From the Guidelines
Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias, as it facilitates early diagnosis and reduces postoperative complications 1.
Diagnosis and Treatment
A diaphragmatic hernia is a condition where abdominal organs protrude into the chest cavity through a defect in the diaphragm. This condition can be congenital (present at birth) or acquired later in life due to trauma or injury. The diagnostic gold standard for evaluating complicated diaphragmatic hernias is a CT scan of the chest and abdomen 1.
Surgical Approach
The choice of surgical approach depends on the patient's stability and comorbidities. For hemodynamically stable patients without significant comorbidities, laparoscopic repair is the preferred technique 1. This approach reduces postoperative complications and facilitates early diagnosis of small diaphragmatic injuries. Open surgery, on the other hand, should be reserved for situations where skills and equipment for laparoscopy are not available, or when the patient is hemodynamically unstable 1.
Postoperative Care
Postoperative care for patients with diaphragmatic hernias includes pain management, respiratory support, and monitoring for complications such as pulmonary hypertension. Damage Control Surgery (DCS) can be life-saving in critical patients 1, and should be considered when the diaphragm cannot be closed or in unstable patients with severely injured abdominal organs.
Key Considerations
- Biological and bioabsorbable meshes are recommended for complicated diaphragmatic hernia repair, as they reduce recurrence 1.
- Gastrostomy and PEG can be used to provide fixation of the anterior stomach to the abdominal wall and relieve symptoms in patients with difficulties in oral intake 1.
- Anti-reflux procedures may be performed successfully in traumatic diaphragmatic hernia patients with a history of gastroesophageal reflux and the need to repair a large defect 1.
From the Research
Definition and Classification of Diaphragmatic Hernia
- Diaphragmatic hernia can be congenital or acquired 2, 3
- Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17-6% 4
- Acquired diaphragmatic hernia can be caused by trauma, with diaphragmatic rupture occurring in about 5% of severe closed thoraco-abdominal injuries 4
Clinical Presentation
- Clinical presentation of diaphragmatic hernia can range from asymptomatic cases to serious respiratory or gastrointestinal symptoms 2, 4
- Symptoms can include respiratory distress, abdominal pain, and gastrointestinal symptoms such as nausea and vomiting 4
- Atypical presentation as lumbar hernia can also occur 2
Diagnosis
- Diagnosis of diaphragmatic hernia is based on clinical investigation and is confirmed by plain X-ray film and computed tomography (CT) scan 2, 4
- CT scan with coronal, axial, and sagittal reconstructions is the best diagnostic tool for chronic diaphragmatic hernias 5
- Thoracic MRI can be used to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity 5
Treatment
- Surgical repair is the treatment of choice for diaphragmatic hernia 5, 6, 4
- Laparoscopic approach has gained popularity in recent years 2, 3
- Surgical repair typically involves primary or patch closure of the diaphragm through an open or endoscopic abdominal or thoracic approach 2
- Prosthetic reinforcement can be used in cases of large defects or when a tension-free suture is deemed unfeasible 5, 3
- Emergency surgery is mandatory in cases of diaphragmatic hernia with respiratory and abdominal symptoms 4