Approach Considerations
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.
No contraindications have been reported for repair of an acquired diaphragmatic hernia. In the trauma setting, the patient must be adequately resuscitated before being 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.
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.
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 has been 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%). [4]
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.
Minimally invasive techniques for diaphragmatic repair have become increasingly common. With advances in technology and surgical skills, repairing both acute and chronic diaphragmatic hernias is possible with laparoscopic, [19, 20] thoracoscopic, robot-assisted, [21, 22] or combined approaches. However, the success of these minimally invasive approaches is highly surgeon-dependent, and laparotomy remains more common in this setting. [23]
Operative 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.
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. [24] 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. [9] There is some limited evidence to suggest that the use of biologic mesh in traumatic diaphragmatic repair may be feasible, at least in chronic cases. [25]
Laparoscopic abdominal exploration in the setting of trauma has become an increasingly popular way of determining 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. [26]
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.
Long-Term Monitoring
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 woman who was a restrained passenger in an automobile accident.
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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.
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Postoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
