How should a patient with a diaphragmatic hernia be managed?

Management of Diaphragmatic Hernia

For complicated diaphragmatic hernia, laparoscopic repair is the preferred approach in hemodynamically stable patients, while open surgery with potential damage control is mandatory for unstable patients. 1

Diagnostic Workup

Initial Imaging Strategy

• CT scan of chest and abdomen with contrast is the diagnostic gold standard with 87% specificity and 14-82% sensitivity, showing critical findings including diaphragmatic discontinuity, the "collar sign" (constriction of herniated organ at rupture level), "dangling diaphragm" sign, and herniation of abdominal contents 1, 2
• Chest X-ray (anteroposterior and lateral) should be obtained first in non-trauma patients with respiratory symptoms, though it misses 25% of cases and can be normal in 11-62% of diaphragmatic injuries 1
• In stable trauma patients with lower chest penetrating wounds and nonspecific symptoms, diagnostic laparoscopy is recommended after non-diagnostic chest X-ray 1
• For pregnant patients, start with ultrasonography followed by MRI if needed, avoiding radiation exposure 1

Critical Imaging Findings Indicating Complications

• Signs of visceral ischemia: absent gastric wall contrast enhancement, intestinal wall thickening with target enhancement, spontaneous hyperdensity of intestinal wall 1
• Elevated hemidiaphragm, abnormal bowel gas pattern, air-fluid levels, mediastinal deviation 1
• Nasogastric tube visualized in herniated stomach confirms diagnosis when contents are uncertain 1

Surgical Approach Algorithm

Hemodynamically Stable Patients

Laparoscopic (transabdominal) repair is the gold standard with demonstrated 0.14% in-hospital mortality, reduced postoperative complications, shorter hospital stays, and facilitation of early diagnosis of small diaphragmatic injuries 1, 2, 3

Hemodynamically Unstable Patients

Open laparotomy is mandatory when patients present with peritonitis, visceral incarceration, strangulation, or hemodynamic instability 1, 2, 3

Critically Unstable Patients

Damage Control Surgery (DCS) should be employed to prevent abdominal compartment syndrome, particularly when the diaphragm cannot be closed primarily or when severely injured abdominal organs require second-look evaluation for ischemic bowel 1, 2, 3

Repair Technique

Primary Repair

• Attempt primary repair first using interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers (mattress technique) whenever tension-free closure is possible 1, 2, 3
• Primary repair alone is only appropriate for small defects that can be closed without tension 1, 3

Mesh Reinforcement

• Mesh is mandatory for defects >8 cm or >20 cm² area, or when primary closure creates excessive tension 1, 2, 3
• Use biosynthetic, biologic, or composite meshes rather than synthetic materials as they demonstrate lower recurrence rates (42% with primary repair alone vs. significantly reduced with mesh), superior infection resistance, and reduced displacement risk 1, 2, 3
• Mesh should overlap defect edges by 1.5-2.5 cm and can be fixed using tackers or transfascial sutures, avoiding tackers near the pericardium due to cardiac complication risk 1
• In clean-contaminated and contaminated fields, biologic or biosynthetic meshes can be safely used 1

Special Surgical Considerations

• For right-sided diaphragmatic hernias, the presence of the liver may necessitate a combined or thoracic approach 1
• In trauma patients with history of gastroesophageal reflux requiring large defect repair, anti-reflux procedures may be performed successfully 1

Adjunctive Procedures for High-Risk Patients

Gastrostomy or PEG should be considered in high-risk elderly patients with oral intake difficulties who are unsuitable for definitive surgical repair, providing fixation of the anterior stomach to the abdominal wall, relieving symptoms, preventing recurrence, and stopping progression of complications with very low morbidity 1, 3

Critical Pitfalls to Avoid

• Never attempt primary repair alone for defects >3 cm—this guarantees high recurrence rates and requires mesh reinforcement 2
• Do not use synthetic mesh in contaminated fields—biosynthetic or biologic meshes are safe even in clean-contaminated cases 1, 2
• Do not delay surgery if conservative management fails—complication rates and hospital stays are significantly higher with delayed intervention 2
• Do not miss the diagnosis in trauma patients—33-66% of traumatic diaphragmatic hernias are initially missed because associated thoraco-abdominal, cerebral, or musculoskeletal injuries dominate the clinical picture 1

Postoperative Management and Outcomes

Monitoring

• Serial clinical and imaging monitoring every 3-6 hours initially with close multidisciplinary follow-up to detect complications 2

Expected Complications

• Common complications include pulmonary complications (atelectasis, respiratory failure), surgical site infection, bleeding, ileus, gastroesophageal reflux, and chronic pain with overall incidence of 11-62.9% 2, 3
• Mortality rates range from 14.3-20% in complicated traumatic cases, emphasizing the importance of prompt recognition and appropriate surgical intervention 2, 3
• Survival is 97-100% in delayed complicated congenital diaphragmatic hernia 3