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Giuffrida M, Perrone G, Abu-Zidan F, Agnoletti V, Ansaloni L, Baiocchi GL, Bendinelli C, Biffl WL, Bonavina L, Bravi F, Carcoforo P, Ceresoli M, Chichom-Mefire A, Coccolini F, Coimbra R, de'Angelis N, de Moya M, De Simone B, Di Saverio S, Fraga GP, Galante J, Ivatury R, Kashuk J, Kelly MD, Kirkpatrick AW, Kluger Y, Koike K, Leppaniemi A, Maier RV, Moore EE, Peitzmann A, Sakakushev B, Sartelli M, Sugrue M, Tian BWCA, Broek RT, Vallicelli C, Wani I, Weber DG, Docimo G, Catena F. Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper. World J Emerg Surg 2023; 18:43. [PMID: 37496073 PMCID: PMC10373334 DOI: 10.1186/s13017-023-00510-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
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.
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Affiliation(s)
| | - Gennaro Perrone
- Department of Emergency Surgery, Maggiore Hospital, Via A. Gramsci 14, 43126, Parma, Italy.
| | - Fikri Abu-Zidan
- Research Office, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Gian Luca Baiocchi
- General Surgery, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- Acute Care Surgery at The Queen's Medical Center, John A. Burns School of Medicine, University of Hawai'I, Honolulu, USA
| | - Luigi Bonavina
- Department of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, , Riverside, California, USA
| | - Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Marc de Moya
- Trauma/Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Department of General Surgery, San Benedetto del Tronto General Hospital, San Benedetto del Tronto, Italy
| | - Gustavo Pereira Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP, Brazil
| | - Joseph Galante
- Trauma Department, University of California, Davis, Sacramento, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Ernest Eugene Moore
- Department of Surgery, Denver Health Medical Center,, University of Colorado, Denver, CO, USA
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland
| | - Brian W C A Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Richard Ten Broek
- Surgery Department, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Imtaz Wani
- Department of Minimal Access and General Surgery, Government Gousia Hospital, Srinagar, India
| | - Dieter G Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Giovanni Docimo
- Department of Medical and Advanced Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
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Garcia EM, Pietryga JA, Kim DH, Fowler KJ, Chang KJ, Kambadakone AR, Korngold EK, Liu PS, Marin D, Moreno CC, Panait L, Santillan CS, Weinstein S, Wright CL, Zreloff J, Carucci LR. ACR Appropriateness Criteria® Hernia. J Am Coll Radiol 2022; 19:S329-S340. [PMID: 36436960 DOI: 10.1016/j.jacr.2022.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Evelyn M Garcia
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; Board Member, Taubman Museum of Art.
| | - Jason A Pietryga
- Division Chief, Emergency Radiology at UNC Chapel Hill, Chapel Hill North Carolina; and University of Alabama at Birmingham, Birmingham, Alabama
| | - David H Kim
- Panel Chair, University of Wisconsin Hospital & Clinics, Madison, Wisconsin; and Vice-Chair of Education, University of Wisconsin Department of Radiology
| | - Kathryn J Fowler
- Panel Vice-Chair, University of California San Diego, San Diego, California; Chair ACR LI-RADS; Division Chief, SAR Portfolio Director, RSNA Radiology Senior Deputy Editor
| | - Kevin J Chang
- Boston University Medical Center, Boston, Massachusetts; Section Chief of Abdominal Imaging, Director of MRI, Chair of Committee on C-RADS
| | - Avinash R Kambadakone
- Massachusetts General Hospital, Boston, Massachusetts; Division Chief, Abdominal Imaging, Massachusetts General Hospital and Medical Director, Martha's Vineyard Hospital Imaging
| | - Elena K Korngold
- Section Chief, Body Imaging/Chair, Department of Radiology Promotion and Tenure Committee; Oregon Health and Science University, Portland, Oregon
| | - Peter S Liu
- Section Head, Abdominal Imaging, Cleveland Clinic, Cleveland, Ohio
| | - Daniele Marin
- Duke University Medical Center, Durham, North Carolina
| | | | - Lucian Panait
- President, Minnesota Hernia Center, Minneapolis, Minnesota; American College of Surgeons; American Hernia Society (member of the Technology and Value Assessment Committee); Practice Advisory Committee Member, American Hernia Society
| | - Cynthia S Santillan
- Vice-Chair of Clinical Operations, Department of Radiology, University of California San Diego, San Diego, California
| | | | | | - Jennifer Zreloff
- Georgia, Primary Care Physician, Emory University, Atlanta, Georiga; Medical Director, Seavey General Medicine Clinic; Assistant Director of Innovation Seavey Comprehensive Internal Medicine Clinic, Emory University, Atlanta, Georgia
| | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia; Section Chief Abdominal Imaging, Director of MRI and CT
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Mohamed M, Al-Hillan A, Shah J, Zurkovsky E, Asif A, Hossain M. Symptomatic congenital Morgagni hernia presenting as a chest pain: a case report. J Med Case Rep 2020; 14:13. [PMID: 31952551 PMCID: PMC6969475 DOI: 10.1186/s13256-019-2336-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background Morgagni hernia is a rare form of congenital diaphragmatic hernia with a prevalence of 2–3%. It occurs due to a defect on the anterior part of the diaphragm, which allows abdominal organs to penetrate into the thoracic cavity. This condition can be detected during fetal life by routine ultrasonography or late during adult life. Late diagnosis of this condition in adults is extremely rare. According to our literature search, only a few cases of symptomatic hernia in adults have been reported so far. Surgery provides definitive treatment for patients with Morgagni hernia; it is always recommended for symptomatic and asymptomatic adult patients to avoid future complications such as volvulus, small bowel obstruction, incarceration, or strangulation. We report a case of a patient who presented with chest pain due to newly diagnosed congenital diaphragmatic hernia. Case presentation A 29-year-old unemployed white man with no significant past medical history or family history of coronary artery disease, who was a current smoker with a 1-pack-per-day history, presented to our hospital with a 1-month history of intermittent chest pain. His chest pain was localized to the right side with a pressure-like quality, moderate intensity 4–6/10, nonradiating, and relieved by standing up and worsened by lying flat. His pain was not associated with increase or decrease in activity level. The pain had progressively worsened, which prompted the patient to come to the emergency room. The patient was admitted for further evaluation. A chest x-ray showed a suspected loop of bowel on the right side of the chest. Subsequently, the patient underwent computed tomography of the chest, which revealed a 7-cm defect in the right hemidiaphragm with a large amount of intra-abdominal fat and a loop of the proximal transverse colon within the hernial sac. The patient was evaluated by a surgeon and eventually underwent laparoscopic repair of the diaphragmatic hernia with mesh repair. In follow-up, the patient’s symptoms resolved. Conclusion Morgagni hernia is a rare form of congenital diaphragmatic hernia. It is commonly found either in the first few hours of life or in the antenatal period. It is less common in adults and is usually diagnosed accidentally in asymptomatic patients. Symptomatic adult cases are extremely rare. Respiratory symptoms are the most common presenting symptoms. The primary management for both symptomatic and incidentally discovered asymptomatic cases of Morgagni hernia is surgical correction. Various thoracic and abdominal surgical approaches have been described without a clear consensus on preference for operative repair technique.
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Affiliation(s)
- Mujtaba Mohamed
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA.
| | - Alsadiq Al-Hillan
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Jay Shah
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Eugene Zurkovsky
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Arif Asif
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Mohammad Hossain
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
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