Research: Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

World J Emerg Surg

. 2023 Jul 26;18(1):43.

 doi: 10.1186/s13017-023-00510-x.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

Mario Giuffrida 1Gennaro Perrone 2Fikri Abu-Zidan 3Vanni Agnoletti 4Luca Ansaloni 5Gian Luca Baiocchi 6Cino Bendinelli 7Walter L Biffl 8Luigi Bonavina 9Francesca Bravi 10Paolo Carcoforo 11Marco Ceresoli 12Alain Chichom-Mefire 13Federico Coccolini 14Raul Coimbra 15Nicola de’Angelis 16Marc de Moya 17Belinda De Simone 18Salomone Di Saverio 19Gustavo Pereira Fraga 20Joseph Galante 21Rao Ivatury 22Jeffry Kashuk 23Michael Denis Kelly 24Andrew W Kirkpatrick 25Yoram Kluger 26Kaoru Koike 27Ari Leppaniemi 28Ronald V Maier 29Ernest Eugene Moore 30Andrew Peitzmann 31Boris Sakakushev 32Massimo Sartelli 33Michael Sugrue 34Brian W C A Tian 35Richard Ten Broek 36Carlo Vallicelli 4Imtaz Wani 37Dieter G Weber 38Giovanni Docimo 39Fausto Catena 4

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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.

Keywords: Congenital; Diaphragm hernia; Emergency surgery; Guidelines; Rupture; Trauma.

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