What is the diagnosis and treatment for Diaphragmatic (DI) hernia?

From the Guidelines

Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias, as it reduces postoperative complications and facilitates early diagnosis of small diaphragmatic injuries. A diaphragmatic hernia is a defect in the diaphragm that allows abdominal organs to move into the chest cavity, which can be congenital or acquired later in life due to trauma or increased abdominal pressure 1. The most common congenital form is a Bochdalek hernia, typically occurring on the left side, while Morgagni hernias occur anteriorly. Symptoms vary depending on severity and may include respiratory distress, cyanosis, and feeding difficulties in infants, or chest pain, shortness of breath, and gastrointestinal symptoms in adults.

Diagnosis and Treatment

Diagnosis typically involves imaging studies such as chest X-rays, CT scans, or MRI, with CT scan of the chest and abdomen being the gold standard for diagnosing the diaphragmatic hernia 1. Treatment is primarily surgical repair of the diaphragmatic defect, with timing dependent on symptom severity. In newborns with respiratory distress, immediate surgical intervention is necessary, often requiring mechanical ventilation and stabilization beforehand. The surgery involves returning the herniated organs to the abdominal cavity and closing the diaphragmatic defect, sometimes using synthetic mesh for larger defects.

Surgical Approach

The choice of surgical approach depends on the patient's stability and comorbidities, with laparoscopic repair being the preferred technique in hemodynamically stable patients without significant comorbidities 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. Damage Control Surgery is an option in the management of critical and unstable patients.

Postoperative Care

Postoperative care involves monitoring for complications such as gastroesophageal reflux, which can occur in up to 62% of patients after repair of congenital diaphragmatic hernia 1. Fundoplication should be performed during congenital hernia repair to manage associated gastroesophageal reflux. The choice of fundoplication technique, such as Nissen or Toupet, depends on the individual case and the surgeon's preference.

Prognosis

Prognosis depends on the size of the hernia, associated complications, and timing of diagnosis, with congenital cases having more variable outcomes depending on lung development and associated anomalies. Overall, prompt surgical intervention and appropriate postoperative care can improve outcomes and reduce morbidity and mortality in patients with diaphragmatic hernias 1.

From the Research

Definition and Types of Diaphragmatic Hernia

• Diaphragmatic hernia can be congenital or acquired 2
• Types of diaphragmatic hernia include:
  • Congenital diaphragmatic hernia
  • Acquired diaphragmatic hernia
  • Traumatic diaphragmatic hernia
  • Iatrogenic diaphragmatic hernia
  • Hiatal hernia
  • Morgagni's hernia
  • Bochdalek hernia

Clinical Presentation

• Clinical presentation of diaphragmatic hernia may range from asymptomatic cases to serious respiratory/gastrointestinal symptoms 2
• Atypical presentation as lumbar hernia can also occur 2
• Symptoms may include respiratory distress, abdominal pain, and gastrointestinal symptoms

Diagnosis

• Diagnosis of diaphragmatic hernia is based on clinical investigation and is confirmed by:
  • Plain X-ray film 2, 3
  • Computed tomography (CT) scan 2, 4, 3
  • Ultrasound (US) 3
  • Magnetic resonance imaging (MRI) 3
• CT scan with coronal and sagittal reformatted images is the most effective and useful imaging technique for diagnosing diaphragmatic hernia 3

Treatment

• Various treatment approaches are available for diaphragmatic hernia, including:
  • Open repair 2, 4, 5
  • Laparoscopic repair 2, 5, 6
  • Combination of open and laparoscopic repair
• Surgical repair typically involves primary or patch closure of the diaphragm through an open or endoscopic abdominal or thoracic approach 2
• Use of prosthesis is recommended in case of very large defects or when a tension-free suture is deemed unfeasible 4

Surgical Management

• Surgery represents the treatment of choice for chronic diaphragmatic hernias 4
• Diaphragmatic hernia direct repair with a tension-free suture is generally attempted 4
• Laparoscopic approach has recently gained popularity for diaphragmatic hernia repair 2
• Open thoracic and abdominal approaches seem feasible for treating diaphragmatic hernia in adults 5