Treatment of Congenital Diaphragmatic Hernia in Adults
Diagnostic Approach
- CT scan of the chest and abdomen is the gold standard for diagnosing diaphragmatic hernia 1
- CDH in adults may present with nonspecific respiratory and gastrointestinal symptoms, or may be discovered incidentally on imaging 2
Surgical Management Algorithm
- For unstable patients with complicated CDH, laparotomy (open surgical approach) is recommended 4
- For stable patients with complicated CDH, minimally invasive approach (laparoscopic) is preferred 4
- Minimally invasive approach has an excellent safety profile with a reported in-hospital mortality rate of only 0.14% 4
- Primary repair should always be attempted when possible using non-absorbable sutures 4
- Primary repair is appropriate for smaller defects with minimal tension 1
- Mesh reinforcement is recommended for defects larger than 8 cm or area greater than 20 cm² 1
- Mesh should overlap the defect edge by 1.5-2.5 cm 1
- Mesh can be fixed using tackers or transfascial sutures 1
- Avoid tackers near pericardium due to risk of cardiac complications 1
Additional Procedures to Consider
- Fundoplication should be performed during congenital hernia repair 1
- Incidence of gastroesophageal reflux after CDH repair is high (up to 62%) 1
- Nissen or Toupet fundoplication can be performed with similar effectiveness 1
- For high-risk elderly patients, gastrostomy or PEG may be considered 4
- Gastrostomy or PEG provides fixation of anterior stomach to abdominal wall 4
- Gastrostomy or PEG is well-tolerated with low morbidity 4
Outcomes and Complications
- Survival rate in adults with delayed complicated CDH varies between 97-100% 1
- Recurrence rates are relatively low when appropriate surgical technique is used 1
- Potential complications include postoperative pulmonary complications (atelectasis) 1
- Potential complications include surgical infection, bleeding, respiratory failure 1
- Potential complications include gastroesophageal reflux (up to 62% incidence) 1
- Potential complications include chronic pain and hernia recurrence 1
Special Considerations
- Robotic surgery is emerging but currently has limited data 5