Diaphragmatic Hernia

Auscultation of borborygma over the area of the lung field suggests the presence of a diaphragmatic hernia, but can be misleading. Standard radiography and ultrasonography procedures are diagnostic. Assume a hernia is present, and carefully manage the patient to minimize discomfort and further organ herniation until the patient is stable enough to allow definitive diagnosis of the hernia.

- Diaphragmatic hernia (DH) is usually not considered a surgical emergency unless the stomach is involved, or the patient’s condition deteriorates or fails to respond to conservative management. In most cases, the patient should be stabilized for shock and other organ injury, with definitive repair of the hernia at a later time. Most patients suffering trauma severe enough to rupture the diaphragm have other pulmonary injuries that would preclude anesthesia and intermittent positive pressure ventilation (IPPV) (e.g., contusions, pneumothorax).
- Emergent repair of a DH may be indicated. Repair is performed via a cranial ventral midline laparotomy, with retraction of the liver and stomach caudally, to afford optimal visualization.
- Some means of positive pressure ventilation is necessary intraoperatively.
- At least 1 thoracostomy tube should be placed intraoperatively and maintained for at least 24 hours post-operatively to manage pneumothorax.
- Generally, rents in the diaphragm due to trauma occur in the muscular portions of the diaphragm, and are readily repaired using a simple continuous suture closure.