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Acquired Diaphragmatic Hernias Treatment & Management

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

Medical Therapy

For traumatic rupture, first provide initial resuscitation according to Advanced Trauma Life Support (ATLS) protocol, with particular attention to 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 necessitates 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 via a celiotomy because concomitant intra-abdominal injuries are more likely to be present than thoracic injuries are (84% vs 53%).[2]

The problem regarding which approach to use arises when the diaphragmatic injury goes unnoticed for months or years. More surgeons approach long-standing hernias via 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 in any case of trauma, the patient's condition must be stabilized, and he or she must be resuscitated to the extent possible before operative treatment. 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, an 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 with monofilament permanent sutures. Small lacerations may be repaired by using interrupted, horizontal mattress, or figure-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 whether diaphragmatic integrity is retained. It provides a minimally invasive mechanism by which the diaphragm can be directly viewed 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

Recurrence is possible after traumatic herniation or a congenital diaphragmatic hernia that was repaired in an adult. Therefore, after an anatomic defect is corrected, periodic assessments of pulmonary function and chest radiography are important (see the 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 wo Postoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
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Outcome and Prognosis

In traumatic ruptures, the outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5% to 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,[13] 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.

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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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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