Diaphragmatic Hernias, Acquired Treatment & Management

  • Author: Anne T Saladyga, MD; Chief Editor: Mary C Mancini, MD, PhD   more...
 
Updated: Jun 2, 2010
 

Medical Therapy

For traumatic rupture, first provide initial resuscitation according to ATLS protocol, most importantly, airway control. Avoid the use of military antishock trousers (MAST).

Prepare the patient for surgery. Sometimes, as with congenital hernias, surgical intervention can be briefly delayed until the patient's condition is stabilized. However, the high incidence of concomitant injuries requires emergency exploration in most cases.

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Surgical Therapy

If the diaphragmatic injury is discovered during the acute phase of trauma, the standard surgical approach is laparotomy or, less commonly, thoracotomy. The generally accepted protocol in the acute setting is that a diaphragmatic rupture is approached by using a celiotomy because the concomitant intra-abdominal injuries are more likely present than thoracic injuries (84% vs 53%).[2]

The problem regarding which approach to use arises when the diaphragmatic injury is unnoticed for months or years. More surgeons approach long-standing hernias with a transthoracic or thoracoabdominal approach because the herniated intra-abdominal contents tend to be firmly attached to intrathoracic structures, making a transabdominal approach difficult.

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Preoperative Details

As with any trauma, the patient's condition must be stabilized, and he or she must be resuscitated as much as possible before the operation. People with traumatic hernias frequently have concomitant injuries and require emergency exploration.

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Intraoperative Details

With traumatic ruptures, the surgical approach depends on the timing of the diagnosis with the surgical intervention. In the acute phase of trauma, abdominal approach is preferred. In the latent phase of trauma, a transthoracic approach may be necessary because patients often have adhesions to intrathoracic organs.

Acute injuries are repaired using monofilament permanent sutures. Small lacerations may be repaired using interrupted, horizontal mattress, or figure-of-eight stitches; larger lacerations may be repaired with continuous or double-layered closures. Absorbable sutures are associated with a high rate of recurrence.[3]

Laparoscopic abdominal exploration in the setting of trauma is becoming a popular way to determine if diaphragmatic integrity is retained. It provides a minimally invasive mechanism to directly view the diaphragm to determine if an injury has occurred. In the absence of other intra-abdominal injuries, the diaphragm can easily be repaired by applying laparoscopic techniques.

The best utility of laparoscopy is with penetrating thoracic and flank injuries when intraperitoneal penetration is being considered and if a projectile injured the diaphragm.

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Follow-up

After an anatomic defect is corrected, periodic assessments of pulmonary function and chest radiography are important (see image below). Although the spontaneous recurrence rate for repaired diaphragmatic hernias is low, small defects in the repair site have been reported; therefore, surveillance is crucial.

Postoperative chest radiograph in a 53-year-old woPostoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
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Complications

Recurrence is possible after traumatic herniation or a congenital diaphragmatic hernia that was repaired in an adult. Therefore, follow-up chest radiography is important.

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Outcome and Prognosis

In traumatic ruptures, the outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5-51%. People with isolated diaphragmatic injuries tend to recover without long-term disability.

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Future and Controversies

Minimally invasive techniques for diaphragmatic repair are becoming more common than before. With advances in technology and surgical skills, repairing both acute and chronic diaphragmatic hernias is possible with laparoscopic, thoracoscopic, or combined approaches.

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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.

Coauthor(s)

Jason M Johnson, DO  General and Laparoscopic Surgeon, Department of General Surgery, William Beaumont Army 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.

Specialty Editor Board

Jeffrey C Milliken, MD  Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at 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, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Daniel S Schwartz, MD, FACS  Assistant Clinical Professor of Cardiothoracic Surgery, Mount Sinai School of Medicine; Chief of Thoracic Surgery, Huntington Hospital

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

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Mary C Mancini, MD, PhD  Professor and Chief, Cardiothoracic Surgery, Department of Surgery, Louisiana State University Health Sciences Center-Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

References
  1. 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. Nov 2004;22(7):601-4. [Medline].

  2. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. Mar 2008;85(3):1044-1048. [Medline].

  3. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg. Jun 2008;33(6):1082-5. [Medline].

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

  5. Hamoudi D, Bouderka MA, Benissa N, Harti A. Diaphragmatic rupture during labor. Int J Obstet Anesth. Oct 2004;13(4):284-6. [Medline].

  6. Hayden JD, Davies JB, Martin IG. Diaphragmatic rupture resulting from gastrointestinal barotrauma in a scuba diver. Br J Sports Med. Mar 1998;32(1):75-6. [Medline].

  7. Mansour KA. Trauma to the diaphragm. Chest Surg Clin N Am. May 1997;7(2):373-83. [Medline].

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

  9. Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am. Mar 2006;44(2):199-211, vii. [Medline].

  10. 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. Nov 2004;22(7):601-4. [Medline].

  11. Ahmed N, Whelan J, Brownlee J, Chari V, Chung R. The contribution of laparoscopy in evaluation of penetrating abdominal wounds. J Am Coll Surg. Aug 2005;201(2):213-6. [Medline].

  12. Düzgün AP, Ozmen MM, Saylam B, Coşkun F. Factors influencing mortality in traumatic ruptures of diaphragm. Ulus Travma Acil Cerrahi Derg. Apr 2008;14(2):132-8. [Medline].

  13. Fell SC. Surgical anatomy of the diaphragm and the phrenic nerve. Chest Surg Clin N Am. May 1998;8(2):281-94. [Medline].

  14. Irish MS, Holm BA, Glick PL. Congenital diaphragmatic hernia. A historical review. Clin Perinatol. Dec 1996;23(4):625-53. [Medline].

  15. Mandell GA, Finkelstein MS, Hallowell M. Delayed presentation of a symptomatic Morgagni hernia. South Med J. Oct 1989;82(10):1299-302. [Medline].

  16. Naunheim KS. Adult presentation of unusual diaphragmatic hernias. Chest Surg Clin N Am. May 1998;8(2):359-69. [Medline].

  17. Shah R, Sabanathan S, Mearns AJ, Choudhury AK. Traumatic rupture of diaphragm. Ann Thorac Surg. Nov 1995;60(5):1444-9. [Medline].

  18. Sharma OP. Traumatic diaphragmatic rupture: not an uncommon entity--personal experience with collective review of the 1980's. J Trauma. May 1989;29(5):678-82. [Medline].

  19. van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. J Trauma. May 1989;29(5):683-6. [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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