What is the treatment for hemidiaphragm (one half of the diaphragm) elevation?

Treatment of Elevated Hemidiaphragm

The treatment of elevated hemidiaphragm depends critically on the underlying cause: symptomatic diaphragmatic hernia requires surgical repair (preferably laparoscopic in stable patients), while diaphragmatic paralysis or eventration requires surgical plication only if symptomatic with disabling dyspnea. 1, 2, 3

Initial Diagnostic Workup

Determine the underlying etiology before proceeding with treatment:

• Chest X-ray is the initial study to identify hemidiaphragm elevation, though it cannot reliably determine the cause 2
• CT scan of chest and abdomen is the gold standard for diagnosis (sensitivity 14-82%, specificity 87%) and should be performed with IV contrast 1, 2
• Look for specific CT findings that distinguish diaphragmatic hernia from other causes: diaphragmatic discontinuity, "dangling diaphragm" sign (free edge curling toward abdomen), "collar sign" (constriction of herniated organ), "dependent viscera" sign (no space between organs and chest wall), and elevated abdominal organs 1, 2
• Fluoroscopy can differentiate eventration (no paradoxic motion) from paralysis (paradoxic motion with respiration) 3
• Ultrasound is useful for demonstrating fibrinous loculation and differentiating pleural fluid from pleural thickening, particularly in pregnant patients 1

Treatment Algorithm Based on Etiology

For Diaphragmatic Hernia (Traumatic or Non-Traumatic)

Surgery is the treatment of choice for symptomatic or complicated diaphragmatic hernia 1, 2

Surgical approach selection:

• In stable patients: Laparoscopic approach is strongly recommended (1B evidence) with shorter hospital stay and lower morbidity compared to open surgery 1
• In unstable patients or those with signs of strangulation/perforation: Laparotomy approach is indicated (2C evidence) 1
• Thoracoscopic approach may be used in chronic herniation due to viscero-pleural adhesions 1

Repair technique:

• Primary repair with non-absorbable interrupted mattress sutures (2-0 or 1-0 monofilament) in two layers should always be attempted when possible 1, 4
• For defects >3 cm: Mesh reinforcement is necessary as primary repair alone has a 42% recurrence rate 1, 4
• Mesh selection: Biosynthetic, biologic, or composite meshes are preferred over synthetic due to lower recurrence rates, higher infection resistance, and lower displacement risk (2C evidence) 1, 4
• Mesh should overlap defect edges by 1.5-2.5 cm 1, 4

For high-risk elderly patients unsuitable for definitive repair:

• Percutaneous endoscopic gastrostomy (PEG) or gastrostomy is suggested as an alternative, providing fixation of the stomach to the abdominal wall with very low morbidity (2C evidence) 1, 4

For Diaphragmatic Paralysis or Eventration

Surgical plication is indicated ONLY in symptomatic patients with disabling dyspnea, not for asymptomatic elevation 5, 3, 6, 7

Patient selection criteria:

• Presence of disabling dyspnea (effort or positional), cardiac or digestive symptoms, or pain that persists despite optimal conservative management 7
• Failure to wean from mechanical ventilation (particularly in postcardiotomy cases) 8
• Thorough morphological and functional investigation of neuromuscular and respiratory components before surgery 7

Surgical approach:

• Minimally invasive thoracoscopic plication is the preferred approach by most thoracic surgeons 5, 3
• Video-assisted mini-thoracotomy is an effective alternative with minimal surgical trauma, short operative time, and minimal blood loss 8
• Traditional lateral thoracotomy remains an option 6, 7

Timing of surgery:

• In adults with postcardiotomy phrenic nerve paresis: Conservative treatment is recommended for 6 months to 2 years as improvement often occurs spontaneously, unless respiratory distress is present 8
• In infants and young children: Early plication is indicated due to severe clinical status and failure to wean from mechanical ventilation 8
• Early surgery may be indicated in non-resolving respiratory failure in adults 8

Expected outcomes:

• Plication is safe and effective with low morbidity and mortality 5, 3, 7
• Long-lasting functional benefit of approximately 100% with significant improvement in dyspnea and quality of life 5, 7
• Goal is to improve lung volumes and decrease paradoxic elevation of the hemidiaphragm 3

Critical Pitfalls to Avoid

• Do not misdiagnose diaphragmatic hernia as simple elevation - look for specific CT signs like the "collar sign" and diaphragmatic discontinuity 2
• Do not overlook malignancy as a cause of diaphragmatic elevation, particularly phrenic nerve invasion from lung cancer with mediastinal involvement 2
• Do not perform plication for asymptomatic elevation - surgery is only indicated when symptoms are disabling 3, 7
• Be aware that normal chest radiographs have been reported in 11-62% of cases with diaphragmatic injuries or uncomplicated hernias 2
• Do not perform preemptive anti-reflux surgery in emergency or complicated hernia settings (2D evidence) 1, 4

Special Considerations

• Phrenic nerve injury from prior procedures (chest tube insertion, cardiac surgery) is a common cause of diaphragmatic paralysis 2
• Pulmonary embolism can present with elevated hemidiaphragm (36% of PE cases vs 25% without PE), though this is nonspecific 2
• For bilateral diaphragmatic dysfunction of central origin (tetraplegia above C3, alveolar hypoventilation), phrenic nerve pacing may be attempted after complete functional investigation, achieving ventilator weaning in >90% of patients 7