• F E Muysoms, K K J Cathenis, R P H M Hamerlijnck, and D A B Claeys.
• Department of General and Cardiovascular Surgery, AZ Maria Middelares, Kortrijksesteenweg 1026, Ghent, Belgium, filip.muysoms@azmmsj.be
• Hernia. 2009 Dec 1; 13 (6): 617-23.

PurposeDuring sternectomy and pedicled omental flap transposition for the treatment of deep sternal wound infections, an ectopic diaphragmatic aperture is created. This may be the site of an iatrogenic diaphragmatic hernia, which may result in the herniation of intra-abdominal organs, and is difficult to repair. Although this complication was described as early as 1991, no effective treatment for this condition has been described previously.MethodsThe defect in poststernectomy diaphragmatic hernias has features similar to other incisional abdominal wall hernias, as well as to parastomal hernias and hiatal diaphragmatic hernias. We describe our laparoscopic approach developed from experience with these other types of hernias. We use an intraperitoneal flat mesh without keyhole. Fixation of the mesh to the anterior abdominal wall and to the diaphragm is done with a combination of sutures and spiral tackers. The omental pedicle is lateralised, fixed to the diaphragm and covered with the mesh. Special caution is needed when spiral tackers are applied to the diaphragm, because fatal complications of pericardial and cardiac injury have been described in laparoscopic hiatal diaphragmatic hernia repair.ResultsWe used this technique in four patients who presented with a symptomatic poststernectomy diaphragmatic hernia. No procedure-related intra-operative or postoperative complications occurred. With a follow up of at least 12 months, no clinical or radiographic recurrence of diaphragmatic herniation has been encountered.ConclusionWe describe a laparoscopic technique to repair this difficult diaphragmatic hernia used in four patients, with a good clinical and computed tomographic outcome at 12 months.

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