Diaphragmatic Hernia - Podcast Version 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x Diaphragmatic herniae are defects in the diaphragm that occur at anatomical points of weakness, and can be either congenital or acquired (traumatic). Left untreated, abdominal contents will herniate into the thorax. As such, diaphragmatic hernia need surgical repair. Acquired diaphragmatic hernia are most commonly causes by penetrating trauma and are beyond the remit of this article. This article will focus on congenital diaphragmatic hernias. By TeachMeSeries Ltd (2022) Figure 1View of the inferior surface of the diaphragm Pathophysiology Congenital diaphragmatic hernias are either Bochdalek hernia or Morgagni hernia. Bochdalek hernia are more common, occurring in 1 in 5000 births, and develop as a result of a defect in the posterior attachment of the diaphragm. They are more typically left sided and around one third of cases occur concurrently with other congenital abnormalities. Morgagni hernia are less common and occur as a result of herniation through the foramen of Morgagni (the space between xiphoid process and the costochondral attachments of diaphragm*). Compared to Bochdalek hernia, Morgagni hernia occur anteriorly and are more often right-sided. *This space is where the internal mammary artery passes through the diaphragm to become superior epigastric artery Clinical Features Whilst some congenital hernia may be asymptomatic, many will present in the perinatal period. If they occur in utero, pulmonary hypoplasia or respiratory compromise may be noted soon after birth, whilst in adults, features include dyspnoea, atypical chest pain, or clinical features of bowel obstruction. The majority of Bochdalek hernia in adults will be small and around 27% will contain abdominal organs such as liver, bowel or spleen. Similar clinical features can occur with Morgagni hernia Investigations In neonates, the mainstay of investigation is with the plain film erect chest radiograph (CXR), which will show bowel loops (or any other abdominal viscera) herniated into the thoracic cavity (Fig. 2) For adult patients, whilst initial diagnosis may be suspected on CXR, often CT imaging of the chest is performed (Fig. 3), as this is especially useful for pre-operative planning Kinderradiologie Olgahospital Klinikum Stuttgart, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons Figure 2CXR showing bowel loops in the thorax from a diaphragmatic hernia in a neonate Management Surgical repair for both types is the only curative option. Repairs can be done either laparoscopically or open, depending on both hernia and patient factors Intra-operatively, once the hernia is reduced and any hernia sac resected, the defect can be closed either through primary closure or with a mesh (depending on the defect location and size). JasonRobertYoungMD, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons Figure 3Sagittal CT chest scan demonstrating a Morgagni hernia (arrow) containing intra-abdominal fat Key Points Diaphragmatic herniae are defects in the diaphragm that occur at anatomical points of weakness and can be either congenital or acquired (traumatic) Congenital diaphragmatic hernias are either Bochdalek hernia or Morgagni hernia In utero, the can present with pulmonary hypoplasia or respiratory compromise, whilst in adults they can present with dyspnoea, atypical chest pain, or clinical features of bowel obstruction Surgical repair is the only treatment option available Frequent questions What is a diaphragmatic hernia? A diaphragmatic hernia is a defect in the diaphragm that allows abdominal contents to move into the thoracic cavity. These hernias can be congenital, arising from anatomical weaknesses, or acquired due to trauma. What are the types of congenital diaphragmatic hernias? The two main types of congenital diaphragmatic hernias are Bochdalek hernia and Morgagni hernia. Bochdalek hernias are more prevalent and typically occur on the left side, while Morgagni hernias are less common and usually present on the right side. What clinical features are associated with congenital diaphragmatic hernias? Congenital diaphragmatic hernias may be asymptomatic or present with significant symptoms, especially in the perinatal period. Symptoms can include respiratory distress in neonates and dyspnoea or atypical chest pain in adults. How are congenital diaphragmatic hernias diagnosed? In neonates, a plain film erect chest radiograph is the primary diagnostic tool, revealing herniated bowel loops in the thoracic cavity. For adults, a chest X-ray may suggest the diagnosis, but CT imaging is often used for more detailed pre-operative assessment. What is the treatment for congenital diaphragmatic hernias? Surgical repair is the only effective treatment for congenital diaphragmatic hernias. The procedure can be performed laparoscopically or via open surgery, depending on the specific characteristics of the hernia and the patient's condition. Rate This Article