Ann Thorac Surg 2006;82:721-722
© 2006 The Society of Thoracic Surgeons
Case report
Abdominal Compartment Syndrome After Late Repair of Bochdalek Hernia
Gregory Dalencourt, MD,
Mark R. Katlic, MD*
Accepted for publication November 28, 2005.
* Address correspondence to Dr Katlic, Geisinger Health System, 1000 E Mountain Dr, Wilkes-Barre, PA 18711 (Email: mrkatlic{at}geisinger.edu).
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Abstract
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Abdominal compartment syndrome is a potential complication of laparotomy, but it is rarely anticipated by thoracic surgeons. We present the case of a 16-year-old girl who manifested this syndrome after emergency repair of a Bochdalek congenital diaphragmatic hernia. Techniques for recognition, measurement, treatment, and prevention are discussed.
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Introduction
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Abdominal compartment syndrome is well recognized as a potential complication of laparotomy for trauma. It has also been reported after repair of large ventral hernias and may be anticipated in any case in which there is a loss of domain for abdominal organs. Pediatric surgeons have devised staged operations to prevent abdominal compartment syndrome when treating gastroschisis and omphalocele.
Interestingly, despite loss of domain in cases of Bochdalek congenital diaphragmatic hernia, abdominal compartment syndrome has not been reported, even in those rare cases in which repair is performed in adults. Thoracic surgeons called to treat these patients may not consider this complication. We present a case that illustrates this problem.
For many years a 16-year-old girl had experienced shortness of breath and occasional left shoulder pain with exertion; she was admitted to the hospital with a 1-day history of left chest and left upper quadrant abdominal pain. Examination revealed decreased breath sounds on the left, abdominal tenderness in the left upper quadrant, and rapid respirations. She was afebrile. Chest roentgenograms (Fig 1) indicated stomach and bowel in the left pleural cavity, with a large air-fluid level and mediastinal shift to the right. Computed tomographic scans revealed absence of intestines, spleen, and much of the stomach in the abdomen (Fig 2), and their presence in the left chest with mediastinal shift to the right (Fig 3). She went emergently to the operating room.
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Fig 3. Chest computed tomographic scan showing stomach, intestines, and spleen in the left pleural cavity.
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Exploration through an upper midline laparotomy showed a 6 x 12 cm left posterolateral diaphragmatic hernia through which disappeared the small bowel, right and transverse colon, spleen, tail of pancreas, and much of the stomach. These organs were withdrawn into the abdomen and returned to normal color with straightening of the mesentery; the tail of the pancreas remained edematous. There was no hernia sac, and the left lung appeared well formed but very small. The diaphragmatic defect was closed with a patch of 2-mm polytetrafluoroethylene, and the laparotomy was closed with running nylon sutures.
The following day the patient was tachycardic with low urine output and bilateral leg swelling. Intraabdominal pressure, measured with a manometer attached to the urinary catheter, was 35 cm H2O. She was given intravenous fluid but was not returned to the operating room. During the next 5 days the pressure decreased to 22 cm H2O, urine output improved, and leg swelling resolved. She was discharged on her 8th postoperative day.
One year later she had no shortness of breath or abdominal problem. The left lung on chest roentgenogram images had expanded but remained two thirds its normal size.
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Comment
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Bochdalek congenital diaphragmatic hernia results from incomplete closure of the normal pleuroperitoneal canal during fetal development. Usually recognized in infancy or in utero now, in rare cases it may present later in life [1, 2]. Symptoms include shortness of breath, pain, and occasionally nausea and vomiting from stomach or bowel obstruction. Fever, tachycardia, and leukocytosis suggest possible gastric or intestinal ischemia and mandate emergency repair. The hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect indicate that our patient had a true Bochdalek hernia.
Abdominal compartment syndrome might have been anticipated in this patient, particularly given the obvious loss of domain evident on computed tomographic scans (Fig 2), but this has not been described after repair of Bochdalek hernia and was not considered intraoperatively. How should this condition be recognized, monitored, treated, and prevented?
Abdominal compartment syndrome was first described more than a century ago and received wider recognition with increasing repair of gastroschisis and omphalocele. These conditions, such as Bochdalek hernia and longstanding ventral hernia, are associated with insufficient room in the abdominal cavity (ie, loss of domain) to accommodate all of the organs without elevation of intraabdominal pressure. Trauma patients who undergo laparotomy and aggressive fluid resuscitation may also experience abdominal compartment syndrome, defined as intraabdominal pressure greater than 25 to 30 mm Hg [3]. This pressure leads to inferior vena cava compression, which in turn results in decreased cardiac preload and leg edema; decreased urine output may result from the lower cardiac output or direct compressive effects.
First, abdominal compartment syndrome must be considered. Once considered, intraabdominal pressure can be measured. An indirect but simple measurement is that of bladder pressure by a Foley catheter. A transducer connected to the irrigation port of a three-way Foley catheter provides continuous measurement in which critics worry about increasing risk of bladder infection; a manometer allows discrete measurement with any urinary catheter. If pressure is high, the abdomen may be closed with a constructed silo of prosthetic material, Wittmann patch, or VAC system. With fluid shifts and abdominal wall stretching for several days, the abdomen can be closed in the operating room. There seems to be no increased risk of subsequent ventral hernia with these techniques [4, 5].
Our patient's abdominal compartment syndrome was not recognized intraoperatively, and she recovered well despite this, which was facilitated by her youth and general fitness. Early recognition by chest surgeons, measurement, and treatment are recommended.
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References
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- Perch P, Houck WV, DeAndra Jr A. Sympotmatic Bochdalek hernia in an octogenarian Ann Thoracic Surg 2002;73:1288-1289.[Abstract/Free Full Text]
- Swain JM, Klaus A, et al. Congenital diaphragmatic hernia in adults Seminars in Laparoscopic Surgery 2001;8(4):246-255.[Medline]
- Surgue M, Bauman A, et al. Clinical examination is an inaccurate predictor of intraabdominal pressure World J Surg 2002;26(12):1428-1431.[Medline]
- Howdieshell TR, Stenberg E, et al. Temporary abdominal closure followed by definitive abdominal wall reconstruction of the open abdomen Am J Surg 2004;188(3):301-306.[Medline]
- Miller PR, Meridith JW, et al. Prospective evaluation of vacuum-assisted fascial closure after open abdomenplanned ventral hernia rate is substantially reduced. Ann Surg 2004;239(5):608-614.[Medline]
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Abstract
Introduction
