Management of Diaphragmatic Hernia with Abdominal Organ Herniation
Surgical repair is required for the elevated left hemidiaphragm with herniation of abdominal organs into the chest cavity, as this represents a diaphragmatic hernia that carries significant risk of complications including bowel obstruction, ischemia, and respiratory compromise.
Diagnostic Assessment
The CT findings of an elevated left hemidiaphragm containing stomach, spleen, colon and small bowel segments are diagnostic of a diaphragmatic hernia. This condition requires careful evaluation to determine:
- Presence of acute complications (obstruction, ischemia, strangulation)
- Respiratory compromise
- Hemodynamic stability
- Etiology (traumatic vs. congenital)
Additional Imaging Considerations
- IV contrast-enhanced CT is the gold standard for evaluating diaphragmatic hernias, with sensitivity >90% 1
- Multiplanar reconstructions help better visualize the hernia defect and contained organs
- No oral contrast is necessary as the fluid-filled bowel provides adequate intrinsic contrast 1
- MRI may be considered for pregnant patients to avoid radiation exposure 2
Management Algorithm
Step 1: Assess for Emergent Complications
- Signs of bowel obstruction: Dilated bowel loops, transition point at hernia
- Signs of ischemia: Abnormal bowel wall enhancement, wall thickening, pneumatosis 1
- Respiratory compromise: Dyspnea, hypoxemia, lung compression
Step 2: Determine Management Approach
For Patients with Acute Complications:
- Emergent surgical intervention is required for:
- Bowel obstruction
- Signs of ischemia or strangulation
- Severe respiratory compromise
- Hemodynamic instability
For Stable Patients without Acute Complications:
- Elective surgical repair is still indicated to prevent future complications 3
- Pre-operative optimization of comorbidities
- Complete evaluation of hernia contents and planning of surgical approach
Step 3: Surgical Approach Selection
Thoracotomy approach is preferred for chronic diaphragmatic hernias 3
- Better visualization of the hernia sac
- Easier management of adhesions between thoracic structures and herniated organs
- Allows for reduction of herniated contents and primary repair of the diaphragm
Combined thoracoabdominal approach may be necessary for:
- Large hernias
- Suspected bowel compromise requiring resection
- Complex cases with extensive adhesions 4
Repair technique:
- Primary repair with non-absorbable sutures is preferred when tissue quality permits 3
- Mesh reinforcement for large defects or attenuated diaphragmatic tissue
Potential Complications and Pitfalls
- Delayed diagnosis can lead to increased morbidity and mortality 4
- Misinterpretation of elevated hemidiaphragm as paralysis or eventration
- Tension pneumothorax can occur during positive pressure ventilation in patients with unrecognized diaphragmatic hernia
- Bowel injury during reduction of chronically herniated and adhered organs
- Recurrence if repair is inadequate or tissue quality is poor
Post-Operative Management
- Close monitoring for respiratory complications
- Early mobilization
- Pain control to facilitate deep breathing and coughing
- Follow-up imaging to confirm successful repair and position of abdominal organs
Special Considerations
- Traumatic diaphragmatic injuries may present with delayed herniation months to years after the initial trauma 5
- Congenital diaphragmatic hernias in adults are rare but may present with similar findings
- Chronic hernias often have a thickened hernia sac that requires complete excision during repair 3
The management of diaphragmatic hernia with abdominal organ herniation requires prompt surgical intervention to prevent life-threatening complications such as bowel obstruction, strangulation, and respiratory compromise. The thoracotomy approach is generally preferred for chronic cases, with primary repair using non-absorbable sutures when feasible.