Department of Surgery, Mt. Sinai-St. Luke’s-Roosevelt Hospital Center, New York, New York, USA (all authors).
Introduction: Herniation of the bowel through a diaphragmatic defect is a rare cause of abdominal pain and obstruction in the adult patient. Most clinically significant congenital hernias are discovered in childhood, and most acquired traumatic and iatrogenic defects are discovered shortly after the injury, if at all. Delayed symptomatic herniation years after initial insult is an uncommon but well-described complication after diaphragmatic injury.
Case Description: A 34-year-old man presented to the emergency department 10 hours after developing sharp left upper quadrant abdominal pain, accompanied by nausea and dry heaves. His surgical history was significant for sequential left ventricular assist device explantation and orthotopic heart transplantation 2 years prior. A chest radiograph demonstrated a loop of colon in the left chest. The patient was taken to the operating room for emergent laparoscopy, reduction, and repair of an incarcerated diaphragmatic hernia. A laparoscopic approach was used to reduce and evaluate the viscera. The hernia defect, which measured 13 cm2, was then closed primarily with nonabsorbable sutures. The patient was discharged uneventfully on postoperative day 2.
Discussion: Although uncommon, left ventricular assist device placement and explantation can lead to iatrogenic diaphragmatic hernia. The possibility of a diaphragmatic hernia should be considered in any patient presenting with abdominal pain after left ventricular assist device explantation. A laparoscopic repair should be used when possible.
Key Words: Left Ventricular Assist Device, Diaphragmatic Hernia, Heart Transplant.