That’s why surgeons must be careful

handling the instruments, thermofusion and ultrasonic this website dissector during laparoscopy [6, 19]. A small diathermy injury may not be observed during surgery; any such defect in the diaphragm is likely to increase in size as a result of the gradient of pressure between the abdominal and pleural cavities. This is what probably happened in our patient who had a 10 cm defect. Patients with large diaphragmatic defects can have critical problems shortly after surgery due to cardiorespiratory disturbances. Unexplained pain in post operative is not specific but should suspect this complication. Other patients may be asymptomatic or have vague symptoms, which may delay the diagnosis. Our patient presented pain one year after the first surgery. The diagnosis of a cyst recurrence was suspected firstly but not the diagnosis of a diaphragmatic hernia. The clinical features are usually chronic symptoms such as upper abdominal and lower chest pain, nausea, dyspnea, and reflux after meals, which may develop into an acute presentation see more with severe epigastric pain, vomiting, and intestinal obstruction [11, 19]. The radiological diagnosis is often complex and includes several imaging modalities [18]. Chest radiograph is a good screening examination, but only 50% of patients show an abnormality [18, 19]. CT scan is the best imaging modality to diagnose diaphragmatic

hernias. Its sensitivity is high but specificity is only 50% for the right side [20, 21]. Surgery is the treatment of diaphragmatic hernia

at the time of diagnosis, even in asymptomatic patients. Some authors think that the thoracotomy is the elective surgical approach that can correct anatomical restoration of the chest and abdominal cavity especially when it is the approach during the initial surgical procedure [22–24]. Though patients who had a thoracotomy approach had the longest length of stay with a higher need for postoperative mechanical ventilation than those undergoing an abdominal approach after diaphragmatic Chlormezanone hernia repair. Paul et al. found that the thoracotomy approach is an independent predictor of the development of a pulmonary embolism [25]. We think that laparotomy through a right subcostal incision is a more efficient approach into the abdominal cavity. Treatment by laparoscopy is feasible with a shorter length of stay. This approach is especially used in left diaphragmatic hernia repair [11, 26]. Because of liver bulk, right side hernia is not amenable to laparoscopic repair, with a high level of conversion. However some authors described this approach with success [27]. In our patient, the hernia was in the right side of hepatic vein, this was the reason we preferred a laparotomy approach. Herniated contents are reduced, the muscular defect is treated and an endothoracic drain is placed [28]. In some cases a bowel resection might be needed in case of ischemia.