The X-ray
in front of my eyes said little about the person to whom it belonged. The lung
on the right side looked almost completely collapsed. And still, the patient in
front of me, a 48 year old office worker was standing normally, walking,
talking, and doing everything a man at his age was expected to do. His only
complaint was that that he didn’t take exertion too well. Climbing more than
two flights of stairs would cause him to breathe heavily. It didn’t affect his
daily work too much, but it had concerned him that his capacity to do the
things that were once easy for him to do had started to get so exhausting over
the last four years. My boss in the mean time was looking at a C.T. scan of
this patient’s chest and abdomen. Handing me the films, he said to the man,
“Sir, your liver is in your chest”.
A couple of
days later R. N. Singh (name changed to protect identity), was lying on a bed
in our ward, while I prepared his file for the elective operation he was about
to have the next day. “I was perfectly well four years ago,” he told me, “until
I had an accident. I was on my scooter and crashed into a car in front of me
which had braked quite suddenly. I had dislocated my left shoulder which I got
fixed and other than a mild ache in my lower right chest that lasted about a
month, I thought I was fine. But over the course of a few months, I found it
harder to catch my breath after straining myself. I just thought I was getting
old, but it got worse in the last couple of months, so I thought I’d get myself
checked just to get some peace of mind. And now I’m here.” Mr. Singh had a post-traumatic diaphragmatic
hernia.
The chest
(called thorax) is separated from our stomach (called abdomen) by a large flat
muscle called the diaphragm. The movement of the diaphragm helps us expand our
lungs and draw air into our body. Various important structures, like major
blood vessels and the food pipe go through this muscle crossing from the thorax
to the abdomen or vice versa. In Mr. Singh’s case, the accident that he had,
had caused a break in the muscle fibers at the right side of his diaphragm at
the back where it attached itself to the posterior part of the rib cage. His liver, had helped form a block at this
opening, plugging it. But due to the continuous expansion and deflation of his
lungs, the liver kept getting sucked into his chest albeit very slowly.
Gradually, the right lung started to get compressed by the large liver abutting
it at the bottom. Since the process went on over four years, his body had
undergone some compensatory changes and so had he, in terms of his lifestyle. By
the time he came to us, his liver had compressed more than half of his right
lung, and was much higher than where it was supposed to be.
The plan
for the operation was to take a look at the hole in the diaphragm before
opening the abdomen. So we did a diagnostic laparoscopy. We filled the abdomen
with air, to help distend it. Then we placed a long scope with a camera into
the abdomen through a 1 cm incision just above his belly button. We were
surprised to find very little liver actually in the abdomen. The larger part of
it had now gone into the chest. Once we confirmed the location of the defect in
the diaphragm, we planned our incision accordingly.
Once we
entered the abdomen the process seemed simple enough. We thought we’d pull the
liver back into the abdomen and close the defect with an artificial mesh. Although
the defect was deep, the senior operating surgeon placed a hand around the
liver, and was pleased to find that three of his fingers could slide around it,
through the defect to its superior part. And then he pulled at it, to bring it
down. But it didn’t. He tried to insinuate his fingers at various points around
the liver, but no matter how much he yanked it, it wouldn’t budge. The part
inside the chest seemed too wide to be able to be pulled back out. But then,
how the hell did so much of it get in there?
We had to
find out what was causing the problem. We needed eyes inside the chest. The
only way to do this seemed to be to put a scope through the chest to see the superior
part of the liver. But we weren’t prepared for a thoraco-scopy. So we took a
different approach. We took the long camera that we had used for the abdomen in
the beginning, and we tried insinuating it through the defect in the diaphragm
below. It worked. We could see that the liver had actually gotten attached to
the lower part of the lung at various places. These adhesions had made it
continuous with the lower part of the covering of the lung. The two organs had
gotten abnormally stuck together.
This was
tricky. Not only was it dangerous to try to remove the adhesions, we had only a
one centimeter gap to work with. We tried
using long thin laparoscopic scissors, graspers and ultrasound based
dissectors. And they worked on the outer ends, but we couldn’t even see the
deep surface let alone reach it through the space that we worked with. It was
time to make a tough decision. Open the chest or enlarge the hole.
Both options
were risky. The post operative
complications of either approach could be dangerous. Finally after much debate
with consultants lining up on either side, our senior most surgeon decided on increasing
the size of the opening in the diaphragm. He let out a prayer, took a scalpel
in his hand and made an incision in the diaphragm so that the defect that had
caused all the trouble had gotten bigger.
The laparoscopic
instruments now fit through the new opening, and as we began to dissect the
adhesions between the liver and the lung covering (pleura), we started to get
more and more exposure, so that it became easier to pull down the liver. Soon,
the liver was back in its rightful place. The large defect in front of us, now
completely exposed had been about twice the size of a man’s fist. We closed it,
and placed a mesh right under it, to help prevent it from opening up again
under pressure. We then placed a chest
tube into the right chest of the patient to get rid of residual air and debris
and then we waited.
We had the
patient sedated and on mechanical ventilation for forty eight hours, allowing
the radically repaired body to settle down. Then we took out the mechanical
tube in his lungs and let him breathe. He was ok.
Three days later,
I found my boss unexpectedly at Mr. Singh’s bedside. This was odd, because he
usually informed us when he came for his ward rounds. He had a bright smile on
his face. Handing me the fresh X-ray of Mr. Singh’s chest, he told him how
lucky he was. The surgical result had been much better than we had expected. In
front of my eyes, was the X-ray film showing a completely expanded right lung,
which in every way looked absolutely normal. Mr. Singh breathed a sigh of
relief. It was a deep, fulfilling breath.
