Incidence and Outcomes of Diaphragmatic Hernia After Living Donor Hepatectomy: The Significance of Bipolar Irrigated Sealer Use.

Background: Acquired diaphragmatic hernia (DH) is a rare and potentially fatal complication after living donor hepatectomy (LDH). This study aimed to assess the incidence and clinical outcomes of DH after LDH.

Methods: Four thousand fourteen living donors who underwent LDH at Asan Medical Center, Seoul, between September 2013 and August 2023 were retrospectively reviewed. We analyzed the incidence of DH before and after the introduction of the bipolar irrigated sealer (BIS). Multivariate logistic regression analysis was used to identify the risk factors for DH.

Results: Postoperative DH occurred in 18 patients (0.40%). Seventeen patients underwent right LDH and developed right-sided DH, whereas 1 patient underwent left LDH and developed left-sided DH. The incidence of DH was 0.22% in the pre-BIS period and >6-fold to 1.36% in the post-BIS period. The median time of postoperative DH occurrence was 11 (range, 3-95) mo. Ten patients underwent elective surgery for DH repair, whereas 8 patients with severe abdominal pain or bowel obstruction underwent emergency surgery, 1 of whom underwent small bowel resection and anastomosis due to severe bowel incarceration. Using BIS was the only significant risk factor for developing DH (p < 0.001; odd ratio, 6.28; 95% confidence interval, 2.43-16.25).

Conclusions: Early recognition and surgical repair of DH after LDH should be considered in living donors with unexplained abdominal or thoracic symptoms. Caution is advised when using peridiaphragmatic hemostasis with BIS in liver surgery. We recommend extending the postoperative follow-up of living donors to at least 3 y, including routine imaging screenings for DH.