CASE REPORT
A 76-year-old patient presented with bloating and abdominal pain, with no history of weight loss. He was booked for an elective Colonoscopy.
He had a history of blunt abdominal trauma in a road traffic accident many years back; this was complicated by splenic, bladder and urethral’s rupture, closed pelvic fracture and multiple rib fractures. At that time, the patients underwent explorative laparotomy with splenectomy; he further required surgeries for bladder and urethral reconstruction.
The colonoscopy was initially performed with no complications, up to the terminal ileum; biopsies were taken for diagnostic purpose.
Upon withdrawal of the scope, a suddenly hard resistance was encountered by the operator. Despite multiple attempts, including inserting a pediatric scope along the colonoscope to dislodge it, the scope was irretrievable.
An emergency fluoroscopy revealed that the scope was inside the chest cavity (Figure 1.A); a computed tomography scan showed a chronic left sided TDH; the colonoscope was observed inside a bowel loop, which was incarcerated in the TDH (Figure 1.B). This was, most likely, a chronic result from the blunt abdominal trauma decades earlier.
After a collegial discussion, between general and cardiothoracic surgeons and the gastroenterologist team, the decision was made for a left thoracotomy to reduce the TDH and to retrieve the scope. The surgical approach was chosen in view of two factors: first, as the scope was being stuck in the thoracic cavity, it carried the potential risk of perforating the colon soiling the chest; second, due to the presence of abdominal adhesions, exploring the abdomen would have carried a significant increased risk. The thoracotomy approach was considered a safer approach in this case.
A left posterolateral thoracotomy was performed at the level of the fifth intercostal space; this allowed easy entry to the chest cavity. The hernia’s sac was identified abutting on the lower lobe of the left lung (Figure 2); after blunt dissection, the adhesions between the lung and the sac were dissolved. The scope was palpable inside the sac; this was opened, showing herniated colon (Figure 3.A). No flogosis was observed at the level of the sac’s neck, with no strangulation.
It was decided to perform a manual reduction of the sac (Figure 3.B); this was temporary, and it allowed an easy retraction of the scope per rectally with no resistance.
A thorough and careful examination of the colon revealed no evidence of perforation or injury.
Despite the initial reduction of the sac, later it was noted a very limited space for the hernial contents to be reduced into the abdominal cavity, likely due to the marked adhesions from previous abdominal surgeries. After an intraoperative collegial discussion, it was felt that any further attempts at reducing the hernia in the abdomen and repairing the diaphragmatic defect, would may result in a colonic ischemia.
A conservative strategy was then performed. The diaphragmatic hernial orifice was enlarged to prevent any future strangulation: this was performed with a partial resection, extended for not more than 0.5 cm circumferentially. The colon was then reduced to the abdominal cavity as much as possible.
The procedure was then completed with no further complications.
The patient was closely monitored for signs of intestinal obstruction; he was then discharged home, on third post-operative day, after an uneventful recovery.