Diaphragmatic Hernias, Acquired Treatment & Management

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.

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.

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.

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.

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.

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

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.

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.