title: Diaphragmatic repair and/or reconstruction during upper abdominal urological laparoscopy.
abstract: OBJECTIVE
  We present our experience with and the technique of laparoscopic mesh reconstruction or suture repair of intentional resection or intraoperative injury of the diaphragm.
  
  
  METHODS
  In a 10-year (1997 to 2006) review of 1,850 upper abdominal renal and/or adrenal laparoscopic procedures at our institution 13 patients (0.7%) sustained diaphragmatic entry, including iatrogenic injury in 7 (0.4%), deliberate laparoscopic excision of a portion of the diaphragm in 2 and diaphragmatic incision during transthoracic adrenalectomy in 4. Laparoscopic repair techniques involved primary suture repair in 11 cases and primary reconstruction with a synthetic graft in 2. A rubber catheter and water seal system were used to primarily evacuate the pneumothorax.
  
  
  RESULTS
  Inadvertent diaphragmatic injury in 7 cases occurred during transperitoneal (6) and retroperitoneal (1) laparoscopy, including partial nephrectomy in 4, radical nephrectomy in 2 and adrenalectomy in 1. A diaphragmatic breach occurred due to hook electrocautery in 5 cases, trocar insertion in 1 and liver retraction in 1. Deliberate diaphragmatic excision and mesh reconstruction in 2 cases were performed after en bloc excision of the diaphragm during radical nephrectomy in 1 and during excision of a metastatic diaphragmatic nodule in 1. Four transthoracic transdiaphragmatic adrenalectomies were completed successfully without any intraoperative complications. All cases were completed laparoscopically without open conversion. A chest tube was placed prophylactically in the initial 2 patients undergoing transthoracic transdiaphragmatic adrenalectomy.
  
  
  CONCLUSIONS
  Laparoscopic and transthoracic repair/reconstruction of the diaphragm is safe and effective.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Jose R
authors.initials: JR
authors.lastname: Colombo
authors.forename: Burak
authors.initials: B
authors.lastname: Turna
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
authors.forename: Georges-Pascal
authors.initials: GP
authors.lastname: Haber
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000315:Adrenalectomy / Q000009:adverse effects / Q000379:methods; D000328:Adult; D000368:Aged; D003964:Diaphragm / Q000293:injuries / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007049:Iatrogenic Disease; D007431:Intraoperative Complications / Q000601:surgery*; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D013526:Surgical Mesh; D013536:Suture Techniques; D016896:Treatment Outcome