What is the management approach for an adult with a diaphragmatic hernia and tachycardia?

Management of Adult Diaphragmatic Hernia with Tachycardia

Adult patients with diaphragmatic hernia and tachycardia require urgent surgical intervention, with CT scan of the chest and abdomen as the gold standard for diagnosis followed by laparoscopic repair in stable patients or open surgical approach in unstable patients. 1

Diagnosis

Initial Assessment

• Chest X-ray (anteroposterior and lateral) is recommended as the first diagnostic study in patients with respiratory symptoms and no history of trauma 1
• Tachycardia in diaphragmatic hernia patients may indicate complications such as strangulation, incarceration, or cardiopulmonary compromise 1
• The presence of bowel sounds in the thorax during auscultation is an important diagnostic clue 2

Advanced Imaging

• CT scan with contrast enhancement of the chest and abdomen is the gold standard for diagnosing diaphragmatic hernia 1
• CT findings may reveal:
  • Herniated abdominal organs into the thoracic cavity
  • Complications such as strangulation, incarceration, or volvulus 1
• Multislice CT with coronal and sagittal reformatted images provides the most accurate assessment of the hernia 3
• In pregnant patients, ultrasonography is suggested as the first diagnostic study, followed by MRI if needed 1

Management Approach

Hemodynamic Stabilization

• Patients with tachycardia require immediate assessment of hemodynamic status 1
• Tachycardia may indicate complications such as bowel strangulation or respiratory compromise 1
• Cardiac monitoring is essential as diaphragmatic hernias can cause cardiac arrhythmias and compromise 4

Surgical Management

• Surgery is strongly recommended for all complicated diaphragmatic hernias 1
• The surgical approach depends on patient stability:
  • In unstable patients with tachycardia, open surgical repair via laparotomy is suggested 1
  • In stable patients, minimally invasive laparoscopic approach is preferred 1, 5
• Surgical principles include:
  • Reduction of herniated contents
  • Inspection for viability of herniated organs
  • Primary repair of the diaphragmatic defect with non-absorbable sutures 1
  • Mesh reinforcement for defects larger than 8 cm or an area greater than 20 cm² 1

Specific Considerations

• Right-sided diaphragmatic hernias may require a combined or thoracic approach due to the presence of the liver 1
• In cases of gastric volvulus with diaphragmatic hernia, gastropexy after detorsion, reduction of herniated structures, and repair of the diaphragmatic defect is recommended 1
• Fundoplication should be considered in congenital hernias due to high incidence (up to 62%) of gastroesophageal reflux after repair 1

Postoperative Care and Outcomes

Monitoring for Complications

• Close monitoring for postoperative pulmonary complications, especially atelectasis 1
• Vigilance for other complications including:
  • Surgical infection
  • Bleeding
  • Respiratory failure
  • Ileus
  • Gastroesophageal reflux
  • Cardiac injury 1

Expected Outcomes

• Laparoscopic repair has lower morbidity (5-6%) compared to open approach (17-18%) 1
• Survival rate in adults with delayed complicated congenital diaphragmatic hernia varies between 97-100% 1
• Mortality rate in complicated traumatic diaphragmatic hernia ranges from 14.3-20% 1
• Recurrence rates are poorly documented but may be related to:
  • Use of absorbable sutures
  • Suture tension
  • Improper fixation of prosthetic material
  • Increased intra-abdominal pressure
  • Poor chest toileting
  • Intra-abdominal sepsis 1

Pitfalls and Caveats

• Delayed diagnosis is common (5-45% of cases) and can lead to serious complications 1
• Diaphragmatic hernias can be asymptomatic for decades before becoming symptomatic 1
• Right-sided diaphragmatic ruptures are commonly missed (50% of delayed diagnoses) 1
• Initial chest radiographs can be misinterpreted in around 25% of cases, with normal chest radiographs reported in 11-62% of diaphragmatic injuries 1
• Tachycardia may be the only presenting sign of impending complications and should never be dismissed 6