What is the initial treatment for a diaphragmatic hernia?

Initial Treatment for Diaphragmatic Hernia

Surgery is the recommended initial treatment for diaphragmatic hernia, with the specific approach determined by the patient's stability and hernia type. 1

Diagnostic Approach

Before proceeding to treatment, proper diagnosis is essential:

• First-line imaging: Chest X-ray (anteroposterior and lateral views) for patients with respiratory symptoms 1
• For trauma patients: CT scan with contrast enhancement of chest and abdomen if stable 1
• For penetrating wounds: Diagnostic laparoscopy in stable patients with lower chest penetrating wounds 1
• For pregnant patients: Ultrasonography followed by MRI if needed 1

Treatment Algorithm Based on Patient Status and Hernia Type

For Traumatic Diaphragmatic Hernia (TDH):

1. Stable patients:

   • Laparoscopic surgical repair is preferred (Strong recommendation, moderate-quality evidence) 1
   • Primary repair with non-absorbable sutures in two layers when possible 1
   • For defects >3 cm or that cannot be closed primarily, mesh reinforcement is indicated 1

2. Unstable patients:

   • Laparotomy approach (Weak recommendation, low-quality evidence) 1
   • Damage Control Surgery (DCS) for patients with:
     • Intraoperative instability
     • Hypothermia
     • Coagulopathy
     • Significant acidosis
     • Impossibility to close the diaphragm 1

For Non-traumatic Diaphragmatic Hernia:

1. Stable patients with complicated hernia:

   • Minimally invasive approach is suggested (Weak recommendation, very low-quality evidence) 1
   • Has excellent safety profile with reported in-hospital mortality rate of only 0.14% 1

2. Unstable patients with complicated hernia:

   • Laparotomy approach (Weak recommendation, low-quality evidence) 1

Surgical Technique Considerations

• Primary repair: Use interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers 1

• Mesh use: For defects >8 cm or area >20 cm², use biosynthetic, biologic, or composite meshes 1

  • Mesh should overlap defect edge by 1.5-2.5 cm 1
  • Avoid tackers near the pericardium due to risk of cardiac complications 1

• Hernial sac management: Controversial, but excision may reduce tissue trauma, fluid collection, and recurrence 1

Special Considerations

• Right-sided hernias: May require combined or thoracic approach due to liver presence 1, 2
• Gastric volvulus: Perform gastropexy after detorsion, reduction of herniated structures, and repair of diaphragmatic defect 1
• Oral intake difficulties: Consider percutaneous endoscopic gastrostomy (PEG) or gastrostomy 1
• Anti-reflux procedures: Not routinely recommended in emergency settings unless patient has history of gastroesophageal reflux 1

Potential Complications to Monitor

• Postoperative pulmonary complications (especially atelectasis)
• Surgical site infection
• Bleeding
• Respiratory failure
• Ileus
• Gastroesophageal reflux
• Chronic pain
• Hernia recurrence
• Cardiac injury 1, 2

The mortality rate in complicated traumatic diaphragmatic hernias ranges from 14.3-20%, highlighting the importance of prompt surgical intervention 1.