Diaphragmatic Hernia Repair: Surgical Approach and Specialty Selection

Surgical Approach by Hernia Type and Patient Condition

For complicated diaphragmatic hernias in unstable patients or those with signs of strangulation/perforation, the abdominal approach (laparotomy) is recommended, typically performed by a general surgeon 1, 2
In stable patients with complicated diaphragmatic hernias, a minimally invasive approach (laparoscopic) is suggested, which can be performed by either general or thoracic surgeons 1, 3
For chronic hernias with viscero-pleural adhesions, a thoracic approach (thoracotomy or thoracoscopy) may be preferred, which would typically involve a thoracic surgeon 1, 4
In some complex cases, a combined thoraco-abdominal approach may be necessary, requiring collaboration between surgical specialties 1, 2

The chronicity of the condition is a primary factor in determining the best surgical approach 1, 2
Surgeon preferences and skills significantly influence the approach chosen 1, 2
Local resources and available expertise play an important role in surgical specialty selection 1, 2
Right-sided diaphragmatic hernias may require specialized approaches due to the presence of the liver, potentially necessitating thoracic surgical expertise 3

Minimally invasive approaches (laparoscopic or thoracoscopic) have become the most commonly used techniques for managing complicated diaphragmatic hernias 1, 2
Robotic surgery for diaphragmatic hernia repair is emerging but currently has limited data 1, 2

For large defects (>8 cm or >20 cm²), mesh reinforcement is recommended regardless of surgeon specialty 3, 5
Tackers should be avoided near the pericardium due to risk of cardiac complications, regardless of which specialist performs the surgery 3