A tale of two unconventional adult diaphragmatic hernias

Abstract

Diaphragmatic hernias can be congenital or acquired and are a protrusion of intra-abdominal contents through an abnormal opening in the diaphragm. Acquired defects are rare and occur secondary to direct penetrating injury or blunt abdominal trauma. This case review demonstrates two unconventional cases of large diaphragmatic hernias with viscero-abdominal disproportion in adults. Case 1 is a 27-year-old man with no prior medical or surgical history. He presented following a 24-h history of increasing shortness of breath and left-sided pleuritic chest pain, and no history of trauma. Chest X-ray demonstrated loops of bowel within the left hemithorax with displacement of the mediastinum to the right. Computed tomography (CT) scan confirmed a large diaphragmatic defect causing herniation of most of his abdominal contents into the left hemithorax. He underwent emergency surgery, which confirmed the viscero-abdominal disproportion. He required an extended right hemicolectomy to reduce the volume of the abdominal comtents and laparostomy to reduce the risk of abdominal compartment syndrome and recurrence of the hernia. Case 2 is a 76-year-old man with significant medical comorbidities who presented with acute onset of abdominal pain. He had a history of traumatic right-sided chest injury as a child resulting in right-sided diaphragmatic paralysis. Chest X-ray demonstrated a large right-sided diaphragmatic hernia with abdominal viscera in the right thoracic cavity. CT scan of the chest, abdomen and pelvis demonstrated both small and large bowel loops within the right hemithorax, compression of the right lung and displacement of the mediastinum to the left. The CT scan also demonstarted viscero-abdominal disproportion. Operative management was considered initially but following improvement with basic medical management and no further deterioration, a non-operative approach was adopted. Both cases illustrate atypical presentations of adults with diaphragmatic hernias. In an ideal scenario, these are repaired surgically. When the presumed diagnosis shows characteristics of a viscero-abdominal disproportion and surgery is pursued, the surgeon must consider that primary abdominal closure may not be possible and multiple operations may be necessary to correct the defect and achieve closure. Sacrifice of abdominal viscera may also be necessary to reduce the volume of abdominal contents.

Keywords: Abdominal compartment syndrome; Blunt and penetrating trauma; Congenital diaphragmatic hernia; Delayed closure; Diaphragmatic hernia; Open and minimal access repair; Viscero-abdominal disproportion.

Figure 1

Admission chest X-ray demonstrating loops of bowel within the left hemithorax and mediastinal shift to the right

Figure 2

Computed tomography scan of the thorax, abdomen and pelvis with contrast demonstrating a large left-sided posterior diaphragmatic defect causing abdominal content to herniate into the left hemithorax with complete collapse of the left lung

Figure 3

Chest X-ray, August 2020, showing marked elevation of the right hemidiaphragm

Figure 4

Admission chest X-ray, January 2021, demonstrating loops of bowel within the right hemithorax and mediastinal shift to the left

Figure 5

Computed tomography scan of the chest, abdomen and pelvis demonstrating both small and large bowel loops within the right hemithorax, compression of the right lung and displacement of the mediastinum to the left