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COMMENTARY |
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Year : 2016 | Volume
: 9
| Issue : 5 | Page : 668-669 |
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Complications of acquired diaphragmatic hernia
Hasan Ekim1, Meral Ekim2
1 Department of Cardiovascular Surgery, Bozok University School of Medicine, Yozgat, Turkey 2 Department Nutrition and Dietetic, Bozok University School of Health, Yozgat, Turkey
Date of Web Publication | 13-Oct-2016 |
Correspondence Address: Hasan Ekim Department of Cardiovascular Surgery, Bozok University School of Medicine, Adnan Menderes Bulvarı, Adliye karısı, Yozgat Turkey
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.192137
How to cite this article: Ekim H, Ekim M. Complications of acquired diaphragmatic hernia. Med J DY Patil Univ 2016;9:668-9 |
The diaphragm is the second most important muscle after the myocardium and comprises the major muscle of respiration. Diaphragmatic rupture leads to a challenging situation requiring surgical repair.[1] It separates the abdominal cavity from the thoracic cavity, thus traumatic injury to either cavity may cause the diaphragmatic hernia. The diaphragmatic hernia is a herniation of abdominal viscera within the pleural space through a diaphragmatic defect; it can be either acquired or congenital.[2] Acquired hernias are most commonly traumatic in origin and may be due to penetrating or blunt thoracoabdominal trauma. Rarely, spontaneous acquired hernia without any symptom may be occurred.[3]
The pressure gradient between the thoracic and abdominal cavities, which may reach up to 100 mmHg during respiration, is the most effective factor contributing to herniation of abdominal contents to the thoracic cavity.[4] Therefore, even a minimal diaphragmatic tear may also result in diaphragmatic hernia.
When severe gastric dilatation occurred, it may cause increased intra-abdominal pressure leading to the abdominal compartment syndrome. Acute renal insufficiency is one of the most important presentations of the abdominal compartment syndrome. As intra-abdominal pressure increases, glomerular filtration rate decreases and oliguria and even anuria may occur.[5] Increased abdominal pressure may be an underlying mechanism in the development of renal dysfunction in these cases. Acute renal dysfunction is quickly reversed by gastric decompression in most cases.[5] In these cases, biochemical parameters should be monitored closely.
Although chest radiograph remains valuable in the acute phase for the diagnosis, computed tomography examination should be done to evaluate intrathoracic and intraabdominal organs.
In patients with diaphragmatic hernia, surgical repair should not be delayed as any delay might cause complications such as volvulus formation, incarceration, strangulation, hemorrhage, and even perforation of a hollow visceral organ.[3]
The management of diaphragmatic hernia consists of reducing the herniated organs to the abdominal cavity and repairing the diaphragmatic defect either by open surgical methods (thoracotomy, laparotomy, or both) or by minimal access surgery.[3] Laparotomy incision is a preferred approach and allows a complete exploration of the entire abdominal space for any associated injury. However, thoracotomy should be preferred in late cases to safely separate the intrathoracic adhesions.[6] The diaphragmatic defect should be repaired using interrupted nonabsorbable polypropylene sutures after reduction of the herniated abdominal organs.[7] Rarely, prosthetic patch graft may be required.
The diaphragm is in a constant state of movement during respiration. Therefore, diaphragmatic ruptures almost never heal without repair.[8] Therefore, surgical correction should be performed immediately in these cases as reported in an article (a case of hiatal hernia presented with acute renal injury) published in this issue of the journal.
References | | |
1. | Haciibrahimoglu G, Solak O, Olcmen A, Bedirhan MA, Solmazer N, Gurses A. Management of traumatic diaphragmatic rupture. Surg Today 2004;34:111-4. [ PUBMED] |
2. | de Meijer VE, Vles WJ, Kats E, den Hoed PT. Iatrogenic diaphragmatic hernia complicating nephrectomy: Top-down or bottom-up? Hernia 2008;12:655-8. [ PUBMED] |
3. | Gupta S, Bali RK, Das K, Sisodia A, Dewan RK, Singla R. Rare presentation of spontaneous acquired diaphragmatic hernia. Indian J Chest Dis Allied Sci 2011;53:117-9. [ PUBMED] |
4. | İçme F, Vural S, Tanrıverdi F, Balkan E, Kozacı N, Kurtoğlu GÇ. Spontaneous diaphragmatic hernia: A case report. JAEM 2014;13:209-11. |
5. | Peces R, Vega C, Peces C, Trébol J, González JA. Massive gastric dilatation and anuria resolved with naso-gastric tube decompression. Int Urol Nephrol 2010;42:831-4. |
6. | 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;33:1082-5. [ PUBMED] |
7. | Peer SM, Devaraddeppa PM, Buggi S. Traumatic diaphragmatic hernia-our experience. Int J Surg 2009;7:547-9. [ PUBMED] |
8. | Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg 2001;20:53-7. [ PUBMED] |
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