Ruptured Diaphragmatic Eventration: Lessons Learned.

Non-small cell lung cancer is the most common malignancy in the world and accounts for an estimated 1 million deaths each year. Metastasis to the mediastinal lymph nodes is one of the most important factors in determining resectability and prognosis. It also influences staging algorithms. Non-invasive radiographic imaging investigations have their limitations, so tissue sampling is needed. Sampling can be achieved both by invasive surgical or non-surgical techniques. According to the ESTS guidelines, among invasive surgical techniques, mediastinoscopy is still considered to be the gold standard in the mediastinal staging in non-small cell lung cancer. This chapter deals with invasive surgical techniques.

Diaphragmatic eventration is a rare condition classified as acquired or congenital. Diaphragmatic eventration associated with megacolon is a clinical finding that does not fit the existing principles of treatment. This study aimed to review this association in order to update the knowledge available on diaphragmatic eventration. We included articles about diaphragmatic eventration associated with megacolon. The search databases included PubMed, Google Scholar, and African Journal Online, which were added to other articles obtained by manual search. We included 21 case reports in the study. From these, we identified four common points: the left side was involved in 95.2% (except one case where the liver was displaced), all patients were adults, the clinical presentations were respiratory symptoms in (90.4%, n =19), and abdominal emergency syndrome in (38%, n =8). The condition is easily detected on standard X-rays, and no cause has been identified for the acquired eventration. The surgical approaches were laparotomy (61.9%), thoracotomy (19%), and laparotomy and thoracotomy (4.8%). This treatment consists of management of eventration and megacolon. Treatment was surgical in 86.7% ( n =18) of patients. It consisted of diaphragm plication in 23.8% ( n =5), colonic resection in 19% ( n =4), diaphragmatic plication, and colonic resection in 42.9% ( n =9). Megacolon can reveal diaphragmatic eventration in adults, especially on the left side. The diagnosis is easily detected on radiography. This can present as a major surgical abdominal emergency and therefore must be managed using an open abdominal approach. Other cases can be managed through the abdominal or thoracic route; however, treatment of colonic distension must be considered.

A 43 year old Female with past history of hypertension, diabetes mellitus presented to the Emergency room with a chief complaint of left flank pain. Her physical examination was notable for left sided flank tenderness with no abdominal rigidity or guarding. Routine blood work showed normal complete blood count, with normal comprehensive metabolic profile. A chest xray showed a soft tissue mass at the right lung base. Further contrast Computed Tomography(CT) of the chest and abdomen showed an incidental soft tissue mass at right lung base that measured 4.4 cm in diameter representing a focal eventration of the right hemi-diaphragm with liver tissue extending through the eventration.(Fig 1,2).2343_A Figure 1. Arrow depicting hepatic herniation2343_B Figure 2. Coronal CT showing hepatic mass extending through diaphragamDiaphragmatic eventration was first recognized by Jean Louis Petit in 1774 and the term was coined by Beclard in 1916. It is defined anatomically by thinning of the diaphragmatic tissue, characterized by the cephalic displacement of all or a part of an intact diaphragm. While complete eventration in more common on left, partial eventration is seen majorly on the right side. Congenital diaphragmatic eventration has been frequently cited as common in infancy, requiring urgent care and observation but it is rarely seen in adults. Typically this entity is frequently asymptomatic but can rarely manifest as progressive dyspnea, chest pain, abdominal discomfort, nausea, vomiting, heartburn and recurrent pneumonia. Partial eventration are usually detected incidentally on chest x-ray as a smooth homogeneous mass in continuation with the diaphragm.Ultrasound may reveal more anatomical detail about the diaphragmatic integrity, specifically eventration content or other diaphragmatic pathologies.If a contrast CT scan is performed, hepatic or omental vascular enhancements are seen as hyper-dense areas. Other modalities such as fluoroscopy with sniff testing and Magnetic resonance imaging are done if the diagnosis is still in doubt. Once diagnosed asymptomatic patients are usually managed conservatively and diaphragmatic plication is done in symptomatic patient. Our patient's left sided pain was musculoskeletal and not related to the diaphragmatic eventration. Her pain resolved with analgesics and she has remained asymptomatic on follow up visits. In summary we present a rare case of partial diaphragmatic eventration with hepatic herniation. Our case highlights conservative management in asymptomatic patients with diaphragmatic eventration.

Background: Eventration of diaphragm is an abnormal elevation of the diaphragm. Publishing on eventration of diaphragm in Iraq is scarce. Objective: This study was carried out to report on the Iraqi experience on eventration of diaphragm. Methods: A total of 18 patients with eventration diaphragm were included in this study. A review of case records of patients with eventration diaphragm treated in Ibn Al-Nafees Teaching Hospital was done. Review of records took place for the period of March 2012 to Dec. 2017. Results: The age of patients was ranged 5 months to 70 years, giving male to female ratio of 2:1. Dyspnea was dominating presenting symptoms followed by cough. The left hemidiaphragm was the most affected site (83.3%). The cause of eventration of diaphragm was idiopathic in 72.2% of patients. Chest X ray showed the elevation of the affected hemidiaphragm. CT scan demonstrated the thinned-out raised hemidiaphragm. The most common complications were atelectasis, and recurrent chest infection. Hospital stay was ranging 4-14 days. Conclusion: Eventration of diaphragm is not uncommon in Iraq. Presentation, management, and complication are similar to that reported in global centers. Key words: Diaphragm. Eventration. Plication. Surgical repair. Phrenic nerve injury

Diaphragmatic eventration (DE) is a distinctive condition characterised by the abnormal elevation or displacement of a portion of the diaphragm, often leading to a protrusion of abdominal contents into the thoracic cavity. Unlike diaphragmatic hernias, eventrations involve a congenital or acquired weakness of the diaphragmatic muscle itself rather than a structural defect. Congenital eventrations typically arise from the incomplete development or muscular hypoplasia of the diaphragm, while acquired forms may result from trauma, surgery, or neurological disorders affecting the phrenic nerve. Clinical manifestations vary widely, with some individuals remaining asymptomatic, while others may experience respiratory difficulties, especially when lying down. The case involves a 65-year-old female with a history of breathlessness exacerbated in the lying position, improved when upright. Examination revealed low oxygen saturation, absent breath sounds on the left chest, and bowel sounds in that region. Chest X-ray and HRCT indicated bowel loops in the left chest due to eventration of the left hemidiaphragm. Surgical intervention involved thoracotomy, identifying a lax left hemidiaphragm, mobilising abdominal contents, and performing plication with proline 1-0. Closure was completed with an intercostal drainage (ICD) in the left thoracic cavity. Postoperative period was uneventful. This case emphasises the significance of prompt diagnosis and surgical intervention in managing DE, showcasing the effectiveness of thoracotomy, hemidiaphragm plication, and ICD placement.

Eventration of diaphragm is an uncommon disorder in which diaphragmatic muscle is replaced by fibroelastic tissue, either partially or completely. Bilateral eventration is even rarer. We present a case of...

Diaphragmatic eventration is an uncommon malady, underdiagnosed and often treated only in emergent situations. Eventration of the diaphragm is best treated by plication of diaphragm with or without meshplasty. Various studies have shown that thoracoscopic plication is as efficient as laparotomy or laparoscopic plication. We present here the report of thoracoscopic diaphragmatic plication for eventration performed in the third trimester of pregnancy in a 28-year-old woman who presented with acute respiratory distress. To our knowledge, we believe this to be the first published case in medical literature.

Diaphragmatic eventration refers to an abnormal elevation of the diaphragm. Here, we report the case of a patient with gastric cancer who underwent successful laparoscopic distal gastrectomy despite the presence of diaphragmatic eventration. The patient was a 72-year-old man diagnosed with early gastric cancer in the antrum, as detected by upper gastrointestinal endoscopy. Preoperative imaging revealed an elevation of the left side of the diaphragm, which was diagnosed as diaphragmatic eventration. Laparoscopic surgery is beneficial for obtaining an optimal field of view. However, there are critical points that must be considered when laparoscopic distal gastrectomy is performed in patients with gastric cancer complicated by diaphragmatic eventration. There were difficulties that affected manipulation because the elevated diaphragm drew the intraperitoneal organs into the thoracic cavity, causing displacement of the normal anatomical position. We found it beneficial to secure the lesser curvature of the stomach given the possible effects of gastric deformation.

Introduction: Diaphragmatic eventration (DE) is the abnormal elevation of one part or the entire hemidiaphragm.This can be caused by lack of muscle or nerve function while maintaining its anatomical attachments.The symptomatic patients of DE usually suffer from shortness of breath while rest or during physical activity along with reduced functional capacity.Purpose: This study aims to investigate whether patients suffering from DE can derive benefits from pulmonary rehabilitation (PR) focusing on inspiratory muscle training (IMT).Design: A case series involving quasi-experimental study to test effectiveness of PR and IMT program on participants who completed six weeks of program.Methods: Four participants with DE who underwent six weeks regimen of PR focusing on IMT were recruited.The outcome measures of this study are: level of dyspnea measured by modified medical research council (mMRC), pulmonary function test (PFT) to test lung capacity and volume by looking at forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) respectively, and 6-minute walk test (6MWT) to test the functional capacity of the participants.The analysis was conducted using dependent t test to evaluate pre-post outcome measures.Results: Four participants completed six weeks of PR with the focus on using IMT device.The dependent t-test for FEV1 and FVC revealed that there was a significant improvement after six weeks, t(3) = -3.154,p 0.05, t(3) = -2.529, p 0.05 respectively.The dyspnea scale (mMRC) showed significant improvement after six weeks t(3) = 5.196, p 0.05.The functional capacity measured by the distance covered in 6MWT was improved significantly after six weeks t(3) = -3.360,p 0.05.

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Background: Surgical advancements have significantly improved patient outcomes by reducing complications, hospital stays, and recovery time. However, in Pakistan, healthcare infrastructure varies across regions, necessitating the optimization of surgical techniques for enhanced efficiency and patient care. Despite global trends favoring minimally invasive procedures, conventional surgical methods remain prevalent due to limited access to technology, gaps in surgeon training, and economic constraints. Aims and Objectives: This study aimed to compare conventional and advanced surgical techniques in general and orthopedic surgery, assessing their impact on patient recovery, postoperative complications, and healthcare costs in tertiary care hospitals in Pakistan. The objective was to evaluate the clinical and economic benefits of minimally invasive techniques and provide evidence-based recommendations for optimizing surgical care. Methods: A comparative study was conducted in multiple tertiary care hospitals in Pakistan, involving 150 patients equally divided into conventional and advanced surgical groups. Patients were followed up for six months postoperatively. Key parameters assessed included hospital stay duration, postoperative complications, return to normal activity, readmission rates, revision surgery rates, and surgical costs. Statistical analysis was performed using SPSS version 26, with a significance threshold of p < 0.05. Results: Patients in the advanced surgery group had a significantly shorter hospital stay (4.2 vs. 7.5 days, P < 0.001), faster recovery (5.6 vs. 8.2 weeks, P < 0.001), and fewer postoperative infections (5.3% vs. 16.0%, P = 0.03). Additionally, the advanced group had lower readmission (6.7% vs. 13.3%) and revision surgery rates (4.0% vs. 10.7%). Although the cost of advanced surgery was higher (PKR 750,000 vs. PKR 500,000, P < 0.001), the improved outcomes suggest potential long-term cost-effectiveness. Conclusion: Minimally invasive surgical techniques in Pakistan have demonstrated superior patient recovery, reduced complications, and improved surgical efficiency. Despite higher initial costs, their long-term benefits justify wider adoption through enhanced training programs, technological investment, and healthcare policy support. Keywords: Surgical techniques, minimally invasive surgery, general surgery, orthopedic surgery, Pakistan, patient recovery, postoperative complications, cost-effectiveness, and healthcare optimization.

Background: Laparoscopic nephrectomy, a minimally invasive surgical technique for kidney removal, has transformed urological surgery since the 1990s. This approach offers numerous benefits over traditional open surgery, including reduced post-operative pain, shorter hospital stays and faster recovery. This study aims to evaluate the efficacy and outcomes of laparoscopic nephrectomy for benign non-functioning kidneys at Indira Gandhi Medical College (IGMC), Shimla. Materials and Methods: This observational study was conducted from July 2018 to June 2019, involving 20 patients with benign non-functioning kidneys due to stone disease, pelviureteric junction narrowing, renal tuberculosis and chronic pyelonephritis. Comprehensive pre-operative evaluations were performed, and patients underwent laparoscopic nephrectomy using the transperitoneal route. Data on surgical duration, blood loss, CO2 usage, complications and post-operative recovery were meticulously recorded and analysed. Results: The study included 20 patients, predominantly female (65%) and aged between 25 and 50 years (70%). Laparoscopic nephrectomy was successfully performed in 60% of cases, while 35% required conversion to open surgery. The mean operative time for successful laparoscopic nephrectomies was 103.7 min, with significantly lower blood loss (145 mL) compared to open surgery (350 mL, P = 0.003). Post-operative recovery was faster in the laparoscopic group, with 90% resuming oral intake within 1–2 days and 55% returning to normal activities within 30 days (P = 0.0072). The overall complication rate was 30%, including 10% major complications. Late presentations were attributed to a lack of awareness, financial constraints and reliance on quack treatments. Conclusion: Laparoscopic nephrectomy at IGMC Shimla demonstrated significant advantages over open surgery, including reduced operative time, blood loss, post-operative pain and faster recovery. The findings support the adoption of laparoscopic techniques as the preferred method for managing benign non-functioning kidneys in a tertiary care setting. However, the cost of disposable equipment and challenges in managing pyonephrotic and xanthogranulomatous kidneys necessitate careful patient selection and pre-operative planning.

Spinal metastasis is becoming more frequent. This raises the topics of pain and neurological complications, which worsen the functional and survival prognosis of oncological population patients. Surgical treatment must be as complete as possible in order to decompress and stabilize without delaying the management of the oncological disease. Minimally invasive spine surgical techniques inflict less damage on the musculocutaneous plan than opened ones. Different minimally invasive techniques are proposed in this paper for the management of spinal metastasis. We used our experience, developed degenerative and traumatic pathologies, and referred to many authors, establishing a narrative review of our local practice. Forty-eight articles were selected, and these allowed us to describe the different techniques: percutaneous methods such as vertebro/kyphoplasty, osteosynthesis, mini-open surgery, or that through a posterior or anterior approach. Also, some studies detail the contribution of new technologies, such as intraoperative CT scan and robotic assistance. It seems essential to offer a lasting solution to a spinal problem, such as in the form of pain relief, stabilization, and decompression. Our department has embraced a multidisciplinary and multidimensional approach to MISS, incorporating cutting-edge technologies and evidence-based practices.

Literature about long constructs in the cervicothoracic junction (CTJ) implanted with a minimally invasive surgical technique is practically nonexistent. Our objective is to present a less invasive-minimally invasive (LIS-MIS) surgical technique to stabilize the CTJ. A midline cervical short incision was made, three or four level lateral mass screws were inserted bilaterally and rods were placed in a conventional technique (LIS field). Percutaneous screws were placed in the upper thoracic spine, and thoracic rods were threaded subfascially through the pedicle sleeves up to the cervical incision (MIS field). Cervical and thoracic rods were linked with parallel connectors. Two cross-links were used in each case. Two patients (33 and 53 years of age) with instability of the CTJ due to metastases were operated on in this way without attempting bone fusion. Mean duration of surgery was 7.5 hours. No patient required blood transfusion. There were no complications related to surgery or the hardware. Opioid consumption diminished after surgery, and both patients remained ambulatory until decease. This LIS-MIS technique seems feasible to stabilize the CTJ in very selected cases when fusion is not necessary.

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