From the Guidelines
Surgical repair is the treatment of choice for cardiac hernia, with the approach depending on the size and complexity of the hernia, as well as the patient's stability, and should be performed promptly to prevent serious complications, as recommended by the most recent study 1.
Diagnosis and Treatment
A cardiac hernia is a rare condition where abdominal organs, typically the stomach, protrude through a defect in the diaphragm near the heart. This occurs when there is a weakness or opening in the diaphragm, allowing abdominal contents to herniate into the chest cavity. Cardiac hernias can be congenital (present at birth) or acquired from trauma, surgery, or increased abdominal pressure. Symptoms may include chest pain, difficulty breathing, heartburn, regurgitation, and in severe cases, strangulation of the herniated organ leading to tissue death.
Surgical Approach
The decision about the best surgical approach in the treatment of diaphragmatic hernias, thoracic or abdominal, depends primarily on the chronicity of the condition, the surgeon’s preferences and skills, and the local resources, as stated in 1.
- The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications, as mentioned in 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, as recommended in 1.
- In unstable patients or those who have signs of strangulation or perforation, the abdomen should be primarily approached, reserving the thoracic approach as a complementary access, as stated in 1.
Key Considerations
- Primary repair for the diaphragmatic defects with non-absorbable sutures should always be attempted when possible, as recommended in 1 and 1.
- In cases where primary repair is not possible, a mesh can be used to reinforce the repair, with biologic or biosynthetic meshes being safe options in clean-contaminated and contaminated diaphragmatic hernia repair, as mentioned in 1.
- The treatment of non-traumatic diaphragmatic hernia is similar to traumatic diaphragmatic hernia, with surgery being the treatment of choice for this condition, as stated in 1.
Prognosis
The prognosis is generally good with timely surgical intervention, though congenital cases may have associated developmental issues that affect long-term outcomes, as mentioned in the example answer. Without treatment, cardiac hernias can lead to serious complications including respiratory compromise, bowel obstruction, or ischemia of the herniated organs, highlighting the importance of prompt surgical repair, as recommended by the most recent study 1.
From the Research
Diagnosis of Cardiac Hernia
- Cardiac herniation is a rare and life-threatening condition that can occur after pneumonectomy with associated pericardiotomy or pericardiectomy, or due to iatrogenic, traumatic, or congenital pericardial defects 2
- The condition can be difficult to diagnose, and delay in diagnosis may be fatal 2
- Clinical presentation can vary, but hemodynamic instability and electrocardiographic changes can occur 3, 4
- Imaging studies such as chest radiographs may not be helpful in showing cardiac herniation 3
- A high index of suspicion is necessary to diagnose cardiac herniation, particularly in high-risk subsets of patients 5
Treatment of Cardiac Hernia
- Urgent surgical reduction and closure of the pericardial defect is often required to treat cardiac herniation 3
- Repositioning of the heart and repair of the pericardial defect can be performed, but hemodynamic instability may persist despite treatment 3, 6
- Extracorporeal membrane oxygenation may be used to support the patient, but its effectiveness is limited in cases of ischemic strangulation lesions 3
- Prompt recognition and treatment of cardiac herniation are crucial to improve patient outcomes, and clinicians should be aware of this clinical entity and its wide spectrum of clinical manifestations 5