Emergency surgery due to diaphragmatic hernia: case series and review

Abstract

Background: Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17-6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods: From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results: Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion: Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Keywords: Congenital diaphragmatic hernia; Diaphragmatic rupture; Emergency surgery; Laparotomy; Mesh; Thoracotomy.

Fig. 1

a CT scan shows collapse of the lung and the mediastinal shift towards to the right side. The left diaphragmatic hernia contained the transverse and descending colon. b Intraoperative evidence: diaphragmatic defect allows migration of viscera

Fig. 2

CT scan shows in left side, large diaphragmatic defect which allows passage of the stomach, spleen and colon (referred to as Bochdalek hernias) and complete collapse of left lung

Fig. 3

Laparoscopic image during correction of defect with synthetic mesh

Fig. 4

a CT scan suggests left diaphragmatic hernia which allowed migration of colon in left chest. b Intraoperatively, biological mesh repairing defect

Fig. 5

a 3D-CT scan shows rib fractures. b CT scan shows stomach and spleen in the left hemi-thorax, complete disruption of all muscular layers. c Intraoperatively, repair of traumatic defect in the left diaphragm

Fig. 6

a X-ray shows herniated stomach into the chest. b Thoracotomy shows large diaphragmatic defect. c Repair of defect

Fig. 7

Flow chart of the literature selection process