Evgeny B Topolnitskiy, Ekaterina S Marchenko, Alex A Volinsky
NIVATS is technically feasible and intraoperatively well tolerated in high-ASA patients, with conversion and immediate complication rates comparable to those of low-ASA patients. However, high-ASA status independently predicts prolonged hospitalization and a substantially increased risk of mortality. These findings underscore the importance of careful patient selection and intensive, tailored postoperative care for high-risk patients undergoing NIVATS.
BACKGROUND: Chronic post-traumatic diaphragmatic hernia is a delayed consequence of missed diaphragmatic injury that presents months to years after trauma. It develops in a stable anatomical setting with mature adhesions and organ migration, creating operative conditions distinct from emergency management of acute rupture.
OBJECTIVE: To evaluate the feasibility and perioperative outcomes of video-assisted thoracoscopic surgery for chronic diaphragmatic hernia and to identify anatomical factors that guide selection between minimally invasive and open repair.
METHODS: From January 2010 to May 2026, 21 consecutive patients underwent elective repair at a single center. Approach selection considered defect size, chronicity, adhesion extent, organ viability, and the anticipated ability to achieve tension‑free defect closure. Outcomes were described for thoracoscopic repair completed without conversion (n = 15) and open thoracotomy (n = 5). One hybrid procedure that begun thoracoscopically and proceeded with conversion under continued video guidance was reported separately.
RESULTS: Thoracoscopic repair was completed in 15 patients with defects measuring 20-100 mm. Five patients underwent planned open thoracotomy for larger or more complex defects ranging from 20 to 200 mm. Thoracoscopic repair was associated with lower median blood loss (10 vs 200 mL), shorter chest tube duration (1 vs. 4 days), and shorter hospital stay (5 vs. 10 days). A 100 mm right-sided defect with hepatic herniation was repaired thoracoscopically, indicating that defect size alone does not preclude minimally invasive repair. No recurrences, conversions for hemodynamic instability, or deaths occurred during follow-up.
CONCLUSIONS: In chronic diaphragmatic hernia, the absence of acute hemorrhage, instability, and visceral compromise favors minimally invasive repair. Thoracoscopic repair appeared feasible in selected patients, whereas larger or complex defects were generally managed by open reconstruction. These findings generate hypotheses and require confirmation in larger prospective studies.