Repair of a diaphragmatic injury during hand assisted laparoscopic nephrectomy using an onlay patch of polypropylene and polyglactin mesh

Purpose: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. Materials and Methods: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 × 2 piece of polypropylene mesh to a 2 × 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. Results: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. Conclusions: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.