Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

Abstract

Background Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. Methods A bibliographic search using major databases was performed using the terms “emergency surgery” “diaphragmatic hernia,” “traumatic diaphragmatic rupture” and “congenital diaphragmatic hernia.” GRADE methodology was used to evaluate the evidence and give recommendations. Results CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. Conclusions Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Rare Diaphragmatic Hernias in Adults—Experience of a Tertiary Center in Esophageal Surgery and Narrative Review of the Literature

“…The question naturally arises whether for asymptomatic patients, discovered incidentally, this recommendation is maintained. Almost all of the articles and studies in the literature recommend surgical intervention and only in exceptional cases, such as the presence of significant comorbidities, recommended abstinence [ 20 , 21 ].…”

Successful Laparoscopic Treatment of Morgagni’s Hernia in an Elderly Female Presenting as a Hypoxemic Hypercapnic Respiratory Distress

“…The recommendation for the use of mesh to reinforce the closure is weak. In defects larger than 3 cm, the use of a mesh assists in reducing the resulting tissue tension [ 1 ].…”

“…The diaphragmatic hernia of Morgagni was first described in 1769 by Morgagni, as an anterior, retrosternal, or parasternal muscular defect in the diaphragm, through which herniation of the abdominal viscera into the thorax occurs [ 1 ]. The occurrence of a congenital diaphragmatic hernia is not uncommon, as it occurred in one in 3,156 births according to a population-based epidemiological study in 2017 [ 2 ].…”

Robotic repair of a large chronic traumatic diaphragmatic hernia

“… 2 Further, patients may remain asymptomatic for a number of years and can present with nonspecific respiratory and gastrointestinal symptoms. 3 Once diagnosed, guidelines recommend surgical repair. 3 Laparoscopic, thoracoscopic, and combined approaches have all been described previously.…”

“… 3 Once diagnosed, guidelines recommend surgical repair. 3 Laparoscopic, thoracoscopic, and combined approaches have all been described previously. 1 The abdominal approach provides access to the retrohepatic vena cava, whereas the thoracic approach allows better access to pleural adhesions for decortication.…”