Maternal diaphragmatic hernia in pregnancy:A systematic review with a treatment algorithm

BACKGROUND Diaphragmatic hernia(DH)is extremely rarely described during pregnancy.Due to the rarity,there is no diagnostic or treatment algorithm for DH in pregnancy.AIM To summarize and define the most appropriate diagnostic methods and therapeutic options for DH in pregnancy based on scarce literature.METHODS Literature search of English-,German-,Spanish-,and Italian-language articles were performed using PubMed(1946–2021),PubMed Central(1900–2021),and Google Scholar.The PRISMA protocol was followed.The search terms included:Maternal diaphragmatic hernia,congenital hernia,pregnancy,cardiovascular collapse,mediastinal shift,abdominal pain in pregnancy,hyperemesis,diaphragmatic rupture during labor,puerperium,hernie diaphragmatique maternelle,hernia diafragmática congenital.Additional studies were identified by reviewing reference lists of retrieved studies.Demographic,imaging,surgical,and obstetric data were obtained.RESULTS One hundred and fifty-eight cases were collected.The average maternal age increased across observed periods.The proportion of congenital hernias increased,while the other types appeared stationary.Most DHs were left-sided(83.8%).The median number of herniated organs declined across observed periods.A working diagnosis was correct in 50%.DH type did not correlate to maternal or neonatal outcomes.Laparoscopic access increased while thoracotomy varied across periods.Presentation of less than 3 days carried a significant risk of strangulation in pregnancy.CONCLUSION The clinical presentation of DH is easily confused with common chest conditions,delaying the diagnosis,and increasing maternal and fetal mortality.Symptomatic DH should be included in the differential diagnosis of pregnant women with abdominal pain associated with dyspnea and chest pain,especially when followed by collapse.Early diagnosis and immediate intervention lead to excellent maternal and fetal outcomes.A proposed algorithm helps manage pregnant women with maternal DH.Strangulated DH requires an emergent operation,while delivery should be based on obstetric indications.

Right Post-Traumatic Diaphragmatic Hernia with Liver Dislocation

Diaphragmatic hernia is a rare consequence of thoraco-abdominal trauma. It may be associated with high morbidity and mortality, particularly if surgical intervention is delayed. We report a case of a right diaphragmatic hernia in a 75-year-old woman. The patient was referred to our hospital with mild dyspnea. Chest radiograph showed an overtly elevated right hemi-diaphragm. Thoracic and abdominal computed tomographic scan was requested and showed a defect of the right diaphragmatic muscle wall with intrathoracic ascension of the liver. During the postoperative course, the patient was still on mechanical ventilation, hemodynamically unstable. She developped urinary peritonitis and an extensive bowel ischemia worsening. We report this case to show that the prognosis is related to associated injuries and possible complications. The possibility of a diaphragmatic rupture should be kept in mind and surgery is mandatory in order to avoid complications.

Diaphragmatic hernia after right donor and hepatectomy: a rare donor complication of partial hepatectomy for transplantation

BACKGROUND: Because of the critical worldwide shortage of cadaveric organ donors, transplant professionals have increasingly turned to living donors. Partial hepatectomy for adult living donor liver transplantation has been performed since the late 1990s. Most often,the complications of living donor hepatectomy have been related to the biliary tract, specifically biliary leaks. METHODS: A 54-year-old man underwent donor right hepatectomy for living donor liver transplantation. Three years after liver donation he presented with upper abdominal pain and fullness. Radiographic workup revealed a diaphragmatic hernia of the right hemithorax. RESULTS: After thoracoscopic evaluation of the right hemithorax, diaphragmatic hernia was repaired. Currently the patient remains well several months after the repair with complete resolution of abdominal pain, normal chest X-ray examination demonstrating no recurrence of diaphragmatic hernia, and normal liver functions tests. CONCLUSIONS: Multiple complications of living donor liver transplantation have been described the transplant literature. Diaphragmatic hernia is a formerly-undescribed complication of right donor hepatectomy for transplantation.

Non-traumatic diaphragmatic hernia of the liver in an adult:a case report

BACKGROUND: Diaphragmatic hernia of the liver is a rare clinical entity, usually found after trauma in adults. This study was undertaken to elucidate a misdiagnosis of non-traumatic diaphragmatic hernia of the liver in an adult. METHOD: The clinical data of one patient with non-traumatic diaphragmatic hernia of the liver was analyzed. RESULTS: A tumor in the right lower thorax was revealed by chest X-ray and computed tomography. Non-traumatic diaphragmatic hernia of the liver was not identified until the operation. Pathological analysis confirmed the finding. The patient recovered well. CONCLUSIONS: Non-traumatic diaphragmatic hernia of the liver in an adult is a rare right-sided diaphragmatic hernia, which can move up into the chest cavity. It should be distinguished from lung cancer. The diagnosis and evaluation of non-traumatic diaphragmatic hernia of the liver can help optimize surgical management.

Laparoscopic repair of diaphragmatic hernia associating with radiofrequency ablation for hepatocellular carcinoma:A case report

BACKGROUND Radiofrequency ablation(RFA)is an effective treatment for early-stage hepatocellular carcinoma(HCC).Although RFA is a relatively safe technique compared with surgery,several complications have been reported to be following/accompanying this treatment.Delayed diaphragmatic hernia caused by RFA is rare;however,the best surgical approach for its treatment is uncertain.We present a case of laparoscopic repair of diaphragmatic hernia due to RFA.CASE SUMMARY An 80-year-old woman with segment VIII HCC was treated twice in 5 years with RFA;28 mo after the second RFA,the patient complained of right hypochondriac pain.Computed tomography revealed that the small intestine was incarcerated in the right thorax.The patient was diagnosed with diaphragmatic hernia and underwent laparoscopic repair by non-absorbable running sutures.The patient’s postoperative course was favorable,and the patient was discharged on postoperative day 12.The diaphragmatic hernia has not recurred 24 mo after surgery.CONCLUSION Laparoscopic treatment of iatrogenic diaphragmatic hernia is effective and minimally invasive.

Traumatic diaphragmatic hernia associated with pelvic fractures: a case report and literature review

Objective： To review the epidemiological feature, clinical, and diagnostic data of post-traumatic diaphragmatic hernia （TDH） associated with pelvic fractures patients reported in recent 10 years. Methods： One case of delayed presentation of TDH after pelvic fractures taken place one month later was present, with a review on the literature of this kind of patients in our country. Results： The incidence of TDH associated with pelvic fractures was relatively rare, and the diagnosis were often delayed or missed. Although the trans-thorax approach was preferred for surgical closure in the acute phase, its mortality was 8.51%. Conclusion： TDH associated with pelvic fractures is difficult to diagnose because of their varied clinical and radiological signs and the patients may not present with symptoms for a long time following the injury. In clinical, a high index of suspicion with appropriate examination is the mainstays of management, which can also increase the prognosis.

Early diagnosis and management of Congenital diaphragmatic hernia

This case report describes the case of a full term girl baby with left congenital diaphragmatic hernia(CDH)born to a 36-year-old mother at 38 weeks of gestation.The baby at birth had an APGAR 8 and birth weight 2.930 kgs.Pre operatively,the baby was ventilated and was kept Nil per oral and continued with Total parenteral nutrition.Nasogastric tube continuous suction was done.The parents were counselled for the surgical repair of CDH.On the third day of life,exploratory laparotomy was performed.5 cm diaphragmatic defect was found.The stomach,pancreas,small bowel,large bowel,and spleen were successfully restored from the left thoracic cavity and the diaphragmatic defect was closed.Post operatively,the baby was breastfed well,thermo regulated,maintained saturation,passed urine and stool and was discharged.

Laparoscopic reduction and repair of acute traumatic diaphragmatic hernia:A video review

Traumatic diaphragmatic hernia is one of the sequela of thoraco-abdominal injury,occurring in about 0.5%-5% of patients presenting post major trauma.Motor vehicle collision is the leading blunt trauma etiology.A high level of suspicion is essential to discover such injuries,as a majority of the patients can be asymptomatic.A case of a successful trans-abdominal laparoscopic reduction and repair of a large acute traumatic diaphragmatic hernia is presented as a video demonstration.We were able to evacuate all intrathoracic air,obliviating the need for a chest tube.Post operatively the patient did well with no complications.If expertise is available,laparoscopic intervention is a feasible option even for large traumatic diaphragmatic hernia preventing the need for a large midline laparotomy incision.

Post-Traumatic Right Diaphragmatic Hernia with Hepatothorax

Introduction: Traumatic right diaphragmatic hernia is an extremely rare entity, given the protection afforded by the liver. Clinical Case: A 51-year-old women who suffered a road-traffic accident presented with a heavy sensation and several episodes of moderate pain in the left hemithorax. Physical and radiological exams revealed a traumatic right hernia. Discussion: The diagnosis of hernia should be established as quickly as possible to reduce morbidity and mortality. Treatment of the injury is always surgical and outcome is invariably positive. Conclusion: The diagnosis of diaphragmatic hernia should always be considered in patients suffering road-traffic accidents to allow early diagnosis and successful treatment.

Post Traumatic Diaphragmatic Hernia Revealing a Colonic Tumor

Post traumatic diaphragmatic injuries have long been known. However their varied clinical, expressions lead to difficulties which cause its delay. The occurrence of herniation of hollow viscera in the thoracic cavity followed by its necrosis or perforation, is a delayed complication, a rare entity with a poor prognosis. The discovery of a colonic tumor in a diaphragmatic hernia is an exceptional clinical circumstance. Here we report the case of a patient with a complicated diaphragmatic hernia, whose symptoms are precipitated by the presence of a colon stenosing tumor. The management consisted of an exclusive laparotomy had allowed dealing in one surgical intervention with both the abdominal and thoracic injuries.

Radiofrequency Ablation-Associated Delayed Diaphragmatic Hernia Treated with the Thoracolaparotomy Approach: A Case Report

Background: Radiofrequency ablation (RFA) is an effective treatment for hepatocellular carcinoma (HCC). However, rare but serious complications may occur after RFA. We describe a case of diaphragmatic hernia associated with RFA. Case Presentation: A 68-year-old man with a history of hepatitis C-related liver cirrhosis was admitted to our hospital because of lower abdominal pain. Three years earlier, he underwent RFA for HCC in segment 8. Computed tomography revealed that the intestine was intruding into the right thoracic cavity through a diaphragmatic hernia. On the basis of the diagnosis of right diaphragmatic hernia with a strangulated ileus, an emergency operation was performed. Perforation of the strangulated transverse colon into the right thoracic cavity was suspected, and a combined approach of laparotomy and thoracotomy was utilized. The operative findings showed that the diaphragmatic hernia was 3.5 × 2.0 cm in diameter, and it was simply sutured with a nonabsorbable suture material. Resection of the intruded ischemic transverse colon was completed, and a covering ileostomy was performed. The patient was discharged without any complications. Conclusions: RFA is widely used for the treatment of HCC. Reports of early- and late-phase complications indicate that heat damage contributes to the fragility of neighboring organs. The occurrence of diaphragmatic hernia after RFA is one of the delayed complications. Although it rarely occurs, this complication requires emergency surgery. In conclusion, if perforation of the intestine into the thoracic cavity is suspected, thoracolaparotomy should be considered as a treatment option to prevent postoperative massive empyema.

Ultrasound diagnosis of congenital Morgagni hernias: Ten years of experience at two Chinese centers

BACKGROUND Morgagni hernias are rare anomalies that are easily misdiagnosed or missed.AIM To summarize the ultrasound(US)imaging characteristics of Morgagni hernias through a comparison of imaging and surgical results.METHODS The records of children with Morgagni hernias who were hospitalized at two hospitals between January 2013 and November 2023 were retrospectively re-viewed in terms of clinical findings,US features,and operative details.RESULTS Between 2013 and 2023,we observed nine(five male and four female)children with Morgagni hernias.Upper abdominal scanning revealed a widening of the prehepatic space,with an abnormal channel extending from the xiphoid process to the right or left side of the thoracic cavity.The channel had intestinal duct and intestinal gas echoes.Hernia contents were found in the transverse colon(n=6),the colon and small intestine(n=2),and the colon and stomach(n=1).Among the patients,seven had a right-sided lesion,two had a left-sided lesion,and all of them had hernial sacs.CONCLUSION US imaging can accurately determine the location,extent,and content of Morgagni hernias.For suspected Mor-gagni hernias,we recommend performing sonographic screening first.

Delayed right-sided diaphragmatic hernia with severe ：raniocerebral trauma

Diaphragmatic hernia （DH） is an uncommon result of trauma, but presents a severe problem in patients With multiple injuries. Right-sided DH is rare, owing to the protection of the liver and strength of the right hemidiaphragm. Here we present a case of delayed right-sided DH with severe craniocerebral trauma.

Antenatal use of bosentan and/or sildenafil attenuates pulmonary features in rats with congenital diaphragmatic hernia

Background:Lung hypoplasia,pulmonary persistent hypertension of the newborn and its morphological changes are the main features in congenital diaphragmatic hernia(CDH).This study was undertaken to investigate if antenatal use of sildenafil and/or bosentan attenuates vascular remodeling,promotes branching,and improves alveolarization in experimental nitrofeninduced CDH.Methods:Nitrofen(100 mg)was gavage-fed to pregnant rats at post conception day(PCD)9 to induce CDH.The rats were randomized to 5 groups:1)control;2)nitrofen;3)nitrofen+sildenafil 100 mg/kg per day at PCD 16-20;4)nitrofen+bosentan 30 mg/kg per day,at PCD 16-20,and 5)nitrofen+bosentan+sildenafil,same doses and administration days.After cesarean delivery,the offsprings were sacrifi ced.The diaphragmatic defect and pulmonary hypoplasia were identified,and the lungs were dissected.Arterial wall thickness,bronchiolar density and alveolarization were assessed.Results:The offsprings with CDH were characterized by severe pulmonary hypoplasia(lung weight-to-body weight ratio:0.0263[95%confidence interval(CI)0.0242-0.0278)]in the nitrofen group versus 0.0385(95%CI 0.0355-0.0424)in the control group(P=0.0001).Pulmonary arterial wall thickness was decreased to 3.0(95%CI 2.8-3.7)μm in the nitrofen+sildenafil group versus 5.0(95%CI 4.1-4.9)μm in the nitrofen group(P=0.02).Terminal bronchioles increased to 13.7(95%CI 10.7-15.2)μm in the nitrofen+bosentan group in contrast to 8.7(95%CI 7.2-9.4)μm in the nitrofen group(P=0.002).More significant differences(P=0.0001)were seen in terminal bronchioles in the nitrofen+sildenafil+bosentan group than in the nitrofen group[14.0(95%CI 12.5-15.4)μm versus 8.5(95%CI 7.1-9.3)μm].Pulmonary arterial wall thickness was also decreased in the former group.Conclusions:In this rat model,antenatal treatment with sildenafil attenuates vascular remodeling.Bosentan promotes the development of terminal bronchioles in nitrofen-induced CDH.

Adult congenital diaphragmatic hernia of the liver: a rare case report

Congenital diaphragmatic hernia (CDH), which mainly occurs in the newborn or in childhood with severe respiratory distress and high mortality, is rarely found in adult, especially for those uncommon right CDH [1–4]. Whereas, liver as the main

Combination of congenital cleft lip and palate with congenital diaphragmatic hernia: a severe disease course

Congenital cleft lip and palate （CLP） is the most ＇common birth defect now in China. The incidence is 1.62%0 according to the data （1988-- 1992） provided by the National Center for Birth Defects Monitoring. It is also one of the congenital anomalies that have excellent prognosis. But severe complications may occur in the cases accompanied some other deformities. Here we report a case of death caused by left-sided posterolateral congenital diaphragmatic hernia （CDH）, type Bochdalek, after the cleft operation.

Predicting Perinatal Outcomes in Fetuses with Congenital Diaphragmatic Hernia Using Ultrasound and Magnetic Resonance Imaging

Congenital diaphragmatic hernia is a congenital fetal disease,which mainly causes pulmonary hypoplasia and pulmonary hypertension.Effective early prenatal diagnosis can detect and predict the prognosis of congenital diaphragmatic hernia in infants,thus provide a reference for prenatal counseling,early intervention,and potential choices for the child’s family.Ultrasound and magnetic resonance imaging are the most commonly used methods for non-invasive examination of the fetus.This paper discusses evaluation parameters based on these two imaging modalities.

Successful management of incarcerated Morgagni＇s diaphragmatic hernia in a 62-year-old man

Morgagni＇s hernia is a rare type of diaphragmatic hernia. It is hardly developed to an incarceratedhernia. It is often misdiagnosed as pneumothorax or effusion. Computed tomography and upper GI contrast studies make contribution to the diagnosis. Transabdominal approach or laparoscopy and thoracoscopy are efficient therapies for the hernia.

Angiotensin converting enzyme inhibitor associated spontaneous herniation of liver mimicking a pleural mass:A case report

BACKGROUND Spontaneous diaphragmatic herniation of the liver is a rare entity.It may mimic pulmonary mass especially in the absence of trauma.Cough is a common side effect of angiotensin converting enzyme(ACE)inhibitors that may cause diaphragmatic rupture due to a sudden increase in trans-diaphragmatic pressure.We present a case of ACE-inhibitor associated spontaneous herniation of the liver mimicking pleural mass.CASE SUMMARY An 80-year-old woman presented with dry cough for 1 mo and sudden onset of cramping abdominal pain for 1 d.She denied history of trauma,prior surgeries,smoking,alcohol or illicit drug use.She has a history of diabetes and was started on an ACE inhibitor 6 mo ago for the management of hypertension.Examination was remarkable for right upper quadrant tenderness.Lab work-up was unremarkable.Chest X-ray showed a right lower lung opacity suspecting right pleural mass.Chest computed tomography scan ruled out pleural mass,however,revealed herniated right lobe of the liver(3.9 cm×3.6 cm×3.4 cm)into the thoracic cavity through the posterolateral diaphragmatic defect.Laparoscopic repair of the diaphragmatic defect was performed and the ACE inhibitor was stopped.Patients’symptoms had completely resolved on follow-up.CONCLUSION ACE inhibitor-associated cough may cause diaphragmatic liver herniation mimicking pleural mass.Early diagnosis,surgical repair and addressing the triggering factors improve patients’outcomes.

Surgically treated diaphragmatic perforation after radiofrequency ablation for hepatocellular carcinoma

We review 6 cases of diaphragmatic perforation, with and without herniation, treated in our institution. All patients with diaphragmatic perforation underwent radiofrequency ablation(RFA) treatments for hepatocellular carcinoma(HCC) performed at Kurume University Hospital and Tobata Kyoritsu Hospital. We investigated the clinical profiles of the 6 patients between January 2003 and December 2013. We further describe the clinical presentation, diagnosis, and treatment of diaphragmatic perforation. The change in the volume of liver and the change in the Child-Pugh score from just after the RFA to the onset of perforation was evaluated using a paired t-test. At the time of perforation, 4 patients had herniation of the viscera, while the other 2 patients had no herniation. The majority of ablated tumors were located adjacent to the diaphragm, in segments 4, 6, and 8. The average interval from RFA to the onset of perforation was 12.8 mo(range, 6-21 mo). The median Child-Pugh score at the onset of perforation(8.2) was significantly higher compared to the median Child-Pugh score just after RFA(6.5)(P = 0.031). All patients underwent laparotomy and direct suture of the diaphragm defect, with uneventful post-surgical recovery. Diaphragmatic perforation after RFA is not a matter that can be ignored. Clinicians should carefully address this complication by performing RFA for HCC adjacent to diaphragm.