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Giuffrida M, Perrone G, Abu-Zidan F, Agnoletti V, Ansaloni L, Baiocchi GL, Bendinelli C, Biffl WL, Bonavina L, Bravi F, Carcoforo P, Ceresoli M, Chichom-Mefire A, Coccolini F, Coimbra R, de'Angelis N, de Moya M, De Simone B, Di Saverio S, Fraga GP, Galante J, Ivatury R, Kashuk J, Kelly MD, Kirkpatrick AW, Kluger Y, Koike K, Leppaniemi A, Maier RV, Moore EE, Peitzmann A, Sakakushev B, Sartelli M, Sugrue M, Tian BWCA, Broek RT, Vallicelli C, Wani I, Weber DG, Docimo G, Catena F. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023; 18:43. [PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable. METHODS A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations. RESULTS CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients. CONCLUSIONS Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.
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Affiliation(s)
| | - Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Fikri Abu-Zidan
- Research Office, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luca Baiocchi
- General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'I, Honolulu, USA
| | - Luigi Bonavina
- Department of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, , Riverside, California, USA
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marc de Moya
- Trauma/Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, Denver Health Medical Center,, University of Colorado, Denver, CO, USA
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland
| | - Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Richard Ten Broek
- Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Imtaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Maternal Bochdalek Hernia during Pregnancy: A Systematic Review of Case Reports. Diagnostics (Basel) 2021; 11:diagnostics11071261. [PMID: 34359342 PMCID: PMC8303225 DOI: 10.3390/diagnostics11071261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Since the first report of a diaphragmatic hernia from Ambroise Paré’s necropsy in 1610, the Bochdalek hernia (BH) of the congenital diaphragmatic hernia (CDH) has been the most common types with high morbidity and mortality in the neonatal period. Due to the nature of the disease, CDH associated with pregnancy is too infrequent to warrant reporting in the literature. Mortality of obstruction or strangulation is mostly due to failure to diagnose symptoms early. Data sources and study selection: A systematic literature search of maternal BH during pregnancy was conducted using the electronic databases (PubMed and EMBASE) from January 1941 to December 2020. Because of the rarity of the disease, this review included all primary studies, including case reports or case series that reported at least one case of maternal BH in pregnant. Searches, paper selection, and data extraction were conducted in duplicate. The analysis was performed narratively regardless of the control groups’ presence due to their rarity. Results: The search retrieved 3450 papers, 94 of which were deemed eligible and led to a total of 43 cases. Results of treatment showed 16 cases in delayed delivery after hernia surgery, 10 cases in simultaneous delivery with hernia surgery, 3 cases in non-surgical treatment, and 14 cases in hernia surgery after delivery. Of 16 cases with delayed delivery after hernia surgery, 13 (81%) cases had emergency surgery and three (19%) cases had surgery after expectant management. Meanwhile, 10 cases underwent simultaneous delivery with hernia surgery, 6 cases (60%) had emergent surgery, and 4 cases (40%) had delayed hernia surgery after expectant management. 3 cases underwent non-surgical treatment. In this review, the maternal death rate and fetal/neonatal loss rate from maternal BH was 5% (2/43) and 16% (7/43), respectively. The preterm birth rate has been reported in 35% (15/43) of maternal BH, resulting from maternal deaths in 13% (2/15) of cases and 6 fetal loss in 40% (6/15) of cases; 44% (19/43) of cases demonstrated signs of bowel obstruction, ischemia, or perforation of strangulated viscera in the operative field, resulting from maternal deaths in 11% (2/19) of cases and fetal-neonatal loss in 21% (4/19) of cases. Conclusion: Early diagnosis and surgical intervention are imperative, as a gangrenous or non-viable bowel resection significantly increases mortality. Therefore, multidisciplinary care should be required in maternal BH during pregnancies that undergo surgically repair, and individualized care allow for optimal results for the mother and fetus.
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Kikuchi S, Nishizaki M, Kuroda S, Kagawa S, Fujiwara T. A case of right-sided Bochdalek hernia incidentally diagnosed in a gastric cancer patient. BMC Surg 2016; 16:34. [PMID: 27245581 PMCID: PMC4888207 DOI: 10.1186/s12893-016-0145-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/30/2016] [Indexed: 11/21/2022] Open
Abstract
Background Bochdalek hernia (BH) is generally congenital, presenting with respiratory distress. However, this pathology is rarely detected in adults. Some adult cases of BH present with symptoms attributed to the hernia, but incidental detection of BH is increasing among asymptomatic adults due to advances in imaging modalities. This report presents the management of incidental BH patients detected in the preoperative period of gastric cancer. Case presentation An asymptomatic 76-year-old woman was diagnosed with advanced gastric cancer during follow-up after radiotherapy for uterine cervical cancer. Computed tomography (CT) was performed to exclude metastatic gastric cancer, incidentally detecting right-sided BH. We planned distal gastrectomy with lymph node dissection for gastric cancer and simultaneous repair of BH using a laparoscopic approach. We performed laparoscopic gastrectomy for gastric cancer and investigated the right-sided BH to assess whether repair during surgery was warranted. Herniation of the liver into the right hemithorax was observed, but was followed-up without surgical repair because the right hepatic lobe was adherent to the remnant right anterior hemidiaphragm and covered the huge defect in the right hemidiaphragm. No intra- or postoperative pneumothorax was observed during pneumoperitoneum. Conclusion Regardless of symptoms, repair of adult BH is generally recommended to prevent visceral incarceration. However, BH in asymptomatic adults appears to be more common than previously reported in the literature. Surgeons need to consider the management of incidental BH encountered during thoracic or abdominal surgery.
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Affiliation(s)
- Satoru Kikuchi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kita-ku, Okayama, 700-8558, Japan
| | - Masahiko Nishizaki
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kita-ku, Okayama, 700-8558, Japan.
| | - Shinji Kuroda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kita-ku, Okayama, 700-8558, Japan
| | - Shunsuke Kagawa
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kita-ku, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kita-ku, Okayama, 700-8558, Japan
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Machado NO. Laparoscopic Repair of Bochdalek Diaphragmatic Hernia in Adults. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2016; 8:65-74. [PMID: 27042603 PMCID: PMC4791901 DOI: 10.4103/1947-2714.177292] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Bochdalek hernia (BH) is an uncommon form of diaphragmatic hernia. The rarity of this hernia and its nonspecific presentation leads to delay in the diagnosis, with the potential risk of complications. This review summarizes the relevant aspects of its presentation and management, based on the present evidence in the literature. A literature search was performed on PubMed, Google Scholar, and EMBASE for articles in English on BH in adults. All case reports and series from the period after 1955 till January 2015 were included. A total of 180 articles comprising 368 cases were studied. The mean age of these patients was 51 years (range 15-90 years) with a male preponderance of 57% (211/368). Significantly, 6.5% of patients were above 70 years, with 3.5% of these being above 80 years. The majority of the hernias were on the left side (63%), with right-sided hernias and bilateral occurring in 27% and 10%, respectively. Precipitating factors were noted in 24%, with 5.3% of them being pregnant. Congenital anomalies were seen in 11%. The presenting symptoms included abdominal (62%), respiratory (40%), obstructive (vomiting/abdominal distension; 36%), strangulation (26%); 14% of them were asymptomatic (detected incidentally). In the 184 patients who underwent surgical intervention, the surgical approach involved laparotomy in 74 (40.27%), thoracotomy in 50 (27.7%), combined thoracoabdominal approach in 27 (14.6%), laparoscopy in 23 (12.5%), and thoracoscopic repair in 9 (4.89%). An overall recurrence rate of 1.6% was noted. Among these patients who underwent laparoscopic repair, 82% underwent elective procedure; 66% underwent primary repair, with 61% requiring interposition of mesh or reenforcement with or without primary repair. The overall mortality was 2.7%. Therefore, BH should form one of the differential diagnoses in patients who present with simultaneous abdominal and chest symptoms. Minimal access surgery offers a good alternative with short hospital stay and is associated with minimum morbidity and mortality.
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