What are the implications of an obstructed diaphragmatic hernia (Congenital Diaphragmatic Hernia - CDH)?

From the Guidelines

An obstructed diaphragmatic hernia is a serious medical emergency requiring immediate surgical intervention, with laparoscopic repair being the preferred technique in hemodynamically stable patients without significant comorbidities, as it facilitates early diagnosis and reduces postoperative complications 1. This condition occurs when abdominal organs protrude through a defect in the diaphragm and become trapped, leading to compromised blood flow and potential tissue death. Patients typically present with severe chest or abdominal pain, difficulty breathing, nausea, and vomiting. Initial management includes:

• Stabilization with IV fluids
• Nasogastric tube placement for decompression
• Oxygen supplementation
• Pain control with medications like morphine 2-4mg IV or hydromorphone 0.5-1mg IV as needed Broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours should be started if bowel ischemia is suspected. Definitive treatment requires surgical repair, which may be performed via laparoscopy or open surgery depending on the patient's condition and hernia complexity. The surgeon will reduce the herniated contents, assess tissue viability, resect any necrotic tissue, and repair the diaphragmatic defect using either primary closure or mesh reinforcement. Obstructed diaphragmatic hernias can be congenital (more common on the left side) or acquired from trauma, and delayed diagnosis significantly increases mortality risk due to complications like strangulation, perforation, and sepsis. According to the AAST grading of traumatic hernia, the severity of the injury can be classified into different grades, with grade I being a contusion and grade V being a laceration with tissue loss greater than 25 cm² 1. The use of biological and bioabsorbable meshes has proven to reduce recurrence, and the laparoscopic approach has a lower morbidity rate compared to the open approach 1. In critical patients, Damage Control Surgery (DCS) can be life-saving, and 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. The diagnosis of a diaphragmatic hernia can be difficult and delayed, and it is essential to distinguish between an acute isolated diaphragmatic injury and the potential presence of other associated injuries 1. Overall, prompt surgical intervention and appropriate management are crucial to improve outcomes and reduce morbidity and mortality in patients with obstructed diaphragmatic hernias.

From the Research

Obstructed Diaphragmatic Hernias

• Obstructed diaphragmatic hernias are a serious condition that can be associated with significant morbidity and mortality 2.
• The condition may be caused by antecedent blunt or penetrating thoracic/thoraco-abdominal trauma, and can present with a wide range of symptoms and signs 2.
• Diagnosis of obstructed diaphragmatic hernias can be made using thoracic and abdominal CT scan, with coronal, axial, and sagittal reconstructions, and sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity 2.

Surgical Management

• Surgery is the treatment of choice for obstructed diaphragmatic hernias, and can be performed urgently in some cases 2, 3.
• The surgical approach can involve direct repair of the diaphragmatic defect with a tension-free suture, or the use of a prosthesis in cases of large defects or when a tension-free suture is not feasible 2.
• Emergency surgery is often required in cases of obstructed diaphragmatic hernias, and can involve reduction of the hernia contents and closure of the diaphragmatic defect with primary repair or mesh 4.

Types of Diaphragmatic Hernias

• There are several types of diaphragmatic hernias, including Bochdalek hernias, Morgagni hernias, traumatic hernias, and type IV hiatal hernias 5.
• Bochdalek hernias are the most common type of congenital diaphragmatic hernia, and can present with symptoms such as back pain and dyspnea 6.
• Morgagni hernias are another type of congenital diaphragmatic hernia, and can also present with symptoms such as back pain and dyspnea 5.

Complications and Outcomes

• Obstructed diaphragmatic hernias can be complicated by tension pneumothorax, bowel perforation, and other serious conditions 6.
• The outcomes of surgical treatment for obstructed diaphragmatic hernias can be favorable, with low mortality and morbidity rates reported in some studies 5, 4.
• However, the condition can be life-threatening if not diagnosed and treated promptly, and emergency surgery is often required to reduce morbidity and mortality 4.