Single-Incision Laparoscopic Nontraumatic Left Lateral Diaphragmatic Hernia Repair Giovanni Dapri, MD, PhD, FACS, Katleen Jottard, MD, Konstantin Grozdev, MD, Daniel Guta, MD, Benjamin Nebbot, MD, and Guy-Bernard Cadie `re, MD, PhD Abstract: Diaphragmatic hernia is a quite uncommon disease, being congenital or posttraumatic. Its diagnosis is frequently accidental. Surgical treatment can be performed through the abdomen as well as through the chest. Laparoscopy and thoracoscopy offer a sur- gical benefit because of reduced wall trauma and added advantages of minimally invasive surgery. Besides the improved cosmetic result, transumbilical single-incision laparoscopy can add other advantages to minimally invasive surgery like reduced post- operative pain, shorter hospital stay, and improved patient’s comfort. The authors describe the technique of transumbilical single-incision laparoscopic suture and mesh reinforcement for a nontraumatic left lateral diaphragmatic hernia, discovered acci- dentally in a 45-year-old male. Key Words: diaphragmatic hernia, repair, single-incision, single- port, single-site, laparoscopy (Surg Laparosc Endosc Percutan Tech 2015;25:e166–e169) S ingle-incision laparoscopy (SIL) gained interest in the last decade, but after a lot of enthusiasm in different surgical fields, it remains less popular than the conventional multitrocar laparoscopy (CML). The main issues remain the cost of the disposable material, the surgeon’s learning curve, the difficulty to work through a single access, and the patient’s selection. In contrast, thanks to the era of SIL, surgeons have assisted to an increased research and mate- rial development with the appearance on the market of new instruments, port devices, and optical systems. 1 Although the majority of the reports regard proce- dures like cholecystectomy, appendectomy, foregut surgery, colon resection and solid organs removal, uncommon dis- ease like lateral diaphragmatic hernia is still not considered to be approached through SIL due to its access difficulties and complex treatment. The authors report a 45-year-old male consulted for a nontraumatic left lateral diaphragmatic hernia, discovered accidentally. The patient was not previously submitted to surgery. Preoperative work-up, including thoraco- abdominal computed tomography scan, showed a left lateral diaphragmatic defect, with migration into the chest of transverse colon segment (Fig. 1). A transumbilical SIL (TSIL) repair by suture and mesh placement was proposed and accepted by the patient [Technique (with video, Supple- mental Digital Content 1, http://links.lww.com/SLE/A121)]. The umbilicus was extroflexed and incised centrally for 1.5 cm. The central umbilical fatty tissue was found and enlarged to directly access the peritoneal cavity. A purse- string suture using polydioxanon (PDS) 1 was placed in the umbilical fascia. A reusable 11-mm trocar was inserted inside the purse-string suture and the pneumoperitoneum was created. A 10-mm, 30-degree, rigid, and standard- length scope was introduced. The exploration of the abdominal cavity showed adherences between the left dia- phragmatic dome and the greater omentum. A bicurved grasping forceps (Fig. 2A) was inserted without trocar through a separate fascia window, created by a 6-mm trocar’s wire, 5 mm outside the purse-string suture at 10 o’clock position. The other instruments, like the monocurved coagulating hook (Fig. 2B), the bicurved needle holder (Fig. 2C), the monocurved scissors (Fig. 2D), and the straight 5-mm tack device were introduced at 3 FIGURE 1. Preoperative thoracoabdominal computed tomo- graphy scan. Received for publication May 18, 2015; accepted July 6, 2015. From the Department of Gastrointestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, Brussels, Belgium. G.D. is a consultant for Karl Storz Endoskope, Tuttlingen, Germany. The other authors have no conflicts of interest to declare. Reprints: Giovanni Dapri, MD, PhD, FACS, Department of Gastro- intestinal Surgery, European School of Laparoscopic Surgery, Saint-Pierre University Hospital, 322, Rue Haute, 1000, Brussels, Belgium (e-mail: giovanni@dapri.net). Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Website, www.surgical-laparoscopy.com. Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. TECHNICAL REPORT e166 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech  Volume 25, Number 5, October 2015 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.