005;19:117–9. fields in extremely close proximity to either a transplanted heart 7. Galvani CA, Loebl H, Osuchukwu O, Samame J, Apel ME, of ongoing mechanical circulatory support was encountered. Ghaderi I. Robotic-assisted paraesophageal hernia repair: ini- A laparoscopic repair would likely not have otherwise been feas- tial experience at a single institution. J Laparoendosc Adv Surg ible in these patients, and the robotic approach spared both Tech A 2016;26:290–5. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Robot-assisted repair of diaphragmatic hernias following ventricular assist device implantation

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Abstract

Use of ventricular assist devices (VADs) is increasingly common, as is the need for surgeons to be familiar with the manage- ment of common complications in this population. Nonetheless, repair of diaphragmatic hernias which commonly develop following VAD implantation remains technically challenging due to intra-abdominal adhesions and the proximity of vital structures. Despite the potential benefits of improved dexterity and visualization, robotic approaches have thus far not been used to address this. We present the first two described cases of robot-assisted repair of diaphragmatic hernias in the setting of prior or current VAD placement. derangements [4]. Laparoscopic repairs of these defects have INTRODUCTION been described, however, the proximity of either LVAD hardware Left ventricular assist devices (LVADs) are increasingly being or a transplanted heart to the surgical field make this approach used to provide durable mechanical circulatory support, either challenging [5]. Although robotic surgery could be expected to as a bridge to transplant or as a destination therapy in select improve this by increasing surgeon dexterity and visualization, to patients. Overall, 1451 LVADs were implanted in 2010, and the thebestofour knowledgethere arenoprior reportsof this prevalence of these devices is projected to increase due to a approach in theliterature[6]. We present herein the first two combination of rising life expectancy and improving technol- reported cases of a robotic approach to repair of LVAD-associated ogy [1]. In light of this expanding utilization, the management diaphragmatic hernias. of patients with LVADs is expected to increase in parallel and it will become more and more important for surgeons to be famil- iar with common complications related to LVAD placement CASE #1 and the management of those complications. A number of intra-abdominal complications from LVAD place- Patient #1 is a 60-year-old male with a history of gastroeso- ment have been well-described, including injury to abdominal phageal reflux disease and ischemic cardiomyopathy. He organs, bowel obstruction and hernia formation [2]. Hernias underwent placement of a Heartmate II LVAD in 2013 before through diaphragmatic defects remain difficult to recognize and undergoing an orthotopic heart transplant (OHT) 2 months manage [3]. While the initial presentation of this process is usu- later. After an initially uncomplicated course, he presented to ally indolent and non-specific, the sequelae can be dramatic, with the emergency department 1 year following transplant with either obstructive symptoms or even significant hemodynamic reflux, epigastric pain and a recent 10-pound weight loss. Prior Received: November 28, 2017. Accepted: January 29, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 M. Ongele et al. Figure 1: Imaging from Case #1. (A) Preoperative X-ray demonstrating loop of bowel in the thoracic cavity. (B) Preoperative CT scan, saggital view of diaphragmatic defect. (C) Preoperative CT scan, coronal view demonstrating colon passing through diaphragmatic defect. (D) Preoperative CT scan, axial view demonstrating intra- pericardial transverse colon. (E) Postoperative X-ray demonstrating reduction of hernia contents. Figure 2: Intraoperative Images from Case #1. (A) Reduction of omentum and transverse colon through hernia defect. (B) Representative image of defect following reduction of intra-abdominal contents; heart border visible to lower left of defect. (C) Following placement of mesh for repair of diaphragmatic hernia. endoscopic evaluations had been normal; however, a chest defect (Fig. 1E). At 1 month, the patient was noted to be toler- X-ray was suggestive of intrathoracic bowel. A subsequent CT ating a regular diet without complaints of any dysphagia or scan demonstrated an intrapericardial hernia containing the reflux. transverse colon (Fig. 1A–D) and the patient was taken to the operating room for a robotic diaphragmatic hernia repair. CASE #2 Intraoperative assessment revealed omentum and trans- verse colon herniating through the left diaphragm defect A 43-year-old male with a past medical history significant for (Fig. 2A). This was reduced manually without difficulty. The non-ischemic cardiomyopathy (NICM) treated with a Heartmate heart was easily seen through the defect (Fig. 2B). The area of II LVAD and a biventricular implantable cardioverter defibrillator the hiatus was evaluated noting a small hiatal hernia. The presented to the emergency department with new-onset change paraesophageal hernia was repaired in standard fashion with in vision, weakness of hands and numbness of upper extrem- Nissen fundoplication. Attention was turned to the diaphragm ities. The patient was admitted for a TIA evaluation. Due to com- defect which was closed using a running 0 permanent V-lock plaints of daily vomiting a barium swallow was ordered, which suture. Subsequently, a 12-cm mesh was underlaid and sewn demonstrated mesenteroaxial gastric volvulus. A subsequent CT circumferentially using 0 permanent V-lock suture (Fig. 2C). scan demonstrated a diaphragmatic hernia (Fig. 3A and B) and Intraoperative endoscopy demonstrated ease of passage through the patient was brought to the operating room for robotic repair the GE junction into the stomach. of the diaphragmatic hernia. The patient’s postoperative course was uneventful. Postoperative A diaphragmatic hernia was noted immediately adjacent to imaging showed apparent resolution of the diaphragmatic the LVAD. The herniated intestinal contents were reduced Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Robot-assisted repair of diaphragmatic hernias 3 Figure 3: Imaging from Case #2. (A and B) Preoperative CT scan demonstrating loop of bowel in the thoracic cavity posterior to the heart and LVAD. (C) Postoperative CT scan, coronal view demonstrating repair of the diaphragmatic defect with mesh overlay. without signs of visceral ischemia. A 20-cm round Parietex patients a major open abdominal operation and a formal lapar- mesh was used to bridge the hernia defect, incorporating the otomy. We have demonstrated that this is a safe, feasible and LVAD device. The mesh was secured to the diaphragm using effective approach when performed by a surgeon with a high running 0-prolene suture. Postoperative course was uneventful degree of robotic skill. and the patient was discharged following therapeutic anticoa- gulation. Postoperative imaging revealed repaired diaphrag- CONFLICT OF INTEREST STATEMENT matic defect without evidence of recurrence (Fig. 3C). The authors have no conflicts of interest to disclose. COMMENTS FUNDING This report documents a novel technique for the management of an uncommon but potentially life-threatening complication None. following LVAD placement or explanation. LVAD implantation requires penetration of the diaphragm by inflow and outflow REFERENCES cannulas at the left lateral and anterior positions, respectively, and hernias can develop at either site. The resultant hernias 1. Birks EJ. A changing trend toward destination therapy: are can be extremely complicated, due to either the immediate we treating the same patients differently? Tex Heart Inst J proximity of hardware seen in Case #2 or the extension of the 2011;38:552–4. herniated contents through the diaphragm into the pericardial 2. Costantini TW, Taylor JH, Beilman GJ. Abdominal complica- space as seen in Case #1. The technical difficultyofsafelyrepair- tions of ventricular assist device placement. Surg Infect (Larchmt) ing these defects is exacerbated by the potential adhesive burden 2005;6:409–18. resulting from intraperitoneal placement of LVAD components. 3. Chatterjee S, Williams NN, Ohara ML, Twomey C, Morris JB, Although those intra-abdominal adhesions may make cannula Acker MA. Diaphragmatic hernias associated with ventricu- defect closure more difficult, limited data suggest that surgical lar assist devices and heart transplantation. Ann Thorac Surg closure at the time of LVAD explanation does decrease the 2004;77:2111–4. risk of hernia formation from 15.9 to 4.3% [3]. 4. Murray J, Demetriades D, Ashton K. Acute tension diaphrag- Although robot-assisted repair of LVAD-associated diaphrag- matic herniation: case report. J Trauma 1997;43:698–700. matic hernias is previously unreported, robotic approaches to 5. Groth SS, Whitson BA, D’Cunha J, Andrade RS, Maddaus MA. both hiatal hernias and esophagectomy are well-described [7]. Diaphragmatic hernias after sequential left ventricular assist Although robot-assisted approaches are likely not necessary device explantation and orthotopic heart transplant: early or appropriate for most cases of diaphragmatic hernias, the results of laparoscopic repair with polytetrafluoroethylene. increased dexterity, improved visualization, and ergonomic ben- J Thorac Cardiovasc Surg 2008;135:38–43. efits of robotic systems may provide a benefit for complex cases. 6. Corcione F, Esposito C, Cuccurullo D, Settembre A, Miranda These cases represent two such complicated cases which are N, Amato F, et al. Advantages and limits of robot-assisted nonetheless representative of the issues that can be expected in laparoscopic surgery: preliminary experience. Surg Endosc this population. In both cases large hernias within re-operative 2005;19:117–9. fields in extremely close proximity to either a transplanted heart 7. Galvani CA, Loebl H, Osuchukwu O, Samame J, Apel ME, of ongoing mechanical circulatory support was encountered. Ghaderi I. Robotic-assisted paraesophageal hernia repair: ini- A laparoscopic repair would likely not have otherwise been feas- tial experience at a single institution. J Laparoendosc Adv Surg ible in these patients, and the robotic approach spared both Tech A 2016;26:290–5. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/2/rjy016/4885383 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Feb 1, 2018

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