What is the management of diaphragmatic hernia or eventration?

Management of Diaphragmatic Hernia or Eventration

Surgery is the definitive treatment for both traumatic and non-traumatic diaphragmatic hernias, with laparoscopic repair being the preferred approach in stable patients. 1, 2

Initial Assessment and Surgical Timing

• All symptomatic or complicated diaphragmatic hernias require surgical intervention regardless of etiology (traumatic vs. non-traumatic, congenital vs. acquired). 1, 3
• Emergency surgery is indicated for patients with signs of visceral incarceration, strangulation, perforation, or hemodynamic instability. 1, 3
• CT scan is the diagnostic gold standard with 87% specificity, showing key findings like the "collar sign" (constriction at rupture level), dependent viscera sign, and intrathoracic herniation of abdominal contents. 1, 2

Surgical Approach Selection Algorithm

For Stable Patients:

• Laparoscopic (transabdominal) approach is strongly recommended as the gold standard, offering superior outcomes with 0.14% in-hospital mortality, reduced morbidity, and shorter hospital stays. 1, 2, 4
• This applies to Bochdalek hernias, Morgagni hernias, eventrations, and chronic traumatic hernias. 4

For Unstable Patients:

• Open laparotomy is indicated for hemodynamically unstable patients, those with multiple visceral injuries, or signs of organ ischemia. 1
• Damage Control Surgery (DCS) should be employed when patients develop intraoperative instability, hypothermia, coagulopathy, or significant acidosis. 1

For Chronic Hernias with Adhesions:

• Thoracoscopic or thoracotomy approach may be preferred when extensive viscero-pleural adhesions are present. 5
• Right-sided hernias may require thoracic approach or combined thoraco-abdominal technique due to liver interference. 1, 5

Operative Technique

Primary Repair:

• Attempt primary closure first using interrupted non-absorbable 2-0 or 1-0 monofilament sutures in two layers (mattress technique). 1, 2
• Primary repair alone has a 42% recurrence rate and should be reserved only for small defects (<3 cm). 1, 2

Mesh Reinforcement:

• Mesh is mandatory for defects >3 cm or when primary closure creates excessive tension. 1, 2
• For defects >8 cm or >20 cm² area, mesh interposition (bridging) rather than reinforcement is required. 1, 5
• Biosynthetic, biologic, or composite meshes are preferred over synthetic materials due to lower recurrence rates, superior infection resistance, and reduced displacement risk. 1, 2
• Mesh should overlap defect edges by 1.5-2.5 cm and can be fixed with transfascial sutures or tackers. 1, 2

Critical caveat: Avoid tackers near the pericardium due to cardiac complication risk. 1, 5

Hernial Sac Management:

• Sac excision remains controversial—retention causes no obvious complications, but excision may reduce fluid collections and recurrence, particularly when colon or stomach is contained. 1
• Excision risks include pneumomediastinum and mediastinal structure injury. 1

Special Considerations

Eventration:

• Managed identically to diaphragmatic hernias with laparoscopic plication and mesh reinforcement when defects are large. 4, 3

Anti-Reflux Procedures:

• Preemptive fundoplication is NOT recommended in emergency or complicated hernia settings. 1, 2
• Consider fundoplication only in patients with documented history of gastroesophageal reflux requiring repair of large defects or paraesophageal hernias. 1
• Congenital diaphragmatic hernias have up to 62% incidence of reflux and warrant fundoplication. 1

High-Risk Elderly Patients:

• Percutaneous endoscopic gastrostomy (PEG) or gastrostomy is an alternative for patients unsuitable for definitive repair, providing gastric fixation and symptom relief with low morbidity. 1, 2
• This approach prevents progression to gastric ischemia while avoiding major surgery. 1

Common Pitfalls to Avoid

• Never attempt primary repair alone for defects >3 cm—this guarantees high recurrence rates. 1, 2
• Do not use synthetic mesh in contaminated fields; biosynthetic or biologic meshes are safe in clean-contaminated cases. 1
• Avoid leaving the diaphragm unrepaired in unstable patients—employ DCS principles and plan staged repair. 1
• Do not perform routine fundoplication in acute traumatic settings without documented reflux history. 1, 2

Postoperative Management

• Intercostal drainage is frequently required (67% of cases in one series) for pleural effusions. 4
• Some hypoplastic lungs may never reinflate despite successful repair. 4
• Typical discharge occurs postoperative days 4-9 with complication rates around 19%. 4