PMC3928060_01
Computed tomography scan of the thorax showing a complete enterothorax (arrows).. Abbreviations: A, anterior; L, left; P, posterior; R, right.
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As the patient was suffering from progredient dyspnea, a computed tomography was performed, which showed a complete enterothorax (Figure 1); therefore, an operative approach was indicated.
A large package of small intestine disappearing on both sides of the chest.
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The upper abdomen was incised by transverse laparotomy revealing a large package of small intestine ventrally disappearing on both sides of the chest (Figure 2).
Huge hernial gap in the diaphragm.
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After repositioning and resection of the hernial sac, the hernial gap could hardly be adapted (Figure 3).
Cutting and fitting of the PERMACOL  implant.. Note: PERMACOL  is manufactured by Covidien Ltd, Dublin, Ireland.
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For this reason, a large flap of PERMACOL  (original size: 18 cm x28 cm x1.5 cm; Covidien Ltd, Dublin, Ireland) was trimmed to fit so that it covered both sides of the dorsal diaphragm and the ventral part of the flap overlapped with the abdominal wall incision (Figure 4).
Final result after fixing the PERMACOL  implant with VICRYL  sutures.. Notes: PERMACOL  is manufactured by Covidien Ltd, Dublin, Ireland. VICRYL  is manufactured by Johnson & Johnson, New Brunswick, NJ, USA.
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The flap was fixed all around with VICRYL  0 sutures (Johnson & Johnson, New Brunswick, NJ, USA; Figure 5).