Can a diaphragmatic hernia heal on its own?

Diaphragmatic Hernias Do Not Heal on Their Own and Require Surgical Repair

Diaphragmatic hernias cannot heal spontaneously and always require surgical intervention to prevent potentially life-threatening complications such as organ strangulation, respiratory failure, and sepsis. 1

Types of Diaphragmatic Hernias

Diaphragmatic hernias can be classified into two main categories:

1. Congenital Diaphragmatic Hernias (CDH)

   • Occur due to incomplete development of the diaphragm during gestation
   • Most commonly Bochdalek hernias (95%), typically on the left side (85%)
   • Usually diagnosed in childhood but can present in adulthood

2. Acquired Diaphragmatic Hernias (ADH)

   • Hiatal hernias (not true diaphragmatic hernias)
   • Traumatic diaphragmatic hernias (from blunt or penetrating trauma)
   • Iatrogenic hernias (from surgical procedures)

Natural History Without Intervention

Diaphragmatic hernias do not have the capacity to heal spontaneously for several important reasons:

• The constant pressure gradient between the abdominal and thoracic cavities causes progressive enlargement of the defect over time 1
• Small traumatic ruptures that initially remain asymptomatic typically worsen with time, leading to delayed complications months or years after the initial injury 1
• The natural history follows Carter's scheme of three phases:
  • Acute phase: Initial injury (often missed in 33-66% of cases)
  • Latent phase: Gradual herniation with nonspecific symptoms
  • Obstructive phase: Visceral obstruction progressing to ischemia 1

Complications of Untreated Diaphragmatic Hernias

Without surgical repair, diaphragmatic hernias can lead to:

• Strangulation of herniated bowel leading to necrosis
• Perforation causing severe peritonitis and sepsis
• Multi-organ failure with high mortality
• Respiratory compromise (25-50% decrease in pulmonary function)
• Cardiac compression 1

Diagnosis

The diagnosis of diaphragmatic hernia should be pursued with:

• Chest X-ray (anteroposterior and lateral) as initial screening
• CT scan with contrast enhancement of chest and abdomen (gold standard)
• MRI in pregnant patients after ultrasonography
• Diagnostic laparoscopy in stable trauma patients with suspected diaphragmatic hernia 1

Management Approach

All diaphragmatic hernias require surgical intervention:

• Laparoscopic approach is preferred for stable patients (lower morbidity rate of 5% compared to 17% with open approach) 2
• Open surgery is indicated for unstable patients or when laparoscopy is not available
• Damage Control Surgery for critically unstable patients 1

Surgical Techniques

• Primary repair with non-absorbable sutures for small defects
• Mesh reinforcement for larger defects (>3 cm) to prevent excessive tension
• Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates and higher resistance to infections 1

Prognosis

• Mortality rate in complicated traumatic diaphragmatic hernias: 14.3-20%
• Survival rate in adults with delayed complicated congenital diaphragmatic hernias: 97-100% 2

Common Pitfalls

• Misdiagnosis due to nonspecific symptoms
• Delayed diagnosis (occurs in 5-45% of all CDH cases)
• Right-sided hernias are more commonly missed (50% of delayed diagnoses)
• Attempting primary closure of large defects (>3-4 cm) without mesh reinforcement leads to high recurrence rates (up to 42%) 1

The evidence is clear that diaphragmatic hernias, regardless of their etiology, require surgical intervention and cannot heal spontaneously. Prompt diagnosis and appropriate surgical management are essential to prevent potentially fatal complications.