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emedicine.medscape.com
Acquired Diaphragmatic Hernia
Updated: Dec 17, 2018
Author: Anne T Saladyga, MD; Chief Editor: Jeffrey C Milliken, MD
Overview
Background
The diaphragm is the major muscle of respiration. Diaphragmatic excursion and chest wall expansion increase the negative
intrathoracic pressure required for inhalation. The sequelae from diaphragmatic rupture and subsequent herniation of intra-
abdominal contents are associated with significant morbidity and mortality.[1]
Diaphragmatic hernias can be divided into the following two categories:
Congenital defects
Acquired defects
Congenital diaphragmatic hernias occur because of embryologic defects in the diaphragm. Most patients with congenital
diaphragmatic hernias present early rather than late in life; however, a subset of adults may present with a congenital hernia that
was undetected during childhood.
Acquired diaphragmatic hernias stem from all types of trauma,[2] with blunt forces accounting for the majority. The 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.[3]
Diaphragmatic hernias require a high level of suspicion to detect. Patients can be asymptomatic in as many as 53% of hernias
from blunt trauma and 44% of those from penetrating trauma. Routine chest x-ray detects only 33% of hernias when interpreted
by the trauma team leader at initial evaluation.[4] Missed injuries are associated with significant morbidity and mortality.[5]
Anatomy
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, as follows:
Septum transversum
Two pleuroperitoneal folds
Cervical myotomes
Dorsal mesentery
Development begins during week 3 of gestation and concludes by week 8. Failure of the development of the pleuroperitoneal
folds, with subsequent muscular migration, results in congenital defects.
The muscular diaphragm originates from the six lowest ribs on both sides, from the posterior xiphoid process, and from the
external and internal arcuate ligaments. Different structures traverse the diaphragm, including three distinct apertures that allow
the aorta, esophagus, and vena cava to pass, as follows:
The aortic aperture is the lowest and most posterior of the openings, lying at the level of T12; it also transmits the
thoracic duct and, sometimes, the azygos and hemiazygos veins
Diaphragmatic muscle surrounds the esophageal aperture, which lies at the level of T10
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The vena caval aperture is the highest of the three 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.[6]
The arterial supply to the diaphragm derives from the right and left phrenic arteries, the intercostal arteries, and the
musculophrenic branches of the internal thoracic arteries. Small branches of the pericardiophrenic arteries that course with the
phrenic nerve, mainly where the nerves penetrate the diaphragm, provide some arterial blood. Venous drainage is through the
inferior vena cava (IVC) and azygos vein on the right and the adrenal/renal and hemizygos veins on the left.
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. (As the saying goes, "C3, C4, and C5 keep the
diaphragm alive.")
Originating around the level of the scalenus anterior, 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 transmission of neurologic impulses through the nerve directly affects the diaphragm.
Pathophysiology
The 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.[7] 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.
Etiology
By far the most common cause of acquired diaphragmatic disorders is trauma, either blunt or penetrating. Motor vehicle
accidents are the leading cause of blunt diaphragmatic injury,[8] whereas penetrating injuries result from gunshot or stab
wounds. In contrast to earlier work, several later retrospective studies found 75% of their patients to have tears from penetrating
injuries.[9, 10] This may stem from increasing awareness of the part of providers or the ability to detect small tears via minimally
invasive methods.
Other rare causes of traumatic rupture include labor in women with prior diaphragmatic hernia repair,[11] barotrauma during
underwater dives in patients with history of Nissen fundoplications[12] and liver transplantation (particularly in children).[13]
The following theories have been postulated to explain the mechanism of rupture for blunt injuries:
Shearing of a stretched membrane
Avulsion of the diaphragm from its points of attachment
Sudden increase in the transdiaphragmatic pleuroperitoneal pressure gradient
The resting pressure differential between the pleural (–5 to –10 cm H2O) and peritoneal (+2 to +10 cm H2O) cavities rises to
100-150 cm H2O with a large cough and does not injure the diaphragm. Forces transmitted to the abdomen from blunt trauma
can raise the pressure gradient to 1000 cm H2O.
It is thought that the right side has more protection than the left and may be slightly stronger than the left; in addition, the liver
may provide another protection for the right hemidiaphragm. Thus, owing to hepatic protection and the increased strength of the
right hemidiaphragm, left-side rupture is more common than right-side rupture (68.5% vs 24.2%). However, the increased
prevalence of left-side hernias may also result from weaknesses in points of diaphragmatic embryologic fusion. Children have
equal rates of rupture per side, likely because of laxity of liver attachments.[14]
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Epidemiology
Of patients admitted to the hospital for trauma, 3-5% have a diaphragmatic hernia.[9, 10] The male-to-female ratio is 4:1, with
most presenting in the third decade of life. Approximately 0.8-1.6% of patients with blunt trauma sustain a rupture of the
diaphragm, accounting for 75% of diaphragmatic hernias. Approximately 69% of hernias are on the left side, 24% are on the
right, and 15% are bilateral.
Prognosis
In traumatic ruptures, the outcome is generally related to concomitant injuries. Reported mortality ranges from 5.5% to 51%.
People with isolated diaphragmatic injuries tend to recover without long-term disability.
Presentation
History and Physical Examination
Clinical findings in patients with acquired diaphragmatic hernia may include the following:
Marked respiratory distress
Decreased breath sounds on the affected side
Palpation of abdominal contents upon insertion of a chest tube
Auscultation of bowel sounds in the chest
Paradoxic movement of the abdomen with breathing
Diffuse abdominal pain
Workup
Imaging Studies
Chest radiography
Chest radiography is standard in the Advanced Trauma Life Support (ATLS) protocol for a trauma workup. Approximately 23-
73% of traumatic diaphragmatic ruptures will be detected by initial chest radiography, with an additional 25% found on
subsequent films.[15] Chest radiography is most sensitive for detecting left-side hernias. Chest radiographic findings that
indicate traumatic rupture include the following:
Abdominal contents in the thorax, with or without signs of focal constriction ("collar sign") [15]
Nasogastric tube seen in the thorax (see the image below)
Elevated hemidiaphragm (>4 cm higher on the left than on the right)
Distortion of diaphragmatic margin
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Preoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident. Note the
bowel contents in the left hemithorax. Nasogastric tube can be seen in the thorax.
Computed tomography
Conventional computed tomography (CT) has been reported to have a sensitivity of 14-82%, with a specificity of 87%.[16]
Helical (spiral) CT has increased sensitivity, 71-100%, with higher sensitivity on the left than on the right.[15] CT findings
indicative of rupture include the following:
Direct visualization of injury
Segmental diaphragm nonvisualization
Intrathoracic herniation of viscera
"Collar sign"
Peridiaphragmatic active contrast extravasation
Ultrasonography
Ultrasonography (US; specifically, focused assessment with sonography for trauma [FAST]) has been reported to detect
diaphragmatic hernias.[3] During visualization of each upper quadrant, the movement of the diaphragm was noted to be
decreased in patients with diaphragmatic hernias. This technique is limited in patients who are on mechanical ventilation
because of the positive pressure of the thoracic cavity.[3]
Procedures
In stable patients in whom an isolated diaphragmatic tear is suspected, diagnostic laparoscopy or video-assisted thoracoscopic
surgery (VATS) is indicated.
Treatment
Approach Considerations
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In traumatic rupture of the diaphragm, surgical intervention is mandatory, 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.
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.
Medical Therapy
For traumatic rupture, first provide initial resuscitation according to Advanced Trauma Life Support (ATLS) protocol, with
particular attention to 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 necessitates emergency exploration in most
cases.
Surgical Therapy
If 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 via a
celiotomy because concomitant intra-abdominal injuries are more likely to be present than thoracic injuries are (84% vs 53%).[4]
The problem regarding which approach to use arises when the diaphragmatic injury goes unnoticed for months or years. More
surgeons approach long-standing hernias via a transthoracic or thoracoabdominal approach because the herniated intra-
abdominal contents tend to be firmly attached to intrathoracic structures, making a transabdominal approach difficult.
Minimally invasive techniques for diaphragmatic repair have become increasingly common. With advances in technology and
surgical skills, repairing both acute and chronic diaphragmatic hernias is possible with laparoscopic,[17] thoracoscopic, robotic-
assisted,[18] or combined approaches.
Operative details
As in any case of trauma, the patient's condition must be stabilized, and he or she must be resuscitated to the extent possible
before operative treatment. People with traumatic hernias frequently have concomitant injuries and require emergency
exploration.
With 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.[19] In the latent phase of trauma, a transthoracic approach may be
necessary because patients often have adhesions to intrathoracic organs.
Acute injuries are repaired with monofilament permanent sutures. Small lacerations may be repaired by using interrupted,
horizontal mattress, or figure-eight stitches; larger lacerations may be repaired with continuous or double-layered closures.
Absorbable sutures are associated with a high rate of recurrence.[9] There is some limited evidence to suggest that the use of
biologic mesh in traumatic diaphragmatic repair may be feasible, at least in chronic cases.[20]
Laparoscopic abdominal exploration in the setting of trauma has become an increasingly popular way of determining whether
diaphragmatic integrity is retained. It provides a minimally invasive mechanism by which the diaphragm can be directly viewed
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.[21]
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The best utility of laparoscopy is with penetrating thoracic and flank injuries when intraperitoneal penetration is being considered
and if a projectile injured the diaphragm.
Long-Term Monitoring
Recurrence is possible after traumatic herniation or a congenital diaphragmatic hernia that was repaired in an adult. Therefore,
after an anatomic defect is corrected, periodic assessments of pulmonary function and chest radiography are important (see the
image below). Although the spontaneous recurrence rate for repaired diaphragmatic hernias is low, small defects in the repair
site have been reported; therefore, surveillance is crucial.
Postoperative chest radiograph in a 53-year-old woman who was a restrained passenger in an automobile accident.
Contributor Information and Disclosures
Author
Anne T Saladyga, MD General Surgery Resident, Department of Surgery, William Beaumont Army Medical Center
Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Daniel S Schwartz, MD, MBA, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic
Health Services
Daniel S Schwartz, MD, MBA, FACS is a member of the following medical societies: American College of Chest Physicians,
American College of Surgeons, Society of Thoracic Surgeons, Western Thoracic Surgical Association
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Disclosure: Nothing to disclose.
Chief Editor
Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical
Professor, Department of Surgery, University of California, Irvine, School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic
Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American
Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart
and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association
Disclosure: Nothing to disclose.
Acknowledgements
Jason M Johnson, DO Resident Physician, Department of General Surgery, Spartanburg Regional Medical Center
Disclosure: Nothing to disclose.
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
Sidney R Steinberg, MD, FACS is a member of the following medical societies: American College of Surgeons, American
Medical Association, Association for Surgical Education, South Carolina Medical Association, and Southeastern Surgical
Congress
Disclosure: Nothing to disclose.
References
1. Simon LV, Burns B. Diaphragm, Rupture. Treasure Island, FL: StatPearls; 2018. [Full Text].
2. Lee K, Atherton NS. Diaphragm, Injury. Treasure Island, FL: StatPearls; 2018. [Full Text].
3. Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in
blunt abdominal trauma. Am J Emerg Med. 2004 Nov. 22 (7):601-4. [Medline].
4. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105
patients over 13 years. Ann Thorac Surg. 2008 Mar. 85 (3):1044-8. [Medline].
5. Lu J, Wang B, Che X, Li X, Qiu G, He S, et al. Delayed traumatic diaphragmatic hernia: A case-series report and literature review.
Medicine (Baltimore). 2016 Aug. 95 (32):e4362. [Medline].
6. West JB. Pulmonary Physiology and Pathophysiology: An Integrated, Case-Based Approach. 2nd ed. Philadelphia: Wolters Kluwer;
2007. 1-30; 116-33.
7. Jacobs R, Honore PM, Hosseinpour N, Nieboer K, Spapen HD. Sudden cardiac arrest during pregnancy: a rare complication of
acquired maternal diaphragmatic hernia. Acta Clin Belg. 2012 May-Jun. 67 (3):198-200. [Medline].
8. Mahamid A, Peleg K, Givon A, Alfici R, Olsha O, Israeli Trauma Group., et al. Blunt traumatic diaphragmatic injury: A diagnostic
enigma with potential surgical pitfalls. Am J Emerg Med. 2017 Feb. 35 (2):214-217. [Medline].
9. Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac
Surg. 2008 Jun. 33 (6):1082-5. [Medline].
10. Ramsay PT, Feliciano DV. The management of diaphragmatic injuries. Cameron JL, Cameron AM, eds. Current Surgical Therapy.
12th ed. Philadelphia: Elsevier; 2017. 1170-5.
11. Hamoudi D, Bouderka MA, Benissa N, Harti A. Diaphragmatic rupture during labor. Int J Obstet Anesth. 2004 Oct. 13 (4):284-6.
[Medline].
12. Hayden JD, Davies JB, Martin IG. Diaphragmatic rupture resulting from gastrointestinal barotrauma in a scuba diver. Br J Sports
Med. 1998 Mar. 32 (1):75-6. [Medline].
13. Emamaullee JA, Nekrasov V, Gilmour S, Kneteman N, Yanni G, Kohli R, et al. Case series and systematic review of acquired
diaphragmatic hernia after liver transplantation. Pediatr Transplant. 2018 Oct 2. e13296. [Medline].
14. Mansour KA. Trauma to the diaphragm. Chest Surg Clin N Am. 1997 May. 7 (2):373-83. [Medline].
https://emedicine.medscape.com/article/428055-print 7/8
5/10/2019 https://emedicine.medscape.com/article/428055-print
15. Sliker CW. Imaging of diaphragm injuries. Radiol Clin North Am. 2006 Mar. 44 (2):199-211, vii. [Medline].
16. Desir A, Ghaye B. CT of blunt diaphragmatic rupture. Radiographics. 2012 Mar-Apr. 32 (2):477-98. [Medline].
17. Xenaki S, Lasithiotakis K, Andreou A, Chrysos E, Chalkiadakis G. Laparoscopic repair of posttraumatic diaphragmatic rupture.
Report of three cases. Int J Surg Case Rep. 2014. 5 (9):601-4. [Medline]. [Full Text].
18. Counts SJ, Saffarzadeh AG, Blasberg JD, Kim AW. Robotic Transthoracic Primary Repair of a Diaphragmatic Hernia and Reduction
of an Intrathoracic Liver. Innovations (Phila). 2018 Jan/Feb. 13 (1):54-55. [Medline].
19. Silva GP, Cataneo DC, Cataneo AJM. Thoracotomy compared to laparotomy in the traumatic diaphragmatic hernia. Systematic
review and proportional methanalysis. Acta Cir Bras. 2018 Jan. 33 (1):49-66. [Medline].
20. Antoniou SA, Pointner R, Granderath FA, Köckerling F. The Use of Biological Meshes in Diaphragmatic Defects - An Evidence-
Based Review of the Literature. Front Surg. 2015. 2:56. [Medline]. [Full Text].
21. Liao CH, Chu CH, Wu YT, Fu CY, Hsieh FJ, Wang SY, et al. The feasibility and efficacy of laparoscopic repair for chronic traumatic
diaphragmatic herniation: introduction of a novel technique with literature review. Hernia. 2016 Apr. 20 (2):303-9. [Medline].
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