You are in: eMedicine Specialties > Thoracic Surgery > Trauma Diaphragmatic Hernias, AcquiredArticle Last Updated: Jan 14, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Anne T Saladyga, MD, General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center Coauthor(s): Jason M Johnson, DO, General and Laparoscopic Surgeon, Department of General Surgery, William Beaumont Army Medical Center; Sidney R Steinberg, MD, FACS, Program Director, Department of General Surgery, Spartanburg Regional Healthcare System; Consulting Surgeon, Department of Surgery, WG Hefner Veterans Affairs Medical Center Editors: Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Daniel S Schwartz, MD, FACS, Clinical Assistant Professor of Cardiothoracic Surgery, New York University School of Medicine; Consulting Staff, Department of Surgery, Division of Thoracic Surgery, North Shore University Hospital/Long Island Jewish Medical Center; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; Mary C Mancini, MD, PhD, Director of Cardiothoracic Transplantation, Professor, Department of Surgery, Louisiana State University Health Sciences Center Author and Editor Disclosure Synonyms and related keywords: hiatal hernia, diaphragm, congenital diaphragmatic hernia, CDH, respiratory dysfunction, respiratory compromise, blunt trauma, penetrating trauma, diaphragmatic rupture, motor vehicle accident, gunshot wound, stab wound, diaphragmatic hernia, acquired hernia, acquired diaphragmatic hernia INTRODUCTIONSection 2 of 12
  The diaphragm is the major muscle of respiration and the second most important muscle after the heart. Spontaneous breathing relies primarily on diaphragmatic excursion to produce negative intrathoracic pressure. Whenever a diaphragmatic function decreases, concomitant respiratory dysfunction ensues. Causes of diaphragmatic dysfunction stem from diseases causing fatigue, physiologic dysfunction, or from mechanical disruption. The body has many inherent mechanisms to compensate for decreased diaphragmatic function, though none can successfully prevent respiratory compromise if excursion of the diaphragm is moderately diminished or simply absent. Diaphragmatic hernias can be divided into 2 categories: congenital defects and acquired defects. Congenital diaphragmatic hernias (CDHs) occur because of embryologic defects in the diaphragm. Most patients with CDH present early rather than late in life; however, a subset of adults may present with a congenital hernia that was undetected during childhood. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article, Hiatal Hernia. Blunt and penetrating traumas cause most acquired diaphragmatic hernias. As many as 1.6% of patients admitted to the hospital for blunt trauma have a diaphragmatic hernia. History of the ProcedureThe first traumatic diaphragmatic hernia was reported by Sennertus in 1541. The first two deaths were described by Ambrose Paré in 1578, one from strangulated bowel.1 FrequencyApproximately 0.8-1.6% of patients with blunt trauma have a rupture of the diaphragm. The male-to-female ratio is 4:1, with most presenting in the third decade of life. Blunt trauma accounts for 75% of ruptures, and penetrating trauma accounts for the rest. Approximately 69% of hernias are left-sided, 24% are right-sided, and 15% are bilateral. Children have equal rates of rupture per side, likely due to laxity of liver attachments.2 EtiologyBy far, the most common cause of acquired diaphragmatic disorders is either blunt or penetrating trauma. The incidence of diaphragmatic rupture is 0.8-1.6% in patients admitted to the hospital for blunt trauma. Motor vehicle accidents are the leading cause of blunt diaphragmatic injury, whereas penetrating injuries result from gunshot or stab wounds. Other rare causes of traumatic rupture include labor in women with a history of congenital or repaired diaphragmatic hernias,3 and barotrauma during underwater dives in patients with history of Nissen fundoplications.4 The following theories have been postulated to explain the mechanism of rupture for blunt injuries: (1) shearing of a stretched membrane, (2) avulsion of the diaphragm from its points of attachment, and (3) sudden force transmission through the viscera (which act as a viscous fluid). Left-sided rupture is more common than right-sided rupture (68.5% vs 24.2%) owing to hepatic protection and increased strength of the right hemidiaphragm. However, the increased prevalence of left-sided hernias may also result from weaknesses in points of diaphragmatic embryologic fusion. Current thought is that the right side has more protection than the left and that it may be slightly stronger than the left. In addition, the liver may provide another protection for the right hemidiaphragm. PathophysiologyThe pathophysiology of acquired diaphragmatic hernias includes circulatory and respiratory depression secondary to decreased function of the diaphragm, intrathoracic abdominal contents leading to compression of the lungs, shifting of the mediastinum, and cardiac compromise. Smaller diaphragmatic hernias are often not found until months or years later, when patients present with strangulation of intra-abdominal organs, dyspnea, or nonspecific gastrointestinal complaints. ClinicalClinical findings include (1) marked respiratory distress, (2) decreased breath sounds on the affected side, (3) palpation of abdominal contents upon insertion of a chest tube, (4) auscultation of bowel sounds in the chest, (5) paradoxical movement of the abdomen with breathing, and/or (6) diffuse abdominal pain. INDICATIONSSection 3 of 12
Traumatic rupture of the diaphragm requires surgical intervention whether the patient presents immediately or some time after the trauma. The high incidence of concomitant intra-abdominal injuries dictates the need for emergency abdominal exploration in the acute trauma setting after initial resuscitation is accomplished. Patients who present in the latent phase or long after the trauma require repair because the hernia contents may become strangulated, leading to dead gut, stomach, liver, spleen, or other organs. RELEVANT ANATOMYSection 4 of 12
The diaphragm is a modified half-dome of musculofibrous tissue that separates the thorax from the abdomen. The thoracic side is covered with parietal pleura, and the abdominal side with peritoneum. Four embryologic components arise during the formation of the diaphragm: the septum transversum, 2 pleuroperitoneal folds, cervical myotomes, and the dorsal mesentery. Development begins during the third week of gestation and concludes by the eighth week. Failure of the development of the pleuroperitoneal folds, and subsequent muscular migration, results in congenital defects. The muscular diaphragm originates from the 6 lowest ribs on both sides, from the posterior xiphoid process, and from the external and internal arcuate ligaments. Different structures traverse the diaphragm, including 3 distinct apertures that allow the aorta, esophagus, and vena cava to pass. The aortic aperture is the lowest and most posterior of the openings, lying at the level of the T12 vertebra. The aortic opening also transmits the thoracic duct and, sometimes, the azygous and hemiazygous veins. Diaphragmatic muscle surrounds the esophageal aperture, which lies at the T10 level. The vena caval aperture is the highest of the 3 openings and lies level to the disk space between T8 and T9. Because of its combination of fast twitch oxidative-glycolytic and slow twitch oxidative fibers, the diaphragm is a muscle resistant to fatigue. Loss of movement of the diaphragm is indicative of fatigue and can be measured by the contractile force. Many patients with chronic obstructive pulmonary disease (COPD) can live at the brink of fatigue.5 The diaphragm receives its sole muscular neurologic impulse from the phrenic nerve, which primarily originates from the fourth cervical ramus; however, it also has contributions from the third and fifth rami. (Remember that "C3, C4, and C5 keep the diaphragm alive.") Originating around the level of the scalenus anterior muscle, the phrenic nerve courses inferiorly through the neck and thorax before reaching its end point, the diaphragm. Because the phrenic nerve has such a long course before it reaches its final destination, any process that disrupts the transmission of neurologic impulse through the nerve directly affects the diaphragm. CONTRAINDICATIONSSection 5 of 12
Relatively no contraindications have been reported for repair of an acquired diaphragmatic hernia. In the trauma setting, the patient must be adequately resuscitated before he or she is transported to the operating room. Many small injuries are discovered during exploratory laparotomy for the repair of other intra-abdominal injuries. Diaphragmatic hernias should always be repaired. Lack of repair of a diaphragmatic hernia can lead to incarceration and strangulation of intra-abdominal contents or respiratory dysfunction. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
TREATMENTSection 7 of 12
Medical TherapyFor traumatic rupture, first provide initial resuscitation according to ATLS protocol, most importantly, airway control. Avoid the use of military antishock trousers (MAST). Prepare the patient for surgery. Sometimes, as with congenital hernias, surgical intervention can be briefly delayed until the patient's condition is stabilized. However, the high incidence of concomitant injuries requires emergency exploration in most cases. Surgical TherapyIf the diaphragmatic injury is discovered during the acute phase of trauma, the standard surgical approach is laparotomy or, less commonly, thoracotomy. The generally accepted protocol in the acute setting is that a diaphragmatic rupture is approached by using a celiotomy because the concomitant intra-abdominal injuries are likely present. The problem regarding which approach to use arises when the diaphragmatic injury is unnoticed for months or years. More surgeons approach long-standing hernias with a transthoracic or thoracoabdominal approach because the herniated intra-abdominal contents tend to be firmly attached to intrathoracic structures, making a transabdominal approach difficult. Preoperative DetailsAs with any trauma, the patient's condition must be stabilized, and he or she must be resuscitated as much as possible before the operation. People with traumatic hernias frequently have concomitant injuries and require emergency exploration. Intraoperative DetailsWith traumatic ruptures, the surgical approach depends on the timing of the diagnosis with the surgical intervention. In the acute phase of trauma, an abdominal approach is preferred because 89% of patients with traumatic rupture have other associated intra-abdominal injuries. In the latent phase of trauma, a transthoracic approach may be necessary because patients often have adhesions to intrathoracic organs. Repair depends on the size of the defect. Interrupted horizontal sutures can be used for small defects, but large defects might eventually require synthetic mesh. Laparoscopic abdominal exploration in the setting of trauma is becoming a popular way to determine if diaphragmatic integrity is retained. It provides a minimally invasive mechanism to directly view the diaphragm to determine if an injury has occurred. In the absence of other intra-abdominal injuries, the diaphragm can easily be repaired by applying laparoscopic techniques. The best utility of laparoscopy is with penetrating thoracic and flank injuries when intraperitoneal penetration being considered and if a projectile injured the diaphragm. Follow-upAfter an anatomic defect is corrected, periodic assessments of pulmonary function and chest radiography are important. Although the spontaneous recurrence rate for repaired diaphragmatic hernias is low, small defects in the repair site have been reported; therefore, surveillance is crucial. COMPLICATIONSSection 8 of 12
Recurrence is possible after traumatic herniation or a congenital diaphragmatic hernia that was repaired in an adult. Therefore, follow-up chest radiography is important. OUTCOME AND PROGNOSISSection 9 of 12
In traumatic ruptures, the outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5-51%. People with isolated diaphragmatic injuries tend to recover without long-term disability. FUTURE AND CONTROVERSIESSection 10 of 12
Minimally invasive techniques for diaphragmatic repair are becoming more common than before. With advances in technology and surgical skills, repairing both acute and chronic diaphragmatic hernias is possible with laparoscopic, thoracoscopic, or combined approaches. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Diaphragmatic Hernias, Acquired excerpt Article Last Updated: Jan 14, 2008 | ||||||||||||||
