DIAPHRAGMATIC AND

HIATAL HERNIA
A diaphragmatic hernia is a birth defect in
which there is an abnormal opening in the
diaphragm

 The opening allows part of the organs from

the abdomen to move into the chest cavity
near the lungs.
 A congenital Diaphragmatic hernia (CDH) is due to the
abnormal development of the diaphragm while the fetus
is forming.

 It’s a rare defect

 More common on the left side

Classification
Classic Clinical Presentation
 Severe respiratory distress, cyanosis, vomit
 Breath sounds: diminished on the side of hernia
 Heart sounds: deviated to the contralateral side
 Scaphoid abdomen
How is a CDH Diagnosed?
 After Birth: Physical Examination
 Chest x-ray with NGT
 CT scan
 Arterial blood gas test
 USG
Management
 Prenatal care

 Preoperative care
◦ Resuscitation
◦ Ventilation
◦ Pharmacology
◦ Surfactant
◦ Nitric Oxide

 Surgical Management
◦ Circulatory stability, respiratory mechanics and gas exchange deteriorate after surgical
repair.

◦ Repair 24 hours after stabilization is ideal but delays of up to 7-10 days are typically
well tolerated.
Surgical Repair Approaches
 Abdominal subcostal
A subcostal incision is made and the abdominal viscera are examined. The
hernia is reduced back by gentle traction and a hernia sac is sought and excised
if found.

After careful dissection of posterior leaf primary repair can be accomplished in a

single layer with non absorbable sutures.

 Small defects can be repaired primarily

 Large defects will require abdominal or thoracic muscle

flaps, or prosthetic patch (tension free).
 Thoracotomy
It typically allows reduction of the liver and viscera back into the
abdomen with excellent exposure of the diaphragm

 Laparoscopic vs Thoracoscopic
a) Minimal Invasive surgery ideal for Morgagni hernias but can be
challenging because the peumoperitoneum widens the defects.
b) Laparoscopically for Bochdalek’s has a high failure rate and is
associated with increase pCO2 and acidemia
c) Contraindicated if very high pCO2
d) Thoracoscopy is better approach for Bochdalek hernia with recurrence of
14%. Open approach 3-22%.
CDH Complications
 CDH recurrence
 Respiratory issues
 Susceptibility to RSV
 Pulmonary HTN
 GIT Issues ( Gerd, Abdominal pain, Appendicitis,

bowel obstruction etc).

HIATAL HERNIA
Types Of Hiatal Hernia
Type1: Sliding Hiatal Hernia
Herniation of both the stomach and the gastro esophageal junction into
the thorax
90% of esophageal hernias
Type 2: Para esophageal Hiatal Hernia
Herniation of all or part of the stomach through the esophageal hiatus into
the thorax with an un displaced GE junction
Least common <10%
Type 3:Combination of type 1 and type 2.
Type 4: Abdominal organs herniate into chest cavity
Clinical Presentation
 Maybe Asymptomatic
 Anemia
 Heartburn
 Chest pain
 Regurgitation
 Chronic cough
Work Up
 Usually an incidental finding
 Barium Swallow
 Chest X-ray
 CT scan/ MRI
 Upper Endoscopy
 Esophageal Manometry
 Ambulatory pH testing
Management
 Sliding Hiatal Hernia
a) Surgical repair of an isolated Type 1 hiatal hernia is usually not
needed.
b) Mainly treat associated GERD with PPIs , Lifestyle
modification, weight loss.
c) If s/s persists despite maximal medical tx, sugery may be
considered.