eMedicine Specialties > Thoracic Surgery > Trauma

Diaphragmatic Hernias, Acquired: Treatment

Author: Anne T Saladyga, MD, General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center
Coauthor(s): Jason M Johnson, DO, General and Laparoscopic Surgeon, Department of General Surgery, William Beaumont Army Medical Center; 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
Contributor Information and Disclosures

Updated: Jan 14, 2008

Treatment

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.

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 likely present.

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.

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.

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, an abdominal approach is preferred because 89% of patients with traumatic rupture have other associated intra-abdominal injuries. In the latent phase of trauma, a transthoracic approach may be necessary because patients often have adhesions to intrathoracic organs.

Repair depends on the size of the defect. Interrupted horizontal sutures can be used for small defects, but large defects might eventually require synthetic mesh.

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 being considered and if a projectile injured the diaphragm.

Follow-up

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

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.

More on Diaphragmatic Hernias, Acquired

Overview: Diaphragmatic Hernias, Acquired
Workup: Diaphragmatic Hernias, Acquired
Treatment: Diaphragmatic Hernias, Acquired
Follow-up: Diaphragmatic Hernias, Acquired
Multimedia: Diaphragmatic Hernias, Acquired
References
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References

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Further Reading

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Keywords

hiatal hernia, diaphragm, congenital diaphragmatic hernia, CDH, respiratory dysfunction, respiratory compromise, blunt trauma, penetrating trauma, diaphragmatic rupture, motor vehicle accident, gunshot wound, stab wound, diaphragmatic hernia, acquired hernia, acquired diaphragmatic hernia

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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.

Medical 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 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, Southwestern Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel S Schwartz, MD, FACS, Clinical Assistant Professor of Cardiothoracic Surgery, New York University School of Medicine; Consulting Staff, Department of Surgery, Division of Thoracic Surgery, North Shore University Hospital/Long Island Jewish Medical Center
Daniel S Schwartz, MD, FACS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Diabetes Association, American Heart Association, American Medical Association, Association for Academic Surgery, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

CME Editor

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, Director of Cardiothoracic Transplantation, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

 
 
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