bubble_chart Overview

Among diaphragmatic diseases, diaphragm hernia is the most common. The formation of diaphragm hernia is related not only to congenital defects and weak points in the fusion of the diaphragm but also to the following factors: ① The pressure difference between the thoracic and abdominal cavities and the mobility of abdominal organs; various factors that increase intra-abdominal pressure, such as bending over, difficulty in defecation, and pregnancy, can push abdominal organs through diaphragmatic defects or weak areas into the thoracic cavity. ② With age, the muscle tone of the diaphragm decreases, and the esophageal ligaments relax, enlarging the esophageal hiatus, allowing the cardia or gastric body to protrude into the posterior mediastinum through the enlarged hiatus. ③ Chest trauma, especially combined thoracoabdominal injuries, can cause diaphragmatic rupture. Diaphragm hernia can be classified differently, such as true hernia and false hernia based on the presence of a hernial sac, but it is generally categorized by the presence of trauma history into traumatic diaphragm hernia and non-traumatic diaphragm hernia. The latter can be further divided into congenital and acquired types. The most common non-traumatic diaphragm hernias include hiatal hernia, Bochdalek hernia, Morgagni hernia, and diaphragmatic absence. The symptoms of diaphragm hernia vary in severity, primarily depending on the volume of abdominal organs herniated into the thoracic cavity, the degree of organ dysfunction, and the impact of increased intrathoracic pressure on respiratory and circulatory functions. However, the symptoms can broadly be divided into two categories: (1) Functional changes due to herniation of abdominal organs into the thoracic cavity, such as postprandial fullness, belching, burning sensation in the upper abdomen or behind the sternum, and acid reflux. These occur because the loss of the cardia mechanism allows stomach acid to flow back into the esophagus, causing esophageal mucosal inflammation or ulcers. In severe cases, hematemesis and dysphagia may occur. Partial obstruction of the gastrointestinal tract can lead to nausea, vomiting, abdominal distension, and fullness. In severe cases, complete or strangulated obstruction may result in hematemesis, hematochezia, abdominal pain, and distension, and even organ necrosis or perforation, leading to shock. (2) Respiratory and circulatory dysfunction caused by compression of thoracic organs. When abdominal organs herniate into the thoracic cavity, the affected lung is compressed, and the heart is displaced to the opposite side. Mild cases may present with chest tightness and shortness of breath, while severe cases can manifest as dyspnea, tachycardia, and cyanosis.

bubble_chart Clinical Manifestations

1. Traumatic diaphragmatic hernia: The patient's symptoms are more severe. In addition to the symptoms of chest trauma, it may also be accompanied by bleeding, perforation, and severe contamination of the thoracic and abdominal cavities caused by rupture of intra-abdominal organs. Left diaphragmatic rupture allows subdiaphragmatic organs to herniate into the thoracic cavity through the diaphragmatic tear, causing severe chest pain that may radiate to the ipsilateral shoulder and upper arm, sometimes with upper abdominal pain or abdominal muscle tension. Due to the space-occupying effect of herniated organs in the chest, lung tissue and the heart are compressed, and the mediastinum shifts to the contralateral side, significantly reducing lung capacity. The patient experiences shortness of breath and dyspnea, with cyanosis in severe cases. Cardiac displacement obstructs venous return, reducing cardiac output, leading to tachycardia, hypotension, and even shock. If the herniated organs in the chest develop obstruction or strangulation, symptoms such as abdominal pain, abdominal distension and fullness, nausea, vomiting, hematemesis, and hematochezia may occur, and severe cases can lead to toxic shock. Physical examination reveals dullness or tympany on percussion of the affected chest, weakened or absent breath sounds, and sometimes audible borborygmi.

2. Congenital diaphragmatic hernia: The presentation varies mainly depending on the location, size, hernia contents, and functional changes of the herniated organs in the chest. Parasternal hernias, due to their small size, often manifest symptoms only in adulthood, primarily presenting as upper abdominal dull pain, bloating, poor appetite, indigestion, intermittent constipation, and abdominal distension and fullness. These symptoms are easily overlooked and misdiagnosed as gastrointestinal disorders. Occasionally, X-ray examination may reveal the presence of gastric bubbles and intestinal shadows behind the sternum, leading to a definitive diagnosis. If the herniated small intestine or colon becomes incarcerated, acute intestinal obstruction or strangulation may occur, presenting with corresponding clinical symptoms.

bubble_chart Diagnosis

1. The diagnosis of traumatic diaphragmatic hernia is generally not very difficult. Based on the location of the thoracoabdominal wound, the entry point and direction of bullets or stab wounds, and the conditions of the bullet's entry and exit points, the anatomical pathway within the body can be roughly determined, thereby inferring whether there is injury to the diaphragm. For traumatic diaphragmatic hernia, chest and abdominal X-ray examinations can easily identify intestinal loops herniated into the thoracic cavity. The presence of free gas under the diaphragm suggests perforation of intra-abdominal organs. However, due to pleural effusion and pneumothorax, it is sometimes difficult to visualize the rupture of the diaphragm and the presence of herniated gastrointestinal organs in the thoracic cavity.

2. For congenital diaphragmatic hernia, depending on the different organs herniated into the thoracic cavity, chest percussion may reveal dullness or tympany, with diminished or absent breath sounds on the affected side. Sometimes, borborygmi can be heard in the chest, and the heart and trachea may shift to the contralateral side. The abdomen appears flat and soft, with the disappearance of the frog-like belly in infants. Chest X-ray examination of congenital diaphragmatic hernia can show gas-filled stomach bubbles and intestinal loops in the affected thoracic cavity, compression of lung tissue, and mediastinal shift of the heart. In a few cases, a barium enema examination may be necessary to confirm the diagnosis.

bubble_chart Treatment Measures

1. Traumatic diaphragmatic hernia: Patients with thoracoabdominal combined injuries have severe symptoms and urgent conditions. In addition to necessary emergency treatment, active preoperative preparations should be made, including shock correction, management of tension pneumothorax, and timely thoracic intercostal drainage. Tracheotomy should be performed for patients with dyspnea to control paradoxical chest wall respiration. Thoracotomy or laparotomy should be performed after the general condition improves. The surgical approach should be determined based on the location and extent of the thoracic or abdominal {|###|}injury{|###|}, the presence of foreign bodies, and their location in the body. Generally, a thoracic incision on the injured side is used to enter the chest. After exploring the thoracic cavity, the diaphragmatic wound is enlarged to perform abdominal organ repair, followed by repositioning the abdominal organs into the abdominal cavity and suturing the diaphragmatic incision. If the {|###|}injury{|###|} involves the abdomen and is extensive, making thoracic exploration difficult, the incision should be extended to the abdomen without hesitation to explore the abdominal organs and perform necessary surgery. For non-penetrating trauma, careful observation may suffice if the patient's symptoms are mild. For {|###|}advanced stage{|###|} traumatic diaphragmatic hernia, elective surgery can be performed.

2. Congenital diaphragmatic hernia: Once congenital diaphragmatic hernia is diagnosed, surgical treatment should be performed as early as possible to prevent long-term adhesion formation or complications such as intestinal obstruction or strangulation. For infant patients, a gastrointestinal decompression tube should be placed preoperatively to avoid further lung compression during anesthesia and surgery, which could lead to severe ventilation dysfunction. For parasternal hernias, a high midline abdominal incision is used for hernia repair. The herniated contents in the retrosternal space are mostly the greater omentum or part of the stomach wall, so repositioning these contents into the abdominal cavity is generally not difficult. After excising the redundant hernial sac, the transversus abdominis {|###|}membrane{|###|} is sutured to the diaphragm and costal margin with silk to repair the defect. For Bochdalek hernias or partial diaphragmatic absence, either a thoracic or abdominal approach can be adopted. The thoracic incision provides better surgical field exposure, facilitating adhesion separation and repositioning of abdominal organs, and diaphragmatic repair is also more convenient. Partial diaphragmatic absence can be repaired using an overlapping or mattress suture technique. If the diaphragmatic defect is large, the diaphragm can be freed from its attachment to the chest wall and repaired as described above, with synthetic fiber mesh reinforcement if necessary. For the transabdominal approach, a midline rectus incision is made. After repositioning the abdominal organs, the diaphragmatic defect is repaired via subphrenic suturing. The abdominal incision is only closed at the subcutaneous and skin layers, with the abdominal {|###|}membrane{|###|} sutured 7–10 days postoperatively. Postoperative gastrointestinal decompression and rectal tube exhaust are critically important.