Surgical Treatment of Diaphragmatic Hernias

What is a diaphragmatic hernia?

The diaphragm is a musculotendinous partition that separates the chest and abdominal cavities.

In a diaphragmatic hernia, abdominal organs may move into the chest cavity through a defect or an anatomical opening in the diaphragm.

The following may move into the hernia sac or through the hernia defect:

• the stomach
• the bowel
• the omentum
• the spleen
• the liver
• other abdominal organs

Depending on the location and mechanism of development, different types of diaphragmatic hernias are distinguished.

Main types of diaphragmatic hernias

Diaphragmatic hernias include:

• *hiatal hernia (hernia of the esophageal hiatus);*
• paraesophageal hernia
• sliding hiatal hernia
• congenital diaphragmatic hernias
• traumatic diaphragmatic hernias
• postoperative defects of the diaphragm
• left-sided and right-sided diaphragmatic defects
• large and giant diaphragmatic hernias

The treatment method is determined depending on the specific type of hernia.

When is surgery needed?

Surgical treatment may be recommended for:

• a symptomatic diaphragmatic hernia
• large hernias
• progression of the hernia
• displacement of a large part of the stomach or bowel into the chest cavity
• obstruction of the gastrointestinal tract
• compression of the chest organs
• repeated episodes of incarceration
• bleeding
• ischemia or necrosis of the hernia contents
• traumatic and postoperative defects of the diaphragm

How is the operation performed?

The operation is performed under general anesthesia.

Depending on the type and location of the hernia, a laparoscopic, thoracoscopic, or open approach may be used.

During the operation, the following may be performed:

• exploration of the diaphragm
• division of adhesions
• mobilization of the organs
• reduction of the hernia contents into the abdominal cavity
• removal or management of the hernia sac when indicated
• closure of the diaphragmatic defect
• reconstruction of the diaphragm
• reinforcement of the defect with a mesh implant in suitable cases
• correction of associated conditions

Large defects may require complex reconstruction of the diaphragm.

Laparoscopic treatment

In suitable cases, the operation can be performed laparoscopically.

The laparoscopic approach makes it possible to:

• assess the abdominal organs
• mobilize the hernia contents
• return the organs from the chest cavity
• reconstruct the diaphragm
• minimize surgical trauma
• reduce postoperative pain
• speed up the patient's mobilization and recovery

The choice of approach depends on the type and size of the hernia, the anatomy of the defect, previous operations, and the patient's general condition.

Repair of the diaphragmatic defect

Small defects can be closed by suturing the patient's own tissues.

Large defects or a significant tissue deficiency may require additional reinforcement of the reconstructed area.

In suitable cases, the following are used:

• primary suture closure of the defect
• repair with the patient's own tissues
• reinforcement with a mesh implant
• combined reconstruction

The technique is determined individually depending on the size and location of the defect.

Large and complex diaphragmatic hernias

In large hernias, a significant part of the abdominal organs may remain in the chest for a long time.

In such cases, returning the organs to the abdominal cavity may be accompanied by a significant change in intra-abdominal and intrathoracic pressure.

That is why complex diaphragmatic hernias require careful preoperative planning and assessment of lung and cardiovascular function.

Diaphragmatic hernia after injury

A traumatic rupture of the diaphragm may occur after:

• road traffic accidents
• falls from a height
• blunt abdominal or chest trauma
• penetrating wounds
• surgical procedures

A traumatic hernia may go unnoticed for a long time and become apparent months or even years after the injury.

Once the defect is detected, the diaphragm is reconstructed and the organs are returned to the abdominal cavity.

Complicated diaphragmatic hernias

If the hernia contents become incarcerated, the blood supply to the organs may be impaired.

Possible consequences include:

• bowel obstruction
• ischemia
• bowel necrosis
• perforation
• peritonitis
• acute breathing problems

In such situations, urgent surgery is needed.

If the hernia contents are not viable, resection of the affected segment of bowel or another organ may be needed.

Advantages of modern treatment

• Individual planning of the operation
• A minimally invasive approach is possible
• The organs are returned to the abdominal cavity
• The integrity of the diaphragm is restored
• Reconstruction of large defects
• Mesh reinforcement can be used when indicated
• Associated conditions treated in the same operation
• Less surgical trauma with a minimally invasive approach
• Modern postoperative care

Recovery after surgery

The length of recovery depends on the type and complexity of the diaphragmatic hernia, the approach, and the extent of the reconstruction.

After surgery, the following are provided:

• early mobilization
• pain control
• monitoring of respiratory function
• prevention of thromboembolic complications
• a gradual return to eating
• monitoring of the surgical wound
• a gradual return to physical activity

After complex operations, the hospital stay and recovery may take longer.

Frequently Asked Questions