The Birmingham Technique: A Novel Dual Cavity Method for Large Diaphragmatic Hernias

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Large diaphragmatic hernia often requires morbid open surgery via thoracotomy, laparotomy, or a thoraco- abdominal approach. The reduction of large abdominal contents can be very challenging using the thoracoscopic-only approach. The laparoscopic-only approach does not allow for proper fixation of posterior defects and the fixation of the mesh near the pericardium. Therefore, the Birmingham technique was developed—a new joint dual cavity minimally invasive double crown technique which offers a safe, durable minimally invasive repair. 

This technique was performed on a case series of five patients with Bochdalek, iatrogenic, and traumatic hernias. Cases were selected after discussion in a dedicated multidisciplinary team meeting, which included general and thoracic surgeons. 

In the first stage, five-port laparoscopy was performed after placing the patient in the Easter position. The hernial sac was dissected and reduced. A composite mesh was sutured to the edges of the defect, forming an inner crown, with the extra mesh edges laid inside the chest. 

In the second stage, video-assisted thoracoscopic surgery (VATS) with three to forts ports was performed. The outer edges of the mesh were fixed with a second crown of Ethibond interrupted sutures. Pericostal sutures were placed posteriorly with small stab incisions, and sutures were placed near the pericardium medially to compensate for deficiencies in the diaphragm and ensure a durable repair. 

The introduction of the double crown technique in diaphragmatic repair is an easy and effective way to reduce the incidence of recurrence. It ensures effective posterior fixation, safe fixation near the pericardium, and a tension-free repair. No recurrence has been reported among the five patients, with the earliest repair performed more than five years ago.  

References

1. Thoracoscopic diaphragm plication Joel Dunning Interactive CardioVascular and Thoracic Surgery, Volume 20, Issue 5, May 2015, Pages 689–690.
2. Kumar A, Parshad R, Suhani, Bhattacharjee HK, Sharma R. Thoracolaparoscopic repair of diaphragmatic hernias. Indian J Thorac Cardiovasc Surg. 2021 Sep;37(5):558-564.

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