Chronic Diaphragmatic Hernia Research Articles

Diaphragmatic Herniation with Pneumothorax Due to Barotrauma – Lessons to Learn: A Case Report

Diaphragmatic hernia is usually congenital or follows thoracoabdominal injury. Diaphragmatic hernia combined with pneumothorax is a rare combination in the clinical setting, where pneumothorax is usually secondary to hollow viscera perforation in the long-term complications of diaphragmatic herniation or rupture of ectopic endometrium over the diaphragm during menstruation. Unlike the aforementioned conditions, we describe a 67-year-old man with chronic diaphragmatic hernia who suffered from pneumothorax and pneumoperitoneum secondary to pulmonary bulla by barotrauma during mechanical ventilation. Computed tomography showed scattered free gas in the thoracic and abdominal cavities, while there was no tenderness and rebound tenderness. The patient was managed conservatively with low PEEP and a lung-protective mechanical ventilation strategy. Finally, the oxygenation index gradually rose from 58 to 107. Unfortunately, in light of the patient’s poor clinical status and significant comorbidities, the patient passed away peacefully 3 weeks after hospital admission. Diaphragmatic hernia combined with pneumothorax should be differentiated from tension pneumothorax. Whether to intubate chest drainage depends on the cause of pneumothorax and pneumoperitoneum, as well as the risks and benefits of chest drainage. Additionally, mechanical ventilation should be applied cautiously, and respiratory parameters should be adjusted reasonably in patients at high risk of pneumothorax.

Chronic diaphragmatic hernia and axial skeletal anomalies in a cat – Case report

Diaphragmatic hernia and congenital anomalies of the axial skeleton are alterations frequently identified in domestic cats. The objective of this case report was to present the electrocardiographic, radiographic, and tomographic findings observed in a 5-year-old neutered domestic shorthair cat, with skeletal malformations simultaneously with chronic diaphragmatic hernia. The cat lived well until he was 10-years old, when he developed progressive respiratory compromise leading to death. To our knowledge, occurrence of combined diaphragmatic hernia and congenital skeletal anomalies in domestic cats is very rare.

Traumatic diaphragmatic hernias in patients with closed chest and abdominal trauma

The OBJECTIVE of the study was the pathomorphological features, diagnosis, and treatment outcomes of diaphragm ruptures in closed trunk trauma.MATERIALS AND METHODS. We prospectively studied diaphragmatic ruptures in 35 hospitalized patients with blunt trunk trauma and diaphragmatic defects in 9 patients with chronic traumatic diaphragmatic hernia, previously not recognized in other hospitals. Damage severity was assessed using the MFS-D (MI) scale; statistical data were processed using the WinPepi program: calculation of the boundaries of 95 % CI of medium and extensive values using the fisher method.RESULTS. Diaphragmatic ruptures were observed in 3.25 % of the victims. Damage to the left side occurred 2.4 times more often than the right side; on the left, they were mainly localized in the lumbar and adjacent costal parts. The average length of the rupture of the right half was 13.5, the left half was 9.8 (2-25) cm. More often, the greater omentum, colon, liver and stomach fell into the pleural cavity. During the first day, 2/3 of diaphragm ruptures were diagnosed, mainly during thoracotomy and laparotomy due to bleeding. Missing a rupture of the left half of the diaphragm was allowed at 6 laparotomies. Mortality rate was 31.4 %, the main causes were acute blood loss, severe brain damage; 2 out of 11 deaths were due to a complicated course of an unrecognized diaphragmatic rupture. All patients with chronic diaphragmatic hernia recovered after surgery.CONCLUSION. Diagnosis of diaphragmatic rupture in severe trunk injury on the first day is difficult, radiation methods: radiography, MSCT, ultrasound are not informative enough. When performing diagnostic studies and abdominal operations, it is necessary to study the diaphragm. Repeated survey radiography and MSCT of the chest during the first three weeks of inpatient treatment of the victim increases the detection of acute traumatic diaphragmatic hernia.

Successful repair of diaphragmatic hernia with simultaneously performed thoracotomy and median laparotomy in a horse

AbstractThis report describes the successful treatment of a chronic diaphragmatic hernia in a 2.5‐year‐old crossbred gelding. The tear remained unidentified until colic signs and dyspnoea appeared. In this case, an unconventional surgical approach was used. Based on the clinical findings, diaphragmatic herniation with non‐strangulating large intestinal involvement was diagnosed. From the ventral midline approach, a diaphragmatic tear with a diameter of 20 cm in the left ventral area was found together with a fractured 10th rib. Repositioning of the large colon was unsuccessful through the ventral midline approach, therefore lateral thoracotomy via rib resection was performed without closing the ventral midline incision. The simultaneous laparotomy with thoracotomy can be a useful approach in the treatment of diaphragmatic hernias when the tear is located ventrally. Advantages of the described surgical technique were easier reposition of the herniated intestine and good access to close the diaphragmatic tear, and disadvantage was the longer surgical time.

Emergency typhlectomy for caecal strangulation caused by chronic diaphragmatic hernia in a dog

A two‐year‐old female entire Catahoula leopard dog was referred for investigation and management of suspected chronic diaphragmatic hernia, 11 months post road traffic accident. The dog had a two‐month history of progressive lethargy and one‐week history of vomiting and anorexia. Physical examination revealed a slight increase in respiratory effort with normal respiratory rate. Cardiac and pulmonary sounds were muffled on thoracic auscultation and intestinal loops were not immediately palpable in the abdomen. Thoracic radiographs acquired before referral were suggestive of a diaphragmatic hernia, which was later confirmed on abdominal and thoracic ultrasound. Cardiorespiratory deterioration was evident eight hours post presentation and an emergency exploratory laparotomy was performed. The small intestines, caecum, and the ascending and transverse colon were found to have herniated into the thorax. Marked caecal necrosis was found intraoperatively. A typhlectomy and repair of the diaphragmatic defect were performed. The patient recovered uneventfully and was in good health nine months postoperatively.

Surgical management of chronic diaphragmatic hernias.

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.

Chronic traumatic diaphragmatic hernia: A case report

Abstract
 A diaphragmatic hernia is a very rare pathology, and clinical suspicion is needed for its diagnosis, and in cases of closed trauma it is much more frequently. For a correct diagnosis in chronic cases we should focus the importance of personal record and imaging studies, because the signs and symptoms may go unnoticed. In this sense, the objective is to describe the main clinical manifestations a diaphragmatic hernia, its approach and, diagnosis. The patient went to the Portoviejo Medical Clinic for a different reason and when performing a chest x-ray, the diagnosis of chronic diaphragmatic hernia was outlined. Currently, the treatment of choice is laparoscopy, but the patient presented complications and had to undergo an open surgical procedure. Conclusions: in order to reduce mortality and complications, a correct diagnosis must be made, recognizing by signs, symptoms and images if we are facing an acute or chronic condition; and always take into account personal record, as that can give the clue that helps in the diagnosis and early treatment.
 Keywords: Chronic traumatic diaphragmatic hernia; complications; closed chest trauma.

Histerocele diafragmática en una gata gestante: Reporte de un caso

A case of animal care, feline, adult, female is described, with diagnosis of chronic diaphragmatic hernia with the gravid uterus in the final stage of gestation as part of the hernial content. Gradual fetal growth during pregnancy led to significant respiratory impairment. The severity of the condition necessitated a surgical interruption of gestation with posterior herniorrhaphy with peritoneal flap, but it did not succeed and the animal died at the end of the surgical procedure. The death was attributed to the chronicity and severity of the clinical condition in which it was found. This report highlights the importance of immediate correction of diaphragmatic hernias and prenatal follow-up during pregnancy.

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias.

Ectopic Intrathoracic Hepatic Tissue and Accessory Lung Lobe Aplasia in a Dog

A 6 yr old male Yorkshire terrier was presented for an ~6 yr history of progressive cough and dyspnea. Thoracic radiographs revealed a 6 cm diameter mass within the right caudal thorax. Thoracic ultrasound identified an intrathoracic mass ultrasonographically consistent with liver tissue and a chronic diaphragmatic hernia was suspected. Exploratory laparotomy was performed, but no evidence of a diaphragmatic hernia was identified. Thoracic exploration identified abnormal lung parenchyma. The accessory lung lobe was removed using a stapling devise near its base. The consolidated mass had the gross appearance of liver and was histologically identified as ectopic hepatic tissue. Ectopic hepatic tissue, unlike ectopic splenic and pancreatic tissue, is rare and generally has a subdiaphragmatic distribution. This solitary case report demonstrates that ectopic intrathoracic hepatic tissue should be considered a differential diagnosis for a caudal mediastinal mass.

Traumatic Diaphragm Injuries: A Comprehensive Review

Traumatic Diaphragmatic Injury although rare, results in high rates of mortality and morbidity if missed. Despite advances in imaging, diagnosis without the presence of a hernia remains difficult and a high index of suspicion must be maintained particularly in penetrating mechanisms of injury. Chest X-ray remains an important tool in early diagnosis. Multi-Detector Computed Tomography improves preoperative diagnosis but is not adequate to rule out smaller injuries or those without the presence of a hernia. Minimally invasive modalities allow for both the diagnosis and repair of suspected injuries in hemodynamically stable patients while avoiding the morbidity and mortality of an open approach. All diaphragmatic injuries require surgical repair. The principles of diaphragmatic injury repair are complete reduction of all abdominal contents and watertight, tension-free closure. Most injuries can be closed primarily, but more complex defects may require the use of prosthetic material or local flaps to achieve closure. Mortality remains primarily dependent on the mechanism of injury and the presence and severity of associated injuries, with little to no additional morbidity if the diaphragm injury is promptly diagnosed and treated. Missed injuries that progress to become chronic diaphragmatic hernias have the potential for high morbidity and mortality. Keywords: Trauma, blunt trauma, diaphragm injuries, diaphragmatic hernia, penetrating trauma, thoracoabdominal trauma.

Time-Trend Analysis of Pulmonary and Diaphragmatic Functionality in Patients with Diaphragmatic Palsy or with Chronic Diaphragmatic Hernia after Surgical Treatment.

Background The aim of this study was to assess long-term pulmonary and diaphragmatic function in two cohorts of patients: the first one affected by diaphragmatic palsy (DP) who underwent plication reinforced by rib-fixed mesh and the second one affected by chronic diaphragmatic hernia (TDH) who underwent surgical reduction and direct suture. Materials and Methods From 1996 to 2011, 10 patients with unilateral DP and 6 patients with TDH underwent elective surgery. Preoperative and long-term (12 months) follow-up assessments were completed in all patients, including pulmonary function tests (PFTs) with diffusion of the lung for carbon monoxide (DLCO), measure of maximum inspiratory pressure (MIP) assessed both in standing and in supine positions, blood gas analysis, chest computed tomographic (CT) scan, and dyspnea score. The Pearson chi-square test, Fisher exact test, and Student t-test were applied when indicated. Results At long-term (12 months) postoperative follow-up, patients operated for DP showed a significant improvement in terms of forced expiratory volume in 1 second (FEV1%) (+ 18.2%, p < 0.001), forced vital capacity (FVC%) (+ 12.8%, p < 0.001), DLCO% (+ 8.3%, p = 0.04), and Po 2 (+ 9.86 mm Hg, p < 0.001) when compared with baseline values. Conversely, when considering the TDH group, only the levels of Po 2 were found to be significantly higher in the postoperative assessment (+ 8.3 mm Hg, p = 0.04). Although MIP increased in both the groups after surgery, a persistent and significant decrease of MIP was detected in TDH group when comparing the levels assessed in supine position with those measured in the standing position (p < 0.001). Medical Research Council dyspnea scale improved in the DP group by a factor of 0.80 (p < 0.001) and in the TDH group by a factor of 0.33 (p = 0.175). Conclusion In patients who underwent surgery for DP, good long-term results may be predicted in terms of pulmonary flows, volumes, and DLCO. Conversely, in patients who underwent elective surgery for chronic TDH, a persistent overall restrictive pattern, lower MIP values in supine position, and paradoxical motion could be expected.

Penetrating Traumatic Diaphragm Injuries

Traumatic diaphragm injuries (TDI) are uncommon but can result in major morbidity or mortality if missed. Penetrating thoracoabdominal injuries carry a high risk of TDI, but can also pose a diagnostic dilemma due to their small size and the frequent lack of an associated hernia. Despite advances in imaging, diagnosis without presence of a hernia remains difficult and a high index of suspicion must be maintained. Chest x-ray remains an important tool in early diagnosis, but primarily relies on the presence of a hernia or a discontinuity of the diaphragm, which is not typically seen with penetrating injuries. Computed tomography has a higher sensitivity and specificity and improves preoperative diagnosis, but most TDI are still diagnosed intra-operatively. Minimally invasive modalities allow for both diagnosis and repair of suspected injuries in hemodynamically stable patients while avoiding the morbidity of an open approach. All penetrating diaphragmatic injuries require repair in order to avoid the major morbidity and mortality of a chronic diaphragmatic hernia. The principles of diaphragmatic injury repair are complete reduction of all abdominal contents, lavage and evacuation of any associated hemothorax or gastrointestinal spillage, and watertight, tension-free closure. Most injuries can be closed primarily, but some may require use of prosthetic material or other advanced reconstructive techniques for larger defects. Mortality remains primarily dependent on the mechanism of injury and the presence and severity of associated injuries, with overall Injury Severity Score serving as an independent predictor of early mortality.

Chronic diaphragmatic hernia: a delayed problem requiring urgent response

Chronic diaphragmatic hernia: a delayed problem requiring urgent response

The spectrum of diaphragmatic injury in a busy metropolitan surgical service

Introduction The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component. Methodology A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study. Results A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy. Conclusion If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.

The role of thoracoscopy for the diagnosis of hidden diaphragmatic injuries in penetrating thoracoabdominal trauma

Patients with a thoracoabdominal stab wound may have hidden diaphragmatic injuries that could finally lead to chronic diaphragmatic hernia. In this study, we analyzed 30 patients with penetrating thoracoabdominal injuries that were stable hemodynamically and did not need emergency exploration. They underwent thoracoscopy in order to find a probable diaphragmatic injury from March 2005 to October 2007. The mean age was 26.2 years and the M/F ratio was 5:1. We observed five occult diaphragmatic injuries (16.7%) in thoracoscopic evaluations. Three cases (9.9%) were repaired through a thoracoscopic approach while laparatomy was inevitable in two (6.6%) patients. Pulmonary parenchymal lacerations were observed in two patients (6.6%) which were repaired through thoracoscopy and intra-abdominal injury was observed in one patient (3.3%) which was repaired via laparatomy. We performed thoracoabdominal CT-scan 6 months later and chronic diagrammatic hernias were not reported. Diagnostic accuracy of thoracoscopy was 100%. Owing to the high diagnostic accuracy rate, minimal invasiveness and therapeutic potency of thoracoscopy we recommend it to be performed in all clinically stable patients with penetrating thoracoabdominal penetrating injury especially in the 8th intercostal space.

Surgically Corrected Chronic Diaphragmatic Hernia in a Dog

Surgically Corrected Chronic Diaphragmatic Hernia in a Dog

Chronic diaphragmatic hernia

Chronic diaphragmatic hernia is a rare entity and requires surgical intervention when it is diagnosed. We report three patients with chronic diaphragmatic hernia that followed a diagnosis of diaphragmatic abnormality with no previous chest injury. Operative findings suggested a diaphragmatic defect in a congenitally weak area. All patients were satisfied with the resolution of their preoperative discomfort and their improved respiratory function after repair using Marlex mesh sheets via thoracotomy and laparotomy. Chronic diaphragmatic hernia should be considered even in patients who had no previous chest injury.

Severe Hypoxemia Following Lateral Positioning after Induction of Anesthesia in a Patient with a Diaphragmatic Hernia - A case report -

A case of acute intraoperative hypoxemia following placement in the lateral decubitus position in a chronic diaphragmatic hernia patient undergoing general anesthesia for hip arthroplasty is p resented. The patient had previously received a series of transurethral cystectomies under general anesthesia without any pulmonary complications, even though the patienthad a diaphragmatic hernia. Hypoxemia occurred after the induction of anesthesia and reposition, and surgery was subsequently postponed. The mechanisms proposed for the hypoxemia were a progressive compression atelectasis of the dependant lung caused by placement in the lateral decubitus position and the presence of the diaphragmatic hernia during anesthesia, and further reduction of the FRC of the dependent lung caused by mechanical ventilation. The patient was intubated with a left-sided endobronchial tube. After placing the patient in the lateral decubitus position, intermittent passive hyperinflation to the dependent lung and then positive pressure ventilation of both lungs was maintained to provide adequate oxygenation throughout the surgery. Therefore, differential ventilation using a double lumen tube is effective at improving hypoxemia of a patient in altered pulmonary compliance, such as in the lateral decubitus position with adiaphragmatic hernia. (Korean J Anesthesiol 2007; 53: 668∼71)

Traumatische Zwerchfellverletzung: notfallmedizinische Diagnose und Behandlung

BACKGROUND: Diaphragmatic injuries (DIs) occur relatively infrequently, but their diagnosis is often missed during the initial emergency department evaluation. Following approval by the Institutional Review Board, we explored our experience with emergency diagnosis and treatment of diaphragmatic injury in a mixed group of blunt and penetrating trauma patients. METHODS: The investigators conducted a retrospective analysis of all acute traumatic DI cases treated in a single university hospital from 1991 to 2002. Patients with chronic diaphragmatic hernias and those pronounced dead on arrival were excluded. Trauma cases were reviewed for mode of injury, clinical presentation, diagnostic workup, operative findings, associated injuries, and outcome. RESULTS: The study identified 45 DI patients (mean age, 43 years; range, 5–81). Pulmonary abnormalities were identified in all patients and were most frequently associated with high-speed motor vehicle accidents (73%), severe chest wall injuries (31%), and ipsilateral rib fractures (31%). All patients had life-threatening visceral injuries requiring emergency surgery. Shock, respiratory distress, pneumothorax, high splenic and hepatic injury grades, and orthopedic injuries correlated highly with DIs. Four patients (9%) died, none as a result of the diaphragmatic injury. CONCLUSIONS: Diaphragmatic injury should be suspected in trauma victims presenting with severe associated injuries. Diagnostic aids should be aggressively utilized for early detection. Emergency surgery for treatment of DIs minimizes the mortality associated with these high-risk traumas.