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Acquired Diaphragmatic Hernias

  • Author: Anne T Saladyga, MD; Chief Editor: Jeffrey C Milliken, MD  more...
 
Updated: Dec 05, 2014
 

Background

The first traumatic diaphragmatic hernia was reported by Sennertus in 1541. The first two deaths were described by Ambrose Paré in 1578, one from strangulated bowel.[1]

The diaphragm is the major muscle of respiration. Diaphragmatic excursion and chest wall expansion increase the negative intrathoracic pressure required for inhalation. The sequelae from diaphragmatic rupture and subsequent herniation of intra-abdominal contents are associated with significant morbidity and mortality.

Diaphragmatic hernias can be divided into the following two categories:

  • Congenital defects
  • Acquired defects

Congenital diaphragmatic hernias (CDHs) occur because of embryologic defects in the diaphragm. Most patients with CDH present early rather than late in life; however, a subset of adults may present with a congenital hernia that was undetected during childhood. Acquired diaphragmatic hernias stem from all types of trauma, with blunt forces accounting for the majority.

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Problem

Diaphragmatic hernias require a high level of suspicion to detect. Patients can be asymptomatic in up to 53% of hernias from blunt trauma and 44% from penetrating trauma. Routine chest x-ray detects only 33% of hernias when interpreted by the trauma team leader at initial evaluation.[2] Missed injuries are associated with significant morbidity and mortality.

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Epidemiology

Frequency

Of patients admitted to the hospital for trauma, 3-5% have a diaphragmatic hernia.[3, 4] The male-to-female ratio is 4:1, with most presenting in the third decade of life. Approximately 0.8-1.6% of patients with blunt trauma sustain a rupture of the diaphragm, accounting for 75% of diaphragmatic hernias. Approximately 69% of hernias are on the left side, 24% are on the right, and 15% are bilateral.

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Etiology

By far, the most common cause of acquired diaphragmatic disorders is trauma, either blunt or penetrating. Motor vehicle accidents are the leading cause of blunt diaphragmatic injury, whereas penetrating injuries result from gunshot or stab wounds. In contrast to earlier work, several more recent retrospective studies found 75% of their patients to have tears from penetrating injuries.[3, 4] This may stem from increasing awareness of the part of providers or the ability to detect small tears via minimally invasive methods.

Other rare causes of traumatic rupture include labor in women with prior diaphragmatic hernia repair[5] and barotrauma during underwater dives in patients with history of Nissen fundoplications.[6]

The following theories have been postulated to explain the mechanism of rupture for blunt injuries:

  • Shearing of a stretched membrane
  • Avulsion of the diaphragm from its points of attachment
  • Sudden increase in the transdiaphragmatic pleuroperitoneal pressure gradient

The resting pressure differential between the pleural (-5 to -10 cm H2 O) and peritoneal (+2 to +10 cm H2 O) cavities rises to 100-150 cm H2 O with a large cough and does not injure the diaphragm. Forces transmitted to the abdomen from blunt trauma can raise the pressure gradient to 1000 cm H2 O.

Left-side rupture is more common than right-side rupture (68.5% vs 24.2%), owing to hepatic protection and increased strength of the right hemidiaphragm. However, the increased prevalence of left-side hernias may also result from weaknesses in points of diaphragmatic embryologic fusion.

Current thought is that the right side has more protection than the left and that it may be slightly stronger than the left. In addition, the liver may provide another protection for the right hemidiaphragm. Children have equal rates of rupture per side, likely because of laxity of liver attachments.[7]

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Pathophysiology

The pathophysiology of acquired diaphragmatic hernias includes circulatory and respiratory depression secondary to decreased function of the diaphragm, intrathoracic abdominal contents leading to compression of the lungs, shifting of the mediastinum, and cardiac compromise.[8] Smaller diaphragmatic hernias are often not found until months or years later, when patients present with strangulation of intra-abdominal organs, dyspnea, or nonspecific gastrointestinal complaints.

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Presentation

Clinical findings in patients with acquired diaphragmatic hernia may include the following:

  • Marked respiratory distress
  • Decreased breath sounds on the affected side
  • Palpation of abdominal contents upon insertion of a chest tube
  • Auscultation of bowel sounds in the chest
  • Paradoxical movement of the abdomen with breathing
  • Diffuse abdominal pain
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Indications

In traumatic rupture of the diaphragm, surgical intervention is mandatory, whether the patient presents immediately or some time after the trauma. The high incidence of concomitant intra-abdominal injuries dictates the need for emergency abdominal exploration in the acute trauma setting after initial resuscitation is accomplished.

Patients who present in the latent phase or long after the trauma require repair because the hernia contents may become strangulated, leading to dead gut, stomach, liver, spleen, or other organs.

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Relevant Anatomy

The diaphragm is a modified half-dome of musculofibrous tissue that separates the thorax from the abdomen. The thoracic side is covered with parietal pleura, and the abdominal side with peritoneum. Four embryologic components arise during the formation of the diaphragm: the septum transversum, two pleuroperitoneal folds, cervical myotomes, and the dorsal mesentery.

Development begins during the third week of gestation and concludes by the eighth week. Failure of the development of the pleuroperitoneal folds, and subsequent muscular migration, results in congenital defects.

The muscular diaphragm originates from the six lowest ribs on both sides, from the posterior xiphoid process, and from the external and internal arcuate ligaments. Different structures traverse the diaphragm, including three distinct apertures that allow the aorta, esophagus, and vena cava to pass, as follows:

  • The aortic aperture is the lowest and most posterior of the openings, lying at the level of the T12 vertebra; it also transmits the thoracic duct and, sometimes, the azygos and hemiazygos veins
  • Diaphragmatic muscle surrounds the esophageal aperture, which lies at the T10 level
  • The vena caval aperture is the highest of the three openings and lies level to the disk space between T8 and T9

Because of its combination of fast twitch oxidative-glycolytic and slow twitch oxidative fibers, the diaphragm is a muscle resistant to fatigue. Loss of movement of the diaphragm is indicative of fatigue and can be measured by the contractile force. Many patients with chronic obstructive pulmonary disease (COPD) can live at the brink of fatigue.[9]

The arterial supply to the diaphragm derives from the right and left phrenic arteries, the intercostal arteries, and the musculophrenic branches of the internal thoracic arteries. Small branches of the pericardiophrenic arteries that course with the phrenic nerve, mainly where the nerves penetrate the diaphragm, provide some arterial blood. Venous drainage is through the inferior vena cava and azygos vein on the right and the adrenal/renal and hemizygos veins on the left.

The diaphragm receives its sole muscular neurologic impulse from the phrenic nerve, which primarily originates from the fourth cervical ramus; however, it also has contributions from the third and fifth rami. (As the saying goes, "C3, C4, and C5 keep the diaphragm alive.")

Originating around the level of the scalenus anterior, the phrenic nerve courses inferiorly through the neck and thorax before reaching its end point, the diaphragm. Because the phrenic nerve has such a long course before it reaches its final destination, any process that disrupts transmission of neurologic impulses through the nerve directly affects the diaphragm.

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Contraindications

Relatively no contraindications have been reported for repair of an acquired diaphragmatic hernia. In the trauma setting, the patient must be adequately resuscitated before he or she is transported to the operating room. Many small injuries are discovered during exploratory laparotomy for the repair of other intra-abdominal injuries.

Diaphragmatic hernias should always be repaired. Lack of repair of a diaphragmatic hernia can lead to incarceration and strangulation of intra-abdominal contents or respiratory dysfunction.

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Contributor Information and Disclosures
Author

Anne T Saladyga, MD General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

Daniel S Schwartz, MD, FACS is a member of the following medical societies: Society of Thoracic Surgeons, Western Thoracic Surgical Association, American College of Chest Physicians, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

Jason M Johnson, DO Resident Physician, Department of General Surgery, Spartanburg Regional Medical Center

Disclosure: Nothing to disclose.

Sidney R Steinberg, MD, FACS Program Director, Department of General Surgery, Spartanburg Regional Healthcare System; Consulting Surgeon, Department of Surgery, WG Hefner Veterans Affairs Medical Center

Sidney R Steinberg, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Surgical Education, South Carolina Medical Association, and Southeastern Surgical Congress

Disclosure: Nothing to disclose.

References
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  4. Cameron JL. Diaphragmatic injury. Current Surgical Therapy. 9th ed. Philadelphia, PA: Mosby-Elsevier; 2008. 975-987.

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  9. West, John B. Normal Physiology; Acute Respiratory Failure. Anthony, Robert. Pulmonary Physiology and Pathophysiology. Baltimore, MD: Lippincott Williams & Wilkins; 2001. 2-3; 129.

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  12. Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. 2004 Nov. 22(7):601-4. [Medline].

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Preoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident. Note the bowel contents in the left hemithorax. Nasogastric tube can be seen in the thorax.
Postoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
 
 
 
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