Open Access

Emergency surgery due to diaphragmatic hernia: case series and review

World Journal of Emergency Surgery201712:23

DOI: 10.1186/s13017-017-0134-5

Received: 14 March 2017

Accepted: 9 May 2017

Published: 18 May 2017

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.

Keyword

Congenital diaphragmatic hernia Diaphragmatic rupture Mesh Emergency surgery Laparotomy Thoracotomy

Background

Congenital diaphragmatic hernia (CDH) is an abnormality found in 1/2500 newborns, with a survival rate of 67% [1]. A primary characterization of CDH is that the diaphragm fails to form properly during embryogenesis. This incomplete formation of the diaphragm allows abdominal contents to herniate into the chest creating a mass-like effect that impedes lung development. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms, and sometimes haemodynamic instability. The broad spectrum of severity in patients with CDH is dependent on the degree of pulmonary hypoplasia and pulmonary hypertension. Posterolateral hernias (Bochdalek hernias) are the most common hernia type (>80%) with the majority occurring on the left side (85%), less frequently on the right side (13%) or bilateral (2%) [2].

Diaphragmatic rupture (DR) is an infrequent complication of trauma that occurs during 5% of trauma, including vehicle accidents [35]. Diagnosis is usually delayed; patients may be asymptomatic for years after trauma, until complications occur. Traumatic rupture of the diaphragm is considered an indication for surgical repair, especially in symptomatic patients [6].

However, there is no consensus on the absolute indications to surgery and about the timing. The onset of complications carries highest mortality and morbidity rates; therefore, it makes emergency surgery mandatory. During the past decades, primary suture repair or covering the defect with a synthetic mesh has been the standard procedures. More recently, biologic meshes have been thought to be effective in closing the diaphragmatic defect, inducing limited inflammatory response and minimizing adhesion formation [7]. Laparotomy or thoracotomy are the traditional treatments for patients with DR. Moreover, laparoscopic approaches for repair of hernias have recently gained in popularity [8]. Robotic approach is not yet described as effective approach in emergency, and it is reported in literature in only one case [9] in elective surgery.

This paper includes the surgical experience of congenital or traumatic diaphragmatic hernia of a surgical unit in emergency setting and reports the literature.

Methods

Six cases of diaphragmatic hernia were observed in emergency at our Academic Department, with respiratory and abdominal symptoms. No breath sounds were detected in the left chest area, but bowel sounds were audible. Emergency surgery was performed in all cases. The hernia contents were reduced, and the defect was closed with primary repair or mesh.

Case 1: A 63-year-old woman was admitted with complaints of bowel obstruction and dyspnoea. Anamnesis revealed chronic abdominal pain, mental retardation and strabismus. In the physical examination, no breath sounds were detected in the left chest area; however, bowel sounds were audible. Chest X-ray and barium enema showed the transverse colon displaced into the left hemithorax above the splenic flexure. Computed tomography suggested collapse of the lung and the mediastinal shift towards the right. The left diaphragmatic hernia contained the transverse and descending colon (Fig. 1a). Emergency laparotomy was performed, and a left diaphragm agenesis, mega colon (diameter 10 cm) and left liver agenesis were found. An intra-operative bronchoscopy revealed hypoplasia of the left lung (Fig. 1b). A subtotal colectomy with ileo-rectal anastomosis was performed, and primary repair of diaphragm was done. The post-operative course was uneventful, and the patient was discharged on the 15th post-operative day. The research of abnormalities of the karyotype, phenotype and genetic pattern was negative for all the known congenital syndromes.
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

Case 2: A 50-year-old woman was admitted with complaints of dyspnoea, chest and abdominal pain. No breath sounds were detected in the left chest area. There was no history of trauma. Chest X-ray revealed mediastinal shift towards the right and bowel gas in the left chest. CT scan showed large annular diaphragmatic defect which allowed passage of the stomach, spleen and colon (Fig. 2). An emergency combined chest-abdominal approach was performed, and contents were reduced repairing the defect with Mersilene mesh®. Thoracotomy approach was used to release the thoracic dense adhesion between the chest and the abdominal contents. Before placing the mesh, the anaesthesiologist increased the tidal volume to expand the collapsed left lower lobe of the lung and a chest drain was placed in the left pleural space. Immediate post-operative chest X-ray showed expansion of the left lung with minimal pleural effusion. Post-operative course was uneventful, and post-operative stay was 13 days.
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

Case 3: A 73-year-old woman arrived with complaint of breathlessness and dysphagia. No history of trauma was evident in anamnesis. Her current medical history included hypertension and hypothyroidism. Chest X-ray and barium studies demonstrated the presence of stomach in left hemithorax. CT scan revealed the presence of large diaphragmatic hernia which allowed the stomach to herniate into the chest. Emergency laparoscopy was performed; hernia contents were reduced; and a repair of the defect with Proceed mesh® was done (Fig. 3). The post-operative course was uneventful, and patient was discharged 7 days after surgery.
Fig. 3

Laparoscopic image during correction of defect with synthetic mesh

Case 4: A 63-year-old woman was admitted with complaints of breathlessness for 2 days, which was gradually progressive and associated with left-sided chest pain and a dry cough. There was a history of a vehicle accident 6 years ago. The initial chest radiograph revealed an elevated left hemi diaphragm with presence of a colon gas shadow in the lower half of the hemithorax. CT scan suggested left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon (Fig. 4a). Surgery was performed in emergency, reducing contents and repairing the defect with biological mesh (Fig. 4b; Tutomesh, bovine pericardium mesh ® ). The patient was discharged on the 10th post-operative day, without complications.
Fig. 4

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

Case 5: A 50-year-old man was involved in a work accident. He was managed in accordance with Advanced Trauma Life Support protocol. He arrived in the emergency room with decreased breath sounds on the left side, dyspnoea, fever, left hypochondrium hematoma, subcutaneous emphysema, and chest and abdominal pain. His current medical history included obesity and treated hypertension. Initial chest radiography and barium studies demonstrated stomach in the left hemithorax. CT scan revealed stomach and spleen in left hemithorax, consistent with a traumatic diaphragmatic rupture with complete disruption of all muscular layers, collar sign and multiple rib fractures, fractured left humerus and scapula (Fig. 5a, b). At exploratory laparotomy, traumatic defect in the left diaphragm was found, with stomach and spleen in the left thorax (Fig. 5c). The hernia contents were reduced and the defect was closed with biologic mesh (Tutomesh bovine pericardium mesh ® ). Post-operatively, the patient was placed in an intensive care unit. He was transferred from the ICU on the 8th post-operative day and discharged on the 20th day.
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

Case 6 [10]: A 51-year-old man, referred to a history of 5 months of dyspnea, abdominal pain, nausea and vomiting. These symptoms had increased in severity during the previous 2 weeks. Anamnesis revealed left splenopancreatectomy 4 years earlier for non-Hodgkin’s lymphoma. The physical examination revealed a moderate peritoneal effusion without a peritoneal reaction. The introduction of a nasogastric tube remarkably improved symptoms. The chest X-ray showed a large fluid level beneath an apparently raised left hemi diaphragm (Fig. 6a) hypothesizing a left hemi diaphragmatic rupture with gastric herniation; diagnosis was confirmed by barium studies and a thoracic-abdominal computed tomography. An emergency left thoracotomy was performed, revealing a volvulus of the stomach, with some intestinal loops. Part of the transverse colon was incarcerated herniating through the torn diaphragm. The hernia was localized into the posterior side of the left hemi diaphragm with a diameter of 12 cm. During surgery, dense adhesions between the herniated organs and the left pleura-lung, as well as a marked reduction in left lung volume and an inflammatory mass in the greater omentum adherent to the diaphragm, were found. Thus, a reduction of the volvulus, an adhesiolysis and a resection of the mass were performed. Finally, a direct suture of the left diaphragmatic defect was employed (Fig. 6b, c). The patient had an uneventful recovery and histology showed Hodgki’s lymphoma.
Fig. 6

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

Review of the literature

A systematic review was performed by consulting PubMed/MEDLINE from 1983 to 2017 using the terms “emergency surgery”, associated with “traumatic diaphragmatic rupture”, and “congenital diaphragmatic hernia”. The search returned 555 papers (Fig. 7). Three hundred twenty-three publications were excluded because these articles were not written in English (N = 87), presented cases in childhood (<19 years old; N = 178) or were not interesting human species (N = 58); 32 papers were excluded because regarded hiatal hernia, 40 paraesophageal hernia and 59 elective setting. Consequently, the full texts of 101 articles were assessed for eligibility: the ethiopathogenesis was traumatic in 697 patients and congenital in 38 (Table 1).
Fig. 7

Flow chart of the literature selection process

Table 1

Review of literature showing demographics data, diagnosis and treatment

Authors,

references

Number of patient, sex, age (years)

Aetiology

Diagnosis

Treatment

Type of hernia

Herniated organs

Lu J et al. Medicine 2016 [41]

1, M, 51

Traffic accident

Barium enema CT scan

Splenectomy

Left hemi diaphragm

Splenic flexure of the colon

1, M, 45

Traffic accident

Chest X-ray, gastrografin contrast

Splenectomy

Left hemi diaphragm

Stomach and small bowel

1, M, 47

Traffic accident

Chest X-ray, gastrografin contrast

Splenectomy

Left hemi diaphragm

Stomach and omentum

1, M, 30

Traffic accident

Chest X-ray, Gastrografin contrast

Nonoperative treatment

Left hemi diaphragm

Stomach and omentum

1, M, 33

Traffic accident

Chest X-ray, gastrografin contrast

Nonoperative treatment

Left hemi diaphragm

Stomach and omentum

1, M, 29

Penetrating injury

Chest X-ray, gastrografin contrast

Nonoperative treatment

Left hemi diaphragm

Stomach and omentum

Manabu Harada, Int J Surg Case Rep. 2016 [42]

1, M, 78

Bochdalek hernia

Chest radiography and computed tomography

Laparoscopic Primary closure

Left hemi diaphragm

Omentum, transverse colon, and small intestine

De la Cour CD; Ugeskr Laeger. 2016 [43]

1, F, 27

Partum

Chest radiography and computed tomography

Primary closure

Left hemi diaphragm

 

Razi K; J Surg Case Rep. 2016 [44]

1, F, 83

Morgagni hernia

Chest radiography and computed tomography

Mesh closure

Left hemi diaphragm

Transverse colon, greater curvature of the stomach and a partial gastric volvulus

Manson HJ Ann R Coll Surg Engl. 2016 [45]

1, F, 30

Bochdalek hernia

Chest radiography and computed tomography

Total gastrectomy with primary Roux-en-Y reconstruction, splenectomy and insertion of a feeding jejunostomy

Left hemi diaphragm

Gangrenous stomach and spleen, cardiac arrest

Massloom HS; N Am J Med Sci. 2016. [46]

1, M, 50

Bochdalek hernia

Computed tomography

Laparotomy and thoracotomy for repairing of defect

Left hemi diaphragm

Bowel

Kumar, J Surg Case Rep. 2016 [47]

1, M, 80

Morgagni hernia

Computed tomography

Laparotomy primary suture

Left hemi diaphragm

Gastric outlet obstruction

Manipadam JMJ Clin Diagn Res. 2016 [48]

1, M, 23

Bochdalek hernia

Chest X-ray

Laparotomy, sleeve resection of the gangrenous portion of the stomach

Left hemi diaphragm

Organoaxial volvulus of the stomach

Harada M, Int J Surg Case Rep. 2016 [49]

1, M, 78

Bochdalek hernia

Chest radiography and computed tomography

laparoscopic repair with primary closure

Left hemi diaphragm

Omentum, transverse colon, and small intestine

Siow SL; J Med Case Rep. 2016 [50]

1, M, 32

Traffic accident

Computed tomographic scan

Laparoscopic surgery with synthetic mesh repair

Left hemi diaphragm

 

A.L. Andreev JSLS 2010 [51]

1, M, 40

Traffic accident 12

years earlier

CT scan

Laparoscopic primary suture

Left hemi diaphragm

Large intestine and greater omentum and acute colon obstruction

 

1, M, 46

Surgery for a stab wound to the chest with injury to the

heart 5 months before

Chest X-ray

Laparoscopic primary suture

Left hemi diaphragm

Transverse

colonic segment

Bhatt NR,

Trauma Mon. 2016 [52]

1, M, 23

Multitrauma 2 y before

Chest X-ray and CT scan

Laparotomy, adhesiolisis and primary repair

Left hemi diaphragm

Small bowel, omentum and large bowel obstruction

Abdullah M, Stonelake P BMJ case rep 2016 [53]

1, F 65

Trauma

Chest X-ray, CT scan

Emergency operation, laparotomy

Left hemi diaphragm

Perforated colon

Razi K; Journal of Surgical Case Reports, 2016 [54]

1, F, 83

Diaphragmatic Morgagni Hernia

Chest X-ray and CT scan

Laparoscopic

repair with a composite mesh with an absorbable tic fixation on the diaphragm

Left hemi diaphragm

Transverse colon, the greater curvature of the stomach with a partial gastric volvulus

A Wigley J Ann R Coll Surg Engl 2014 [55]

1, F, 72

Traffic accident

    

Atef Mejri Medicine

2015 [56]

1, M, 56

Bochdalek hernia

Chest X-ray, barium studies and CT scan

Primary repair Laparoscopy was converted laparotomy

Left hemi diaphragm

Gastric volvulus

Mahmut Tokur

Ulus Travma Acil Cerrahi Derg, July 2015 [57]

1, F, 27

Congenital DH

Chest X-ray, CT scan

Thoracotomy, primary repair

Left hemi diaphragm

Gastro thorax

Topuz Mustafa

Ulus Travma Acil Cerrahi Derg. 2014 [58]

1, F, 55

Traffic accident

Chest X-ray, CT scan

Laparotomy primary repair

Right hemi diaphragm

Liver causing mechanic compression on ventricle

Moussa G

Ann R Coll Surg Engl. 2014 [17]

1, F, 65

Previous history of pericardial window fenestration and sarcoidosis

Chest X-ray, CT scan

Laparoscopy, mesh repair

Right hemi diaphragm

Left lobe of liver, stomach and colon

Nakamura T, Ulus Travma Acil Cerrahi Derg. 2014 [18]

1, M, 81

History of HCC treated with Radiofrequency ablation

Chest US, CT scan

Laparotomy, primary hernia repair, small bowel resection

Right hemi diaphragm

Liver, incarcerated small bowel

Haratake Naoki

Surgery today 2015 [59]

1, F, 50

 

CT scan

Laparotomy, primary hernia repair

Right hemi diaphragm

Heterotopic endometriosis in a patient with Chilaiditi syndrome

Gali BM, Niger J Med. 2014 [60]

1, M, 28

Penetrating injury years before

CT scan

Laparotomy, primary repair

Left hemi diaphragm

Bowel

Michael Joseph Newman, BMJ Case Rep 2014

[61]

1, M, 25

Bochdalek hernia

Chest X-ray, CT scan

Laparotomy, primary repair, gastric resection

Left hemi diaphragm

Stomach and bowel

Tyagi Sam,

Ann Thorac Surg. 2014 [62]

1, M, 36

Morgagni hernia

Chest X-ray, CT scan

Laparoscopy Gore-Tex fixed with a spiral tacker

Left hemi diaphragm

Omentum and transverse colon

Kurniawan N, Acta Chir Belg. 2013 [32]

1, M, 17

Bochdalek hernia

Chest X-ray, CT scan

Laparoscopy primary sutture

Left hemidiaphragm

Stomach, spleen colon

Ota H

Ann Thorac Cardiovasc Surg. 2014 [63]

1, M, 62

Fall accident

ECO FAST,

Chest X-ray, CT scan

Video assisted mini thoracotomy

Primary suture

Right hemi diaphragm

Hemothorax

G, et al. BMJ Case Rep 2013 [64]

1, M, 60

Fall

Chest X-ray, CT scan

Laparoscopy and laparotomy

Left diaphragm

Stomach, bowel and spleen

Sonthalia N, J Emerg Med. 2013 [65]

1, F, 78

Morgagni hernia

Chest X-ray, CT scan, barium studies

Thoracotomy

Left diaphragm

Gastric volvulus

Nayak HK

BMJ Case Rep. 2012 [66]

1, M, 50

Blunt trauma

EGDS, barium studies, CT SCAN

Laparoscopic repair

Left hemi diaphragm

Gastric volvulus and duodenum

Vernadakis S,

Transplant Proc. 2012 [67]

1, F, 46

Liver donor

Chest X-ray, CT scan, barium studies

Laparotomy

Right diaphragm

Bowel

Ngai I,

BMJ Case Rep. 2012 [68]

1, F, 31

Pregnancy

MRI

Nasogastric tube

Left hemi diaphragm

Spleen, bowel, stomach and pancreas

Elangovan A

J Emerg Med. 2013 [69]

1, M, 30

Accident

Chest X-ray and CT scan

Laparoscopy

Left hemi diaphragm

Stomach

Kuppusamy A, Ulus Trauma Acil Cherrai Derg 2012 [70]

1, M, 28

Trauma

CT scan

Thoracotomy

Right hemi diaphragm

Liver

Ismail Okan,

Ulus Travma Acil Cerrahi Derg. 2011 [71]

10 cases,

44,3 y

Trauma

CT scan

7 laparotomy

1 thoracic-abdominal approach

2 thoracic

9 left side

 

Ioannis Baloyiannis

General Thoracic and Cardiovascular Surgery 2011 [72]

1, M, 56

Trauma

 

Laparotomy

  

Vassileva CM

Ann Thorac Cardiovasc Surg. 2012 [73]

1, F, 25

Morgagni hernia

Chest X-ray, CT scan

Laparoscopic repair

Right hemi diaphragm

Omentum

Agrafiotis AC

Acta Chir Belg. 2011 [74]

1, F, 52

Bochdalek hernia

Chest X-ray, CT scan

Laparoscopic approach, and mini laparotomy prosthetic polypropylene mesh

Left hemi diaphragm

Small bowel loops and the right colon

Tan K K, Singapore Med J 2009 [75]

14, median age 38 y

Trauma

Chest X Ray, CT Scan, RMN

Laparotomy, thoracotomy or VATS

Primary repair (85.7%) patients or patch repair

five (35.7%) right-sided and nine (64.3%) left-sided diaphragmatic ruptures

 

Akhtar K,

Br J Hosp Med (Lond). 2009 [76]

1, M, 27

Bochdalek hernia

Chest X Ray, Upper gastrointestinal endoscopy,

CT scan

Laparoscopy

Goretex dual mesh

Left hemi diaphragm

Small bowel, ascending and transverse colon, and spleen

Ozpolat B,

Ulus Travma Acil Cerrahi Derg. Nov; 2009 [77]

1, M, 52

Tube thoracostomy at the seventh left intercostal

Chest X-ray, MRI

Left standard thoracotomy, primary suture

Left hemi diaphragm

Omentum

Altinkaya N Hernia. 2010 [78]

12 patients

mean age of 60 years,

ten were female.

Morgagni hernia

CT scan

Six patients had surgery. 1 emergency surgery for hernia, 2 laparoscopic hernia repair, 3 trans-abdominal repair and 1 transthoracic repair

Right hemi diaphragm

Omentum and colon

Syed Murfad Peer, Int J Surg. 2009 [79]

2496 patients25 (86%) males4 (14%) females mean age 33.6 y

Trauma

Chest X-ray diagnostic in 20 (69%) patients CT scan in 4 (14%) patients. Intra-operative diagnosis of rupture diaphragm was made in 5 (17%) patients.

29 (1.1%) underwent to surgery

20 thoracotomy (69%)

8 laparotomy (27.5%)

1 Thoracoabdominal approach (3.5%)

Right defect: 6

left defect:23

 

Sung HY

J Korean Med Sci. 2009 [80]

1, F, 49

Congenital hernia

Chest radiography

Thoracotomy

Left hemi diaphragm

Stomach, spleen, splenic flexure of the colon bowel loops

Ouazzani A

Acta Chir Belg. 2009

[81]

1, M, 24

Trauma

Chest X-ray computed tomography

Laparoscopically, with mesh

Left diaphragm

Stomach

Kavanagh D

Acta Chir Belg. 2008 [82]

1, M, 76

Bochdalek hernia

Chest radiograph and computed tomogram

Laparotomy, primary repair

Right diaphragm

Strangulation of a portion of transverse colon

Yeh-Huang Hung; J Chin Med Assoc. 2008 [83]

1, M, 74

1, F, 75

Bochdalek hernia

Bochdalek hernias

Chest X-ray CT scan

MRI

Laparotomy

Transthoracic repair

Left diaphragm

Right diaphragm

Intestinal obstruction

Small and large bowels

Sano A

Surg Today. 2008 [16]

1, F, 25

Diaphragm hernia during pregnancy

Chest radiograph and computed tomography

Emergency caesarean section

sutures and a Gore-Tex sheet

Left diaphragm

Bowel loop

Gourgiotis S, Turkish Journal of Trauma & Emergency Surgery 2008 [84]

1, M, 25

Trauma

Chest X-ray

CT scan

Laparoscopic primary repair

Left diaphragm

 

Walchalk LR, J Emerg Med. 2010 [85]

1, F, 57

Trauma

    

Mohammadhosseini B, J Coll Physicians Surg Pak. 2008 [86]

1, M

Bochdalek hernia

    

Boyce S, Obes Surg. 2008 [87]

 

Diaphragmatic hernia post surgery

CT of the chest and abdomen

Laparotomy an repair of hernia

Left diaphragmatic hernia

Ischemic small bowel

Tsuboi K, Surg Today. 2008 [88]

1, M, 50

16 months after surgery

Computed tomography of the chest

Laparotomy

Left diaphragmatic hernia

Stomach had herniated into the thoracic cavity

Vogelaar Obes Surg. 2008 [89]

1, F, 37

Six months after gastric banding

Chest X-ray computed tomography scan

Laparotomy

Left diaphragm

Intra thoracic stomach distended, rotated, and perforated at the orifice of the hernia

Young-Shun Wu; Am J Emerg Med. 2008 [90]

 

History of left-sided upper abdominal blunt injury 2 months before

CT scan

Thoracotomy and primary repair

Left traumatic diaphragm rupture

 

Igai H, Y Gen Thorac Cardiovasc Surg. 2007 [91]

1, M, 48

Trauma

Chest X-ray, CT scan

 

Right diaphragm rupture

Hepatothorax

Rifki Jai S Arch Gynecol Obstet. 2007 [92]

1, F, 27

32-week gestation

no history of trauma

Chest X-ray

CT scan

Emergency laparotomy

Left hemi diaphragm.

Stomach, transverse colon and greater omentum herniated in the left hemithorax

Rout S Hernia. 2007

[93]

1, F, 35

Bochdalek hernias

Chest X-ray

CT scan

Emergency laparotomy defect was repaired using non-absorbable sutures

Right-sided Bochdalek hernia

Colon

Campbell AS Hernia. 2007 [94]

1, M, 85

 

Chest X-ray CT scan

Emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed

Left hemi diaphragm.

Diaphragmatic herniation of bowel

Testini M Surg Today. 2006 [10]

1, M, 51

Left splenopancreatectomy

4 years earlier

Chest X-ray, CT scan, MRI

Left thoracotomy

Left hemi diaphragm

Stomach

Luu TD, Ann Thorac Surg 2006 [95]

1, F, 34

33 weeks’ gestation

Chest roentgenogram, CT scan, barium study Esophagoscopy

the patient went into preterm labour and had a spontaneous vaginal delivery of a healthy new-born at 34 weeks’ gestation. left thoracotomy

Left hemi diaphragm

Necrotic stomach

Iso Y., Hernia 2006

[96]

1, F, 81

Morgagni’s hernia

Chest X-ray

The diaphragm defect was sutured first, and partial resection of the transverse colon

Right thorax

transverse colon

Eglinton T, ANZ J Surg. 2006 Jul [97]

3 cases

During third trimester of pregnancy

Chest X-ray

Laparotomy and thoracotomy in one case. Delivery was by Caesarean section at the time of emergency surgery

  

Barbetakis N, World J Gastroenter ol. 2006 Apr 21 [98]

1, F, 31

Bochdalek hernias during pregnancy (23-week gestation)

Chest X-ray, chest ultrasound

Left thoraco- abdominal incision, segmental resection of the involved portion of large bowel. The diaphragmatic defect was repaired with interrupted sutures

Left hemi thorax

Strangulated Right and transverse colon, necrotic the greater omentum and stomach

Barret J, J Emerg Med. 2006 [99]

1,M, 50

Trauma

Electrocardiogram and CT scan

 

Left hemi thorax and pericardium

 

Abboud B, J Med Liban. 2004 [100]

1 M

Trauma

Chest X-ray, exploratory laparotomy

Laparotomy, colectomy resection of ileum with anastomosis

left hemi thorax

Transverse colon and a proximal small bowel

Hsu YP, Hepatogastroenterology. 2005 [101]

78 patients

Trauma

Chest roentgenogram

Only 20% of elderly patients were operated on within 24 h of trauma, 87% of young patients

  

P Ransom Emerg Med J 2005 [102]

1, M, 21

Trauma

Chest radiograph, ultrasound, oesophago-gastro- duodenoscopy

Thoracotomy

Left diaphragm

Stomach and a loop of colon had herniated through a 6 cm defect

Tiberio GA Acta Chir Belg. 2005 Feb [103]

33 p

Blunt (22 patients) or penetrating injury

Chest X-ray, CT scan

Laparotomy

  

Barakat MJ, BMC Surg. 2005 [19]

1, F, 43

CDH in Marfan’s syndrome

Chest X-ray, CT scan

Laparoscopy

Right hemi diaphragm

Perforated gangrenous appendix

Gupta V Eur J Emerg Med. 2005 [104]

1, M, 43

Spontaneous rupture

CT scan

 

Left hemi diaphragm

 

Kara E Ann Acad Med Singapore 2004 [105]

1, M, 28

Trauma

Chest X-ray, CT scan

Left thoracotomy

Left hemi diaphragm

Gastric fundus

Sirbu H Hernia. 2005 [106]

1, M, 67

Trauma

CT scan

Laparotomy and right thoracotomy

Delayed bilateral diaphragmatic ruptures

 

Dalton AM Emerg Med J. 2004 [107]

1, M, 43

Bochdalek hernia

Chest radiograph

Thoracotomy

Left hemi thorax

Stomach, transverse colon, and spleen in to the chest.

Niwa T Respiration. 2003 [108]

1, F, 53

Bochdalek hernia

Chest X-ray

Thoracotomy

Left hemithorax

Stomach and greater omentum

Genc MR,

Obstet Ginecol 2003 [109]

1, M, 29

Bochdalek hernia during pregnancy

Chest X-ray, CT scan

Antepartum repair

Left hemithorax

Bowel obruction

Sato M, Jpn J Thorac Cardiovasc Surg. 2002 [110]

1, M, 57

Traffic accident

Chest X-ray, CT scan, MRI

Toracoscopy

Right hemidiaphragm

Liver

Guven H, Acta CHir Belg 2002 [111]

2 cases

Morgagni hernia

   

Bowel perforation

Upper gastrointestinal bleeding

Kanazawa A, Surg Today 2002 [112]

1 F 63 y

Bochdalek hernia

Chest X-ray, CT scan,

Thoraco-Laparotomy

Primary suture

Right hemidiaphragm

Colon and right kidney

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Pathogenetic mechanism

Diaphragmatic rupture with abdominal organ herniation was first described in 1541 by Sennertus [11]. Congenital diaphragmatic hernias are prenatally or during the neonatal period diagnosed. On the contrary, CDH in adulthood are exceedingly rare and can occur through an anterior parasternal Morgagni foramen or through a posterolateral, mainly left-sided, named as Bochdalek hernia, firstly described in 1848 [12]. The aetiology is still under study, but the disease is due to the failure of closure of the canal between the septum transversum and the oesophagus during the 8th week of gestation. Morgagni hernia is a rare disease caused by the defective development of the sternal attachments to the diaphragm. Traumatic diaphragmatic hernias are thought to be produced by a sudden increase in the pleuroperitoneal pressure gradient occurring at areas of potential weakness along embryological points of fusion [13].

DR usually result from blunt or penetrating injuries or iatrogenic causes and result in entry of an abdominal hollow viscus or the omentum into the pleural cavity, which may lead to incarceration and even strangulation with a fatal outcome. Traumatic diaphragmatic hernias are frequently caused by a penetrating injury (10–19%), sometimes by blunt thoracic-abdominal trauma (5%) [14, 15]. Moreover, some authors described rare and particularly cases of DR after surgery or pregnancy; that is Sano A. et al. reported a case of a pregnant woman in the 28th week of pregnancy, who was underwent to emergency caesarean section and repair of the diaphragm [16]; Moussa G. et al., described a right DR in a patient with previous history of window fenestration and sarcoidosis [17]; Nakamura T. et al., reported a case of right DR in patient with a history of hepatic carcinoma treated with radiofrequency ablation [18]. Furthermore, there was an association between Marfan’s syndrome and CDH as Barakat et al. reported [19].

Site of rupture

CDH formation is found 80% on the left side [20]. Also, 88–95% of diaphragmatic ruptures occurred on the left side [21], especially, blunt trauma causes large diaphragmatic defects, commonly involving (>80%) the left posterolateral diaphragm [22]. The right haemidiaphragm is stronger than the left one because of the size of the liver which has a protective effect. For this reason, the side ruptures are very rare and associated with high mortality and morbidity rate [23].

The review of literature reported in this study confirmed the high frequency of left defect 80%, and only two cases of bilateral DR were reported.

Presenting symptom and investigations

Nayak et al. described severe symptoms, in 46% of CDH cases with 32% of mortality due to visceral strangulation [24]. Moreover, the literature analysis shows a variable rate of delayed symptoms (5–45.5%) [25, 26]. Late-presenting CDH of left sided typically produces acute, obstructive, gastrointestinal symptoms, chronic dyspnea, chest pain, recurrent abdominal pain, postprandial fullness and vomiting, evolving to cardiorespiratory failure [27]. Indeed, right-sided CDH is usually associated with only respiratory issues because partial liver displacement may block the further herniation of hollow viscera [1]. Although the presence of bowel sounds within the chest and the absence of breath sounds are typical findings associated with a CDH, a misdiagnosis rate of 38% has been reported [28]. Obviously, in totally asymptomatic cases, diagnosis is very hard. On the contrary, when acute presentations occur because of the increasing of abdominal pressure and consequent rapid visceral displacement into the chest or due to rapid distension of previously herniated viscera, diagnosis is clear [29, 30]. Chest X-ray and barium studies are useful for determining which viscera have herniated into the thorax. The most common reported radiological finding of CDH is the opaqueness of the hemithorax usually associated with mediastinal shift to the contralateral side. Moreover, the position of the nasogastric tube in the chest cavity will provide an important indicator and prompt correct diagnosis. Computed tomography can be considered the gold standard technique for diagnosis, offering the unique opportunity to evaluate the presence, size and location of a diaphragmatic defect, as well as the contents of various types of diaphragmatic hernias [31] and showing sensitivity and specificity of 14–82% and 87%, respectively [32]. MRI is also useful, but usually it is not performable in emergency. However, it is usually employed in stable patients or where the CT scan is equivocal [33]. According with literature, in this reported experience, a definitive diagnosis was made with CT scan and barium studies.

Late-presenting CDH is considered as a benign condition but it can rapidly becomes a life-threatening disease [1, 27, 28, 31, 33]; consequently, an immediate surgical treatment is mandatory. Associated anomalies in late-presenting CDH patients, such as congenital heart disease, Fryns syndrome and trisomy 18, have been reported in 8.6–80% of cases [1, 2, 27, 28], significantly increasing the mortality rate. At this proposal, in case 1, even if there was a high suspicion of congenital syndrome, surprisingly it was not confirmed by genetic studies.

Surgical treatment

Surgical repair typically involves primary or patch closure of the diaphragm through an open abdominal approach. When the diagnosis is delayed, due to suspicions of adhesions between viscera and chest, thoracotomy or combined thoracic-abdominal approach is preferred, as in the reported case 2. Some authors have reported success with thoracoscopic approach but vitiated by an increased incidence of hernia recurrence [3436]. Furthermore, during thoracoscopy, an intraoperative pulmonary hypertension with subsequent hemodynamic instability could develop; moreover, the placement and management of a patch results in substantially longer operating times. For these reasons, thoracoscopic repair of CDH is preferred in the presence of small diaphragmatic defects and/or mild pulmonary hypertension [37]. Nowadays, the laparoscopic approach is safe and feasible for CDH and it could be an excellent option [37], as in case 3.

However, emergency surgery is the treatment of choice for diaphragmatic rupture. In delayed cases, thoracic approach is recommended to reduce viscera-pleural adhesions and to avoid intra-thoracic visceral perforation with catastrophic complications [38]. When the suspicion of intestinal obstruction is evident, an abdominal approach may also be required to control organs. Although the type of closure used for diaphragmatic hernias is still a matter of debate, it is generally accepted that most defects can be primarily closed with a non-absorbable suture [39]. Mesh repair usually is used when the defect is too large to be primarily closed and the use of tension free mesh is vital to the success of the procedures. Recently, biologic mesh has been introduced to replace the synthetic one because of its lower rate of hernia recurrence, higher resistance to infections and lower risk of displacement [7, 40]; however, limited evidence in literature yet exists about their superiority. Indeed, in our previous experience, biologic meshes have also been used in contaminated surgical fields with favourable results [40]. However, because of the rarity of this condition, clinicians should be encouraged to publish their experience with biologic meshes in diaphragmatic hernia repair [7].

Conclusions

When a diaphragmatic hernia is diagnosed, surgery is the treatment of choice, above all in emergency setting. A multidisciplinary approach in dedicated centres is advisable.

Abbreviations

CDH: 

Congenital diaphragmatic hernia

CT: 

Computed tomography

DR: 

Diaphragmatic rupture

MRI: 

Magnetic resonance imaging

Declarations

Acknowledgements

The authors would like to thank Dr Channielle Mascarenhas and Dr Luke Palma for the English language revision.

Funding

This study did not receive funding.

Availability of data and materials

All data and materials are available in case of request.

Authors’ contributions

Authors contributed to this study as follows: MT contributed to the conception and design. AG contributed to the writing acquisition of the data. RMI contributed to writing. GC and AD contributed to the critical revision. AP contributed to the review of literature. AG contributed to the conception and design and critical revision. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Ethics approval and consent was waived because this study is a review of literature with a retrospective case series based on six patients that gave consent to participate for publication.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School “Aldo Moro” of Bari
(2)
Department of Thoracic Surgery, University of Bari
(3)
Unit of Laparoscopic Surgery, Department of Emergency and Organ Transplantation, University Medical School “A. Moro” of Bari

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