What is the treatment for diaphragmatic hernia?

From the Guidelines

Surgical repair is the recommended treatment for diaphragmatic hernia, with a laparoscopic approach being the preferred technique in hemodynamically stable patients. The treatment of diaphragmatic hernia typically involves reducing the herniated organs back into the abdominal cavity and repairing the diaphragmatic defect, either through open surgery or minimally invasive laparoscopic/thoracoscopic techniques 1.

Key Considerations

• The use of biological and bioabsorbable meshes has proven to reduce recurrence in complicated diaphragmatic hernia repair 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.
• Damage Control Surgery is an option in the management of critical and unstable patients 1.
• Primary repair for the diaphragmatic defects with non-absorbable sutures should always be attempted when possible, and biologic or biosynthetic meshes can be safely used in clean-contaminated and contaminated diaphragmatic hernia repair 1.

Treatment Approach

• For congenital diaphragmatic hernias in newborns, immediate stabilization is crucial, including endotracheal intubation, mechanical ventilation with gentle settings, and possibly extracorporeal membrane oxygenation (ECMO) for severe cases.
• In adults with traumatic or acquired hernias, timing depends on symptom severity and associated injuries.
• Postoperatively, patients require pain management, respiratory support as needed, and gradual advancement of diet.
• Long-term follow-up is essential to monitor for complications such as recurrence, respiratory issues, or gastrointestinal problems.

Rationale

The surgical approach is necessary because diaphragmatic hernias don't resolve spontaneously and can lead to serious complications including respiratory compromise, bowel obstruction, or strangulation if left untreated 1.

From the Research

Treatment Approaches for Diaphragmatic Hernia

The treatment for diaphragmatic hernia can vary depending on the type and severity of the condition. Some of the approaches include:

• Open repair: This is a traditional approach that involves making an incision in the abdomen or chest to access the diaphragm 2, 3, 4.
• Laparoscopic repair: This is a minimally invasive approach that uses small incisions and a camera to visualize the diaphragm 2, 5, 4, 6.
• Combination approach: This involves using both open and laparoscopic techniques to repair the diaphragm 6.

Surgical Repair Techniques

Surgical repair of the diaphragm typically involves:

• Primary closure: This involves closing the defect in the diaphragm with sutures 3, 6.
• Patch closure: This involves using a mesh patch to reinforce the diaphragm 4, 6.
• Mesh placement: This involves placing a mesh material over the defect to support the diaphragm 6.

Considerations for Surgical Approach

The choice of surgical approach depends on various factors, including:

• Type of diaphragmatic hernia (congenital or acquired) 2, 5, 3.
• Severity of symptoms 2, 5, 3.
• Patient's overall health and stability 6.
• Presence of associated injuries or conditions 6.

Outcomes and Comparisons

Studies have compared the outcomes of open and minimally invasive surgical approaches for diaphragmatic hernia repair, with results showing:

• Minimally invasive surgery (MIS) is associated with decreased length of hospital stay, reduced mortality rate, and postoperative ECMO usage 4.
• However, MIS repair has a higher rate of recurrence compared to open repair 4.