Treatment for Left Hemidiaphragm Issues
Surgery is the recommended treatment for left hemidiaphragm issues, with a laparoscopic approach preferred in stable patients and laparotomy for unstable patients with complicated diaphragmatic hernias. 1
Diagnostic Approach
Before treatment, proper diagnosis is essential:
- Initial imaging: Chest X-ray (anteroposterior and lateral) as first-line imaging, with sensitivity of 2-60% for left-sided hernias 2
- Gold standard: CT scan with IV contrast (sensitivity 14-82%, specificity 87%) 1, 2
- Key diagnostic signs: "Dangling diaphragm" sign, "Dependent viscera" sign, "Collar sign", and intrathoracic herniation of abdominal contents 1, 2
Treatment Algorithm for Left Hemidiaphragm Issues
1. For Diaphragmatic Hernias
Stable Patients:
- Preferred approach: Minimally invasive laparoscopic repair 1
Unstable Patients:
- Recommended approach: Open laparotomy 1
- Consider Damage Control Surgery (DCS) in patients with:
- Intraoperative instability
- Hypothermia
- Coagulopathy
- Significant acidosis
- Impossibility to close the diaphragm 1
2. Repair Technique
- Primary repair: Use interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers 1
- For defects >3 cm: Mesh reinforcement is recommended due to high recurrence rate (42%) with primary repair alone 1
- For defects >8 cm or area >20 cm²: Mesh interposition with 1.5-2.5 cm overlap of defect edge 1
- Mesh selection: Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher resistance to infections, and lower risk of displacement 1
- Mesh fixation: Use tackers or transfascial sutures, but avoid tackers near the pericardium due to risk of cardiac complications 1
3. For Diaphragmatic Paralysis/Eventration
- Indication: Surgical treatment only for symptomatic patients with persistent effort or positional dyspnea, cardiac or digestive symptoms, or pain despite conservative management 3
- Procedure of choice: Diaphragmatic plication through lateral thoracotomy or video-thoracoscopy 3, 4
4. Special Considerations
- For central origin paralysis: Consider phrenic nerve pacing in selected cases (validated for tetraplegia above C3 and alveolar hypoventilation of central cause) 3
- For gastric volvulus with diaphragmatic hernia: Perform gastropexy after detorsion of the volvulus, reduction of herniated structures, and repair of the diaphragmatic defect 1
- For patients with oral intake difficulties: Consider percutaneous endoscopic gastrostomy (PEG) or gastrostomy 1
Potential Complications and Management
Postoperative complications (11-62.9% rate) 1:
- Pulmonary complications (especially atelectasis)
- Surgical infection
- Bleeding
- Respiratory failure
- Ileus
- Gastroesophageal reflux (up to 62% after repair of congenital diaphragmatic hernia)
- Chronic pain
- Hernia recurrence
- Cardiac injury
Mortality rate: 14.3-20% in complicated traumatic diaphragmatic hernias 1
Important Caveats
- Treatment delay beyond 24 hours increases complication rates from 33% to 70% 5
- Excision of the hernial sac is controversial; some studies show benefits in reducing tissue trauma, fluid collection, and recurrence 1
- Avoid preemptive anti-reflux surgery in emergency traumatic diaphragmatic hernia settings 1
- For right diaphragmatic hernias, repair can be more difficult due to the presence of the liver, and may require a combined or thoracic approach 1
- Recurrence is largely due to failure of the host-prosthesis interface, while synthetic patch integrity is usually maintained 1
Early diagnosis and prompt surgical intervention are crucial for optimal outcomes in left hemidiaphragm issues, with the surgical approach tailored to the patient's stability and the nature of the diaphragmatic defect.