Diaphragmatic hernias after sequential left ventricular assist device explantation and orthotopic heart transplant: early results of laparoscopic repair with polytetrafluoroethylene.

Abstract

Patients who undergo an orthotopic heart transplant after explantation of an intraperitoneal left ventricular assist device are at an increased risk of developing diaphragmatic hernias. The aim of this study was to determine the incidence of these hernias and to evaluate the morbidity and short-term efficacy of laparoscopic repair. Using our prospectively maintained database, we performed a single-institution, retrospective review of all patients who underwent laparoscopic repair of a diaphragmatic hernia resulting from defects created by left ventricular assist device explantation. From January 1, 1995 to March 1, 2007, 5 men at our institution (median age, 56 years) out of 97 patients at risk developed a diaphragmatic hernia after left ventricular assist device explantation (5.2% incidence). The median time to presentation was 25.4 months (range, 9-62 months). The median size of the hernia defect was 8 cm (range, 6-15 cm). We performed all repairs completely laparoscopically. None of the defects were repaired primarily because doing so would have resulted in significant tension. Instead, we secured a polytetrafluoroethylene patch over the defect with pledget-reinforced, braided, nonabsorbable, handsewn mattress sutures, followed by reinforcement with laparoscopic tacking screws. We noted no perioperative complications. The median length of stay was 2 days (range, 1-4 days). At a median follow-up period of 12.2 months (range, 1-31 months), no recurrences had occurred. Laparoscopic repair of diaphragmatic hernias with polytetrafluoroethylene can be performed with minimal morbidity and excellent short-term results.