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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 4  |  Page : 391-394

Our surgical experience in traumatic and congenital diaphragmatic hernia: Single-center study


Department of General Surgery, Dicle University, Faculty of Medicine, Diyarbakir/, Turkey

Date of Submission30-Sep-2020
Date of Acceptance11-Mar-2022
Date of Web Publication19-Apr-2022

Correspondence Address:
Dr. O Basol
Department of General Surgery, Dicle University Medical Faculty, Yenisehir, Diyarbakir - 21280
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_605_20

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   Abstract 


Background and Aim: Diaphragmatic hernias can develop congenitally or secondary to trauma. Congenital diaphragmatic hernias occur with Bochdalek hernia and Morgagni hernia (MH). In this study, we aimed to present laparoscopic and open surgical treatment for traumatic and congenital diaphragmatic hernias, and complications and length of hospital stay in the light of the literature. Patients and Methods: Twenty-two patients who were diagnosed with diaphragmatic hernia between January 2013 and January 2020 in our clinic were examined retrospectively in terms of demographic features, clinical and radiological findings, and length of hospital stay. Results: The complaints of the patients diagnosed with diaphragmatic hernia were often abdominal pain, shortness of breath, early satiety, nausea, vomiting, and abdominal distention. The mean age of the patients was 54 (19–88) years. Sixteen patients were females and six were males. Two patients were operated due to stab injury, six patients were operated due to ileus, and the remaining fourteen patients were operated due to congenital diaphragmatic hernia. Eight patients were operated under emergency conditions. The remaining patients were operated under elective conditions. The average hospital stay was 6(3-15) days. The length of hospital stay of those who underwent laparoscopic surgery was 4 (3–5) days. No patient had an exitus. All patients were discharged with healing. This rare pathology should be remembered especially in patients presenting with acute abdominal complaints accompanied by respiratory complaints. Conclusion: We think that cases with MH detected incidentally should be operated laparoscopically before becoming complicated.

Keywords: Laparoscopic surgical repair, Morgagni hernia, traumatic diaphragmatic hernia


How to cite this article:
Basol O, Bilge H. Our surgical experience in traumatic and congenital diaphragmatic hernia: Single-center study. Niger J Clin Pract 2022;25:391-4

How to cite this URL:
Basol O, Bilge H. Our surgical experience in traumatic and congenital diaphragmatic hernia: Single-center study. Niger J Clin Pract [serial online] 2022 [cited 2022 May 23];25:391-4. Available from: https://www.njcponline.com/text.asp?2022/25/4/391/343469




   Introduction Top


Traumatic injuries of the diaphragm occur as a result of penetrating and blunt trauma. The clinical picture can be missed due to the concealment of accompanying organ injuries.[1] When traumatic diaphragmatic injuries, which rarely cause death on their own, are missed, they cause significant complications and death with gastrointestinal herniation.[2] Morgagni hernia (MH) is a rare form of hernia and occurs as a result of congenital defects in the retrosternal area.[3] In embryonic development, migration of the intestines from the yolk sac into the abdomen and the formation of the diaphragm cause delay or change in the period, diaphragmatic eventration, or congenital diaphragmatic hernias. MH occurs as a result of a defect in anteromedial localization in the diaphragm.[4] MH is a common type of congenital diaphragmatic hernias and occurs in 4–6%. It is also called anterior, anteromedial, retrosternal, or parasternal hernia. The defect results from the anterior triangular defect between the costal border and the muscles of the sternum as a result of junction anomaly in the sternal and costal parts of the diaphragm. This defect, which is mostly located right, is more common in women. Clinical symptoms of MH vary. Most patients are asymptomatic when diagnosed.[4] In some patients, it may be manifested by frequent respiratory infections, dyspepsia, dysphagia, retrosternal fullness/pain, and acute upper gastrointestinal obstruction. While diaphragmatic rupture due to trauma is mostly 80% on the left in blunt traumas, this ratio is approximately equal in penetrating injuries.[5] Diaphragmatic injuries are generally associated with concomitant organ injuries.[6] The general condition of these patients and their associated organ injuries lead to overlooking of the preoperative diagnosis. The most important diagnostic tool in radiology is a posteroanterior chest X-ray.[7] Ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), barium upper gastrointestinal system examination, and peritoneal lavage help diagnosis.[8] In the ruptured region, the most herniated abdominal organs are the stomach and colon. The most common concomitant organ injuries were spleen, liver, and hollow organs.[9] In our series, the right kidney, liver, spleen, and colon injuries occurred in two patients due to the injury of the cutting device.

In this article, patients who underwent laparoscopic or open surgical treatment for traumatic and congenital diaphragmatic hernias were presented.


   Material and Methods Top


Twenty-two patients who were diagnosed with diaphragmatic hernia between January 2013 and January 2020 at Dicle University, Faculty of Medicine, General Surgery clinic were examined retrospectively in terms of demographic characteristics, clinical and radiological findings, and length of hospital stay.


   Results Top


The most common complaints of the patients who presented with a diagnosis of diaphragmatic hernia were abdominal pain, shortness of breath, early satiety, nausea, vomiting, and abdominal distension. The mean age of the patients in our series was 54 (19–88) years, and it was in accordance with the literature. Sixteen of the patients in our series were females and six were males. Two of the patients were operated due to stab injury, six patients were operated for ileus, and the remaining fourteen patients were operated for congenital diaphragmatic hernia. Eight patients were operated under emergency conditions due to ileus and stab injuries. The remainder were operated under elective conditions. Seven of the patients who were operated under emergency conditions underwent open surgery, one was laparoscopic, and fourteen of the patients who were taken under elective conditions were laparoscopic. The average hospital stay of the patients was 6 (3–15) days. The average hospital stay of those who had laparoscopic surgery was 4 (3–5) days. None of the patients died. All of the patients were discharged with full recovery.


   Discussion Top


Foramen Morgagni, also known as the Larrey area, is a space that can be found on both sides of the sternum. This generally triangular gap is located between the costal rim of the diaphragm and the muscle fibers starting from the xiphisternum. Here, the most common is the omentum hernia, followed by the hernia of the colon, small intestine, stomach, and other intra-abdominal organs.[10] MH is a rare and generally asymptomatic diaphragmatic hernia in adults.[10] It constitutes 2–4% of non-traumatic diaphragmatic hernias in adults. MH is observed 90% on the right, 8% on the left, and 2% bilaterally.[11] Generally, patients are diagnosed during the radiological examination or when they apply to the emergency room due to the strangulation or volvulus of the organs inside the hernia sac [Figure 1]. MHs in adults are more common in obese and women. Those who are asymptomatic may experience symptoms with exercise. Generally, asymptomatic adult MHs may present a blunt pain in the subcostal region and signs of obstruction if the herniated organ is strangulated.[4] Due to the displacement of the intra-abdominal organs, it can give different symptoms and signs, from the acute abdomen to acute respiratory distress. While symptoms related to the abdomen area are in the foreground, cases presenting with only respiratory distress have also been reported.[12] Generally, posteroanterior chest and abdominal X-ray, thoracoabdominal CT, or contrast radiographs are used for diagnosis. CT image of the patient who was taken to emergency surgery with the diagnosis of ileus is shown in [Figure 2]. Surgical repair of diaphragmatic hernias can be performed with both thoracic and abdominal approaches, and it is the surgeon's preference that determines this approach. In addition to publications that prefer laparotomy or prefer thoracotomy, there are also publications that suggest laparoscopic surgery[3] [Figure 3]. The need to remove the hernia sac is still controversial. Most authors have stated that it is not necessary to remove the hernia sac to avoid phrenic nerve injury.[13] We did not exclude any patient's hernia sac in our series. In general, a transabdominal approach is preferred in patients with the preoperative diagnosis.[14] In our series, except for patients diagnosed with ileus and stab injury, the laparoscopic abdominal repair was performed since all other patients had a preoperative diagnosis. Recently, it is also a frequently applied endoscopic surgery method. Especially with laparoscopic interventions, hernia and defects in the diaphragm are repaired.[14] As a result of the developments in laparoscopic surgery in the last 10 years, there are publications reporting that MH has also been treated with laparoscopic methods. With laparoscopic treatment, port diversity is increased and patches are used for a hernia [Figure 4].[15] By using some laparoscopically developed sütüre materials, the operation time was reduced to an average of 90 min. Most of the surgical period takes back intra-abdominal organs and dissection of the hernia sac. Post-operative pain was lower in patients treated laparoscopically than those who underwent open surgical treatment. At the same time, it has been observed that complications related to the incision site are significantly reduced.[16] Diaphragmatic injuries occur as a result of blunt traumas and penetrating injuries to the thoracoabdominal region. Blunt traumas mostly occur as a result of traffic accidents, falls from height, and industrial accidents.[17] The diagnosis cannot be made in 44% of penetrating diaphragmatic injuries and 55% of blunt diaphragmatic injuries by physical examination.[18],[19] Chest radiographs play a key role in the diagnosis of diaphragmatic rupture.[1]
Figure 1: Computed tomography image of Morgagni hernia

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Figure 2: X-ray image of a 75-year-old patient with emergency respiratory distress and ileus

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Figure 3: View of hernia during laparotomy

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Figure 4: Image after repair with mesh

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In conclusion, this rare pathology should be remembered especially in patients presenting with acute abdominal complaints accompanied by respiratory complaints. We think that cases of MH detected incidentally should be operated laparoscopically before becoming complicated. Also, diaphragmatic injuries are one of the injuries that can be skipped concealing organ injuries. Therefore, suspecting diaphragmatic injury in lower and upper abdomen injuries will decrease mortality and morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hood MR. İnjury to the trachea and major bronchi. Hood MR, Arthur BD, Culliford AT (eds); Thoracic Trauma, Philadelpia; 1989;p.267-89.  Back to cited text no. 1
    
2.
Wiencek RG Jr, Wilson RF, Steiger Z. Acute injuries of the diaphragm. An analysis of 165 cases. J Thorac Cardiovasc Surg 1986;92:989-93.  Back to cited text no. 2
    
3.
Minneci PC, Deans KJ, Kim P. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9.  Back to cited text no. 3
    
4.
Bragg WD, Bumpers H, Flynn W. Morgagni hernias: An uncommon cause of chest masses in adults. Am Fam Physician 1996;54:2021-4.  Back to cited text no. 4
    
5.
Al-Salem AH. Congenital hernia of Morgagni in infants and children. J Pediatr Surg 2007;42:1539-43.  Back to cited text no. 5
    
6.
Polat KY, Akçay MN, Çapan I. Akut diafragma yaralanmaları. Ulusal Travma Dergisi,1995;1:59-62.  Back to cited text no. 6
    
7.
Smithers BM, O'Loughlin B, Strong RW. Diagnosis of ruptured diaphragm following blunt trauma: Results from 85 cases. Aust N Z J Surg 1991;61:737-41.  Back to cited text no. 7
    
8.
Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture of the diaphragm in blunt trauma: Analysis of 60 patients. J Trauma 1980;26:587-92.  Back to cited text no. 8
    
9.
McHugh K, Oglvie BC, Brunton FJ. Delayed presentation of traumatic diaphragmatic hernia. Clin Radiol 1991;43:246-50.  Back to cited text no. 9
    
10.
Fell SC. Surgical anatomy of the diaphragm and the phrenic nerve. Chest Surg Clin N Am 1998;8:281-94.  Back to cited text no. 10
    
11.
Swain JM, Klaus A, Achen SR. Congenital diaphragmatic hernia in adults. Seminars in Laparoscopic Surgery. Vol. 8, No. 4. Sage CA: Thousand Oaks, CA: Sage Publications; 2001. p. 246-55.  Back to cited text no. 11
    
12.
Singh S, Bhende MS, Kinnane JM. Delayed presentation of congenital diaphragmatic hernia. Pediatr Surg Int 2001;17:269-71.  Back to cited text no. 12
    
13.
Orita M, Okino M, Yamakashita K. Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni. Surg Endosc 1997;11:668-70.  Back to cited text no. 13
    
14.
Çiftci İ, Gündüz M. Çocukta diyafragmatik Morgagni Hernisinin laparoskopik onarımı. Genel Tip Dergisi,2012;22:112-4.  Back to cited text no. 14
    
15.
Stone ML, Julien MA, Dunnington GH Jr, Lau CL. Novel laparoscopic hernia of morgagni repair technique. J Thorac Cardiovasc Surg 2012;143:744-5.  Back to cited text no. 15
    
16.
Durak E, Gur S, Cokmez A, Atahan K, Zahtz E, Tarcan E. Laparoscopic repair of Morgagni hernia. Hernia 2007;11:265-70.  Back to cited text no. 16
    
17.
Johnson CD. Blunt injuries of the diaphragm. Br J Surg 1988;75:226-30.  Back to cited text no. 17
    
18.
Miller LW, Bennett EV, Root HD. Management of penetrating and blunt diaphragmatic injury. J Trauma 1984;24:403-9.  Back to cited text no. 18
    
19.
Arendrup HC, Jensen BK. Traumatic rupture of the diaphragm. Surg Gynecol Obstet 1980;154:526-30.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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