Innovative and Contemporary Interventions of Diaphragmatic Disorders

Abstract

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Laparoscopic repair and total gastrectomy for delayed traumatic diaphragmatic hernia complicated by intrathoracic gastric perforation with tension empyema: a case report

“…Blunt TDH is caused by indirect force that suddenly increases the intra-abdominal pressure, leading to diaphragmatic tears [ 2 , 3 ]. While most blunt diaphragmatic injuries are due to motor vehicle accidents, some are induced by fall and collision traumas, as was in the present case [ 8 , 9 ].…”

“…First, it is often accompanied by associated injuries (e.g., cardiovascular system, liver, spleen, kidney, and lung), which are relatively severe. Second, it may initially present no symptoms, particularly when the defect is small [ 2 , 8 , 10 ]. Since the defect cannot be closed spontaneously because of the continuous negative pressure of the thoracic cavity and movement of the diaphragm, it can cause visceral hernias [ 2 , 3 ].…”

“…Second, it may initially present no symptoms, particularly when the defect is small [ 2 , 8 , 10 ]. Since the defect cannot be closed spontaneously because of the continuous negative pressure of the thoracic cavity and movement of the diaphragm, it can cause visceral hernias [ 2 , 3 ]. If blunt TDH cases are missed, mortality due to late-onset complications is as high as 30%, and when the prolapsed organ is strangulated, this rate can reach 66% [ 10 – 12 ].…”

“…Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury frequently caused by traffic accidents and accounts for approximately one-third of traumatic diaphragmatic tears [ 1 , 2 ]. Because other associated injuries are often comparatively severe, blunt diaphragmatic hernia could be missed at the time of injury and may lead to delayed presentations, including visceral obstruction, strangulation, and perforation, which are critical complications [ 3 ].…”

Catamenial Pneumothorax (CP)

“…Repair of defects is typically followed by pleurectomy or pleurodesis by mechanical or chemical means (Talc powder) to promote fibrosis and adhesion between lung and diaphragmatic surfaces3. Surgical intervention is followed with medical treatment to prevent recurrence [15].…”