Chapter 47 - Diaphragmatic hernias

Question 1

Types of diaphragmatic hernias ?

Answer 1

Congenital :

• Pleuro-peritoneal (failure of fusion of the pleuroperitoneal membrane across the pleuroperitoneal canal during embryological development)
• Peritoneal pericardial (abdominal structures herniate into the pericardial sac while maintaining an intact pleural space)
• Hiatal hernia (abdominal contents (most commonly the stomach) through the esophageal hiatus)

Acquired (85% cases), acute or chronic
- Trauma

Question 2

Symptoms ?

Answer 2

• Peritoneal Pericardial DH: tachypnea, dyspnea, vomiting, anorexia, exercise intolerance, and cough
• Hiatal hernia: regurgitation, vomiting, hypersalivation,
  dysphagia, respiratory distress, anorexia, and/or
  weight loss
• Acute acquired DH: dyspnea and tachypnea ; majority presented following a traumatic event: various stages of shock
• Chronic TDH: dyspnea, vomiting. Non-specific clinical signs (either developed acutely or more insidious, chronic, and intermittent in nature (e.g. anorexia, lethargy, and weight loss)

Question 3

Organs herniated ?

Answer 3

• Liver is the most commonly reported herniated
  organ,
• Followed by the small intestine, stomach, spleen,
  omentum, pancreas, colon, cecum, and kidney.
• Other reported herniated structures are the gall bladder and mummified fetus

Question 4

Indications for emergency surgical intervention?

Answer 4

Early studies of TDH suggested that early intervention (<24 h) resulted in higher mortality rates. However, more recent studies suggest that surgical intervention within 24 hours of TDH may not have an adverse effect.
Emergency surgical intervention is indicated if:
●● the stomach is located in the thoracic cavity; gastric distension can lead to cardiovascular
compromise
●● the patient cannot be stabilized due to suspected continualhemorrhage
●● abdominal pain is refractory to appropriate pain management.

Question 5

How to avoid reperfusion pulmonary edema ?

Answer 5

Reperfusion pulmonary edema is a life-threatening
complication in these patients. Intermittent positive
pressure ventilation is required for the duration of the
surgical procedure and should not exceed 15–20 cm H2O.
The atelectic lung lobes should not be forcibly expanded, but should rather be allowed to slowly expand on their own

Question 6

Prognosis ?

Answer 6

85% success rate approximately

Question 7

Complications ?

Answer 7

• Pneumothorax,
• Pleural effusion,
• Pulmonary edema,
• Cardiac dysrhythmias,
• Hemothorax,
• Shock,
• Cardiac arrest,
• Gastrointestinal rupture/strangulation