What is the management and treatment approach for a patient diagnosed with a diaphragmatic hernia?

Management and Treatment of Diaphragmatic Hernia

Surgery is the definitive treatment for diaphragmatic hernia, with laparoscopic repair being the preferred approach in hemodynamically stable patients, while unstable patients require open laparotomy. 1

Diagnostic Approach

CT scan of the chest and abdomen is the gold standard for diagnosis, with sensitivity of 14-82% and specificity of 87%. 1 Key radiological findings include:

• Diaphragmatic discontinuity and the "dangling diaphragm" sign 1
• "Collar sign" showing constriction of herniated organs at the rupture site 1
• Signs of ischemia: absent gastric wall enhancement, intestinal wall thickening, portal venous gas 1

Chest X-ray has limited sensitivity (2-60% for left-sided, 17-33% for right-sided hernias) but remains useful as an initial screening tool. 1

Surgical Management Algorithm

For Hemodynamically Stable Patients

Laparoscopic repair is strongly recommended as it reduces postoperative complications, facilitates early diagnosis of small injuries, and has lower morbidity (5-6%) compared to open approach (17-18%). 1

• Traumatic diaphragmatic hernia: Laparoscopic approach with strong recommendation (1B evidence) 1
• Non-traumatic complicated hernia: Minimally invasive approach suggested (2D evidence) 1
• Overall in-hospital mortality rate with laparoscopic approach: 0.14% 1

For Hemodynamically Unstable Patients

Open laparotomy is indicated in patients with:

• Hemodynamic instability 1
• Intraoperative instability, hypothermia, coagulopathy, or significant acidosis 1
• Need for exploratory laparotomy due to associated injuries 1

Damage Control Surgery (DCS) is strongly recommended when the diaphragm cannot be closed or in critically unstable patients to prevent abdominal compartment syndrome. 1

Repair Technique

Primary Repair

Attempt primary repair with non-absorbable sutures first using interrupted 2-0 or 1-0 monofilament or braided sutures in two layers. 1 This should be done whenever possible for defects that can be closed without tension. 1

Mesh Reinforcement

Use mesh for defects >8 cm or >20 cm² area when tension-free primary closure is difficult. 1

• Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher infection resistance, and lower displacement risk 1
• Mesh should overlap defect edges by 1.5-2.5 cm 1
• Avoid tackers near the pericardium due to risk of cardiac complications 1
• Use transfascial sutures or tackers for fixation 1

Special Considerations for Right-Sided Hernias

Due to liver presence, repair can be difficult and may require a combined or thoracic approach. 1

Adjunctive Procedures

Gastropexy/PEG

Consider PEG, gastrostomy, or jejunostomy in patients with oral intake difficulties, especially high-risk elderly patients unsuitable for definitive repair. 1 These procedures provide anterior stomach fixation to the abdominal wall and have very low morbidity. 1

Anti-Reflux Surgery

• Fundoplication should be performed during congenital diaphragmatic hernia repair due to high incidence (up to 62%) of postoperative gastroesophageal reflux 1
• Preemptive anti-reflux surgery is NOT recommended in emergency traumatic or complicated hernia settings 1
• Consider fundoplication only in patients with history of GERD requiring repair of large defects 1

Gastric Volvulus Management

If gastric volvulus is present, perform gastropexy after detorsion, reduction of herniated structures, and diaphragmatic defect repair. 1

Clinical Outcomes and Complications

Common postoperative complications (11-62.9% incidence) include: 1

• Pulmonary complications and atelectasis (most common) 1
• Surgical site infection, bleeding, respiratory failure 1
• Ileus, gastroesophageal reflux, chronic pain 1

Mortality rates: 14.3-20% in complicated traumatic diaphragmatic hernia; 97-100% survival in delayed complicated congenital diaphragmatic hernia. 1

Recurrence rate: Primary repair alone has 42% recurrence rate, which is significantly reduced with mesh reinforcement. 1

Critical Pitfalls to Avoid

• Do not rely solely on chest X-ray as it misses 25% of cases and can be normal in 11-62% of diaphragmatic injuries 1
• Do not use synthetic mesh in contaminated fields - use biologic or biosynthetic meshes instead 1
• Do not attempt laparoscopy in unstable patients - proceed directly to laparotomy 1
• Do not place tackers near pericardium due to cardiac injury risk 1