Reducing the herniated viscera such as the spleen, the liver, and the bowel in thoracoscopic repair of congenital diaphragmatic hernia can be challenging. The small instruments involved can easily create damage, particularly to the friable capsule of the solid organs involved. We herein demonstrate a new gentle method of reducing the diaphragmatic hernia using sequential twisting of the sac. The patient was a 3 day old girl with left sided Bochdalek diaphragmatic hernia. Chest X-ray showed intestinal herniation into the thoracic cavity, and we planned to perform elective Minimal-invasive surgery. Once in the chest, the fundus of the hernia sac is grasped with a blunt endosurgical grasper. The grasper is then turned, twisting the sac around the shaft of the instrument and thereby reducing the hernia content. Once maximal reduction with one hand is achieved, the twisted tissue is grasped with the contralateral instrument and the maneuver repeated until the entire hernia content is reduced. Subsequently, the sac is removed circumferentially using the monopolar electrocautery hook. The diaphragm is then closed with interupted figure-eight sutures of 2-0 silk. The operative time was 65 min, and there were no intraoperative complications. She was discharged home on postoperative day 5. Half a year later, she was asymptomatic without any signs of recurrence. In conclusion, the twisting technique allows for gentle, gradual reduction of diaphragmatic hernias with a sac without injury to the herniated viscera.

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