Diaphragmatic Hernia

A 67-year-old man presented to the emergency department with flank pain of 4 days’ duration. A right obstructing ureteric calculus, acute renal failure, and “perinephric reaction” were diagnosed. Preoperative medical consultation revealed a history of a motor vehicle accident with diaphragmatic eventration, probable vocal cord paralysis, and dysphonia. The patient had no other significant past medical history. He had undergone recent outpatient stress echocardiography, which was negative, and he reported that he was able to perform vigorous daily aerobic exercise without difficulty.

A preoperative ECG was unremarkable. The preoperative chest radiograph (A) demonstrated abnormalities consisting of pulmonary encroachment by expansion of a diaphragmatic hernia. The patient was medically stable for surgery, and perioperative airway management recommendations were conveyed that advised the avoidance of bag mask ventilation and use of a laryngeal mask. The patient was taken to the operating room for a ureteral stone removal under general anesthesia. Multiple attempts at endotracheal intubation were unsuccessful, and ultimately a #5 laryngeal mask airway (LMA) was placed. The patient tolerated cystoscopy with stone extraction and was discharged home later in the day.

He returned to the emergency department with complaints of worsening shortness of breath. A radiograph (B) and CT scan (C) demonstrated atelectasis of the right lung with opacified loops of bowel in the thorax. The patient was taken for emergent laparotomy, reduction, and repair of a diaphragmatic hernia. He underwent intraoperative colonoscopy and cecostomy tube placement for bowel decompression. Postoperatively, the patient developed a deep venous thrombosis that required anticoagulation and a prolonged ileus that required total parenteral nutrition. He was ultimately discharged on warfarin and wound care for his colostomy.

A paucity of literature in either the pediatric or adult disciplines exists regarding perioperative risk and management of diaphragmatic hernias. Extrapolation from neonatal practice with congenital hernias led to our recommendations to decompress the stomach and avoid bag mask ventilation or LMA. Recent American College of Physicians risk assessment guidelines were designed to reduce postoperative pulmonary complications in patients undergoing surgery; however, they lack recommendations for management of diaphragmatic hernias. Review of the literature did not identify randomized studies and only disclosed a few case reports with various anecdotal recommendations.^1,2 One of the case reports involved a patient who had a diaphragmatic injury and underwent an elective lumbar laminectomy. The patient tolerated the procedure well, undergoing perioperative prophylactic GI decompression, endotracheal intubation, and positioning to allow the abdomen to be freely dependent.²

Literature suggests that traumatic diaphragmatic hernias are relatively common and occur in 5% to 10% of patients who are involved in motor vehicle accidents or who sustain penetrating trauma. We recommend a low threshold for obtaining a preoperative chest radiograph based on risk assessment, history of chest trauma, or severe reflux symptoms. In addition, empiric nasogastric tube insertion, perioperative antacids, and avoidance of prolonged bag valve mask or LMA are strategies that may decrease postoperative pulmonary complications in patients with untreated diaphragmatic hernias.