Central Tendon Diaphragmatic Hernia Laparoscopic Repair With Mesh Found Incidentally During Minimally Invasive Surgery for Multiple Post-Operative Abdominal Hernias

Aim Spontaneous Hernias of the Central Tendon of the Diaphragm are extremely rare in adults. We show the operative video of the laparoscopic repair with mesh of a spontaneous Central Tendon Diaphragmatic Hernia (CTDH) found incidentally during the repair of multiple post-operative hernias in an adult patient. Materials and Methods A 66-year-old overweight (BMI 37.5) lady underwent laparoscopic surgery for the repair of multiple incisional hernias. Symptoms included pain from a large incarcerated incisional para-umbilical hernia, and an unexplained dull pain behind the right-lower costal area. Surgical history included open cholecystectomy and appendectomy, multiple laparoscopic gynecologic and uro gynecologic operations, and two spine operations. There was no history of accident or iatrogenic injury at the diaphragm. The CT scan showed seven incisional hernias. Our video shows the dissection of the hernias with special focus on the laparoscopic repair of a 7 cm incidental right CTDH with incarcerated abdominal fat. The hernia fat was reduced and after a partial thoracoscopy the CTDH was repaired with a dual-faced 15 × 15 cm mesh fixated with absorbable tacks. The rest of the hernias were repaired with multiple meshes using the IPOM technique. Results The post-operative course was uneventful. The patient was discharged at 48-hours with the need of minor analgesics. A post-operative re-evaluation of the CT scan identified the missed CTDH. Clinical examination and ultra-sound were unremarkable at three months. Conclusions Minimally-invasive surgery with mesh is appropriate for the repair of a CTDH. The diaphragm should be meticulously assessed in the pre-operative CT scan of obese patients with multiple hernias.