title: Large Sized Left Inferior Phrenic Artery and Parahiatal Type of Diaphragmatic Hernia Generating Confusion During Robotic Surgical Repair.
abstract: BACKGROUND
  As an advanced minimally invasive surgical procedure, the repair of the diaphragmatic hernia may sometimes be very challenging especially when the anatomy is unclear.
  
  
  METHODS
  We are presenting a rare case of a parahiatal hernia defect repair where the understanding of the anatomy was complicated by the presence of an unusual large sized left inferior phrenic artery. The Da Vinci surgical platform was used to perform the entire procedure. Hernia sac dissection, identification of the crura, primary closure of the defect, and use of biologic mesh reinforcement were the main steps performed in the usual manner for hernia repair. In addition, the use of intraoperative ultrasound was of great utility to clarify the vascular anatomy.
  
  
  RESULTS
  The additional time required for the intraoperative ultrasound and identification of the vascular anatomy has increased the duration of the procedure that otherwise was uneventful. The accurate identification of the anatomy allowed for a safe surgical outcome. The postoperative course was favorable and patient was free of symptoms at 1-month follow-up.
  
  
  CONCLUSIONS
  The challenge of the repair of this rare, parahiatal type of diaphragmatic hernia where a large sized left inferior phrenic artery was also encountered was successfully mitigated by the use of the intraoperative Doppler ultrasound and by compliance with the basic steps of the procedure.
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Marius Liviu
authors: ML
authors: Calin
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Gabriel
authors: G
authors: Arevalo
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Kathryn
authors: K
authors: Harris
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Rocio
authors: R
authors: Fuentes
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Aziz
authors: A
authors: Sadiq
authors: 2 Department of Surgery, Bronx Lebanon Hospital , New York, New York.
authors: Baongoc
authors: B
authors: Nasri
authors: 1 General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana.
authors: Kirpal
authors: K
authors: Singh
mesh_terms: D001158:Arteries / Q000033:anatomy & histology* / Q000000981:diagnostic imaging / Q000601:surgery; D003964:Diaphragm / Q000098:blood supply* / Q000000981:diagnostic imaging; D005260:Female; D065630:Hernias, Diaphragmatic, Congenital / Q000000981:diagnostic imaging / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D065287:Robotic Surgical Procedures; D013526:Surgical Mesh; D018608:Ultrasonography, Doppler; D018084:Ultrasonography, Interventional
keywords: Bochdalek; diaphragmatic; parahiatal hernia; phrenic artery