From the Guidelines
A diaphragmatic hernia of 12 cm is a large defect in the diaphragm that requires surgical repair, and laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias, as recommended by the World Journal of Emergency Surgery 1.
Diagnosis and Treatment
The diagnosis of a diaphragmatic hernia is typically made using a CT scan of the chest and abdomen, which is the gold standard for evaluating complicated diaphragmatic hernias 1.
- The treatment of a diaphragmatic hernia involves reducing the herniated contents back into the abdominal cavity and closing the defect with sutures and/or mesh.
- Mesh reinforcement is typically required due to the large defect size, and biological or bioabsorbable meshes can be safely used in clean-contaminated and contaminated diaphragmatic hernia repair 1.
Surgical Approach
The decision about the best surgical approach depends on the chronicity of the condition, the surgeon’s preferences and skills, and the local resources 1.
- For stable patients, a laparoscopic approach is suggested, as it facilitates early diagnosis of small diaphragmatic injuries and reduces postoperative complications 1.
- Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable 1.
Post-Operative Care
Post-operative care includes pain management with medications such as acetaminophen and ibuprofen, with opioids like oxycodone as needed for breakthrough pain.
- Activity restrictions include no heavy lifting (over 10 pounds) for 6-8 weeks.
- Patients should watch for warning signs including severe chest pain, shortness of breath, fever above 101°F, or incision site redness/drainage, which require immediate medical attention 1.
Special Considerations
In critical patients, Damage Control Surgery (DCS) can be life-saving, and should be considered when the diaphragm cannot be closed 1.
- Anti-reflux procedures combined with diaphragmatic hernia repair may be performed successfully in patients with a history of gastroesophageal reflux and the need to repair a large defect 1.
From the Research
Diaphragmatic Hernia Size and Treatment
- A diaphragmatic hernia of 12 cm is considered large and requires prompt surgical attention 2.
- The size of the hernia defect is an important factor in determining the treatment approach, with larger defects often requiring the use of prosthetic mesh 3, 4.
Treatment Approaches
- Laparoscopic repair is a popular treatment approach for diaphragmatic hernias, offering a minimally invasive option with reduced recovery time 5, 3, 4.
- Open surgical repair is also an option, particularly for larger defects or in cases where laparoscopic repair is not feasible 2, 6.
- The use of prosthetic mesh is often recommended for large defects or when a tension-free suture is not possible 2, 4.
Surgical Techniques
- Primary sutured closure and prosthetic reinforcement are common surgical techniques used in diaphragmatic hernia repair 4.
- The choice of surgical approach and technique depends on the size and location of the hernia, as well as the patient's overall health and medical history 5, 3, 2, 4, 6.