Surgical management of chronic diaphragmatic hernias

Abstract

Chronic diaphragmatic hernia (CDH) is an uncommon disease which may be associated with significant morbidity and mortality. Antecedent (even many months or years before CDH development) blunt or penetrating thoracic/thoraco-abdominal trauma is generally recognized. A wide spectrum of different mechanisms of injury, timing in presentation, size of the diaphragmatic defect, types and amount of abdominal viscera herniated into the chest cavity, clinical symptoms are observed in CDHs. Thoracic and abdominal CT scan (with coronal, axial and sagittal reconstructions) is the best diagnostic tool; sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity. Surgery (sometimes urgent) represents the treatment of choice for CDH; diaphragmatic hernia direct repair with a tension-free suture is generally attempted; in case of very large defects or when a tension-free suture is deemed unfeasible, the use of prosthesis is recommended. This review article will discuss about CDH aetiology, clinical presentation diagnosis and surgical treatment.

Keywords: Diaphragm; chronic; hernia; injury; trauma.

Figure 1

Severe small bowel ischemia following a right CDH (A,B). Abdominal viscera resection and diaphragmatic repair have been performed through a posterolateral thoracotomic approach. CDH, chronic diaphragmatic hernias.

Figure 2

Penetrating trauma. (A,B) Penetrating (suicide attempt) left-side thoracic trauma; (C) intraoperative view of the lung & diaphragm injury; (D) the 18-cm-long kitchen knife.

Figure 3

Acute penetrating left thoracic trauma (Figure 2 clinical case): CT reconstruction with the left hemidiaphragm injury evidence.

Figure 4

Penetrating trauma. (A) Multiple left-sided knife wounds in a 35-year-old man; at the operative inspection, several lung and diaphragmatic injuries have been found; (B) lower left chest (red line & red arrow): this area is at high risk for diaphragmatic injuries, especially after a penetrating trauma.

Figure 5

Schematic representation of the most common sites of diaphragm injury after a blunt trauma (black lines).

Figure 6

Severe small bowel ischemia (A) and perforation (B) in a right chronic diaphragmatic hernia after blunt trauma.

Figure 7

Severe small bowel ischemia after blunt trauma. Severe small bowel ischemia (A) after a left chronic diaphragmatic hernia following blunt trauma. Visceral resection and anastomosis have been performed through a laparotomic approach; (B) final result.

Figure 8

Chest X-ray demonstrating a right chronic diaphragmatic hernia (colon and small bowel in the chest cavity) (A) and a left one (B) with stomach and colon herniation.

Figure 9

Right chronic diaphragmatic hernia: omentum and colon are herniated into the chest, but their reduction into abdomen is technically complicated. (A) the diaphragmatic lesion enlargement is performed, and (B) the organs are carefully replaced in abdomen.

Figure 10

Large diaphragmatic chronic defect (A), appropriately treated with a tension-free direct suture (B).

Figure 11

Large right CDH: (A) the repair starts with a second lower thoracotomic approach, using the same skin incision; (B) the Duo-mesh prosthesis is placed: the final result. CDH, chronic diaphragmatic hernias.