Surgical Management: Other Diaphragmatic Hernias in Adults

  • Taher Gulamhusein
  • Nabeel R. Obeid
  • Aurora D. PryorEmail author


The diaphragm is an anatomically complex organ composed of muscular and tendinous portions with a rich neurovascular network. An intact and functioning diaphragm is critical for respiration, and it serves as a barrier between the chest and abdominal cavities. Diaphragmatic hernias not located at the esophageal hiatus can either be congenital (Morgagni or Bochdalek hernias) or traumatic (either accidental or postoperative) in nature. Abdominal organs may be pulled into the thoracic cavity through any diaphragmatic defect, encouraged by the pressure differential between the chest and abdomen. In general, in patients with reasonable operative risk, any diaphragmatic hernia should be repaired when diagnosed. Surgical repair of non-hiatal diaphragmatic defects can be either transabdominal or transthoracic and may incorporate minimally invasive techniques. Repair often includes primary tissue apposition, due to the redundancy of diaphragmatic muscular tissue. When mesh is required, most surgeons prefer a nonporous mesh material. Postoperatively, the diet can be restarted immediately. Long-term recurrence is unusual following repair.


Hernia Diaphragm Bochdalek Morgagni Traumatic Repair Mesh Laparoscopic 


  1. 1.
    Ashcraft KW, Holcomb GW, Murphy JP, Ostlie DJ, editors. Ashcraft’s pediatric surgery. 6th ed. London/New York: Saunders/Elsevier; 2014.Google Scholar
  2. 2.
    Anraku M, Shargall Y. Surgical conditions of the diaphragm: anatomy and physiology. Thorac Surg Clin. 2009;19(4):419–29. Scholar
  3. 3.
    Eren S, Çiriş F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 2005;54(3):448–59. Scholar
  4. 4.
    Downey R. Anatomy of the normal diaphragm. Thorac Surg Clin. 2011;21(2):273–9. Scholar
  5. 5.
    Schumpelick V, Steinau G, Schlüper I, Prescher A. Surgical embryology and anatomy of the diaphragm with surgical applications. Surg Clin North Am. 2000;80(1):213–39.CrossRefGoogle Scholar
  6. 6.
    Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphragm: anatomy and function. Radiographics. 2012;32(2):E51–70.CrossRefGoogle Scholar
  7. 7.
    Maish MS. The diaphragm. Surg Clin North Am. 2010;90(5):955–68. Scholar
  8. 8.
    Perez Cabanas I, de Miguel Velasco M, Rodriguez Garrido J. Perez_Necrosis gastrica total por hernia de Bochdalek.pdf. Necrosis Gástrica Total Por Hernia Bochdalek Estrangulada En El Adulto. 1991;5:385–7.Google Scholar
  9. 9.
    Ferrer A. Alternativas a la polisomnografía convencional en el diagnóstico y tratamiento del síndrome de apneas durante el sueño. Arch Bronconeumol. 1995;31:259–63.CrossRefGoogle Scholar
  10. 10.
    Brown SR, Horton JD, Trivette E, Hofmann LJ, Johnson JM. Bochdalek hernia in the adult: demographics, presentation, and surgical management. Hernia. 2011;15(1):23–30. Scholar
  11. 11.
    Thomas S, Kapur B. Adult Bochdalek hernia—clinical features, management and results of treatment. Jpn J Surg. 1991;21(1):114–9.CrossRefGoogle Scholar
  12. 12.
    Fingerhut A, Purcher J, Pelletier J. Deux Obs Hernia Diaphragmatique Postero-Laterale Congenitale Dite Bochdalek Revel L’age. Adulte Par Complicat Sev. 1978;115:135–43.Google Scholar
  13. 13.
    Alfonso L, Centeno C, Alvarez F. Severas malformaciones asociadas a hernia diafragmática congénita: factores condicionantes de mortalidad. An Esp Pedr. 1993;1:22–4.Google Scholar
  14. 14.
    Mullins ME, Saini S. Imaging of incidental Bochdalek hernia. Semin Ultrasound CT MRI. 2005;26(1):28–36. Scholar
  15. 15.
    Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. Am J Roentgenol. 2001;177(2):363–6.CrossRefGoogle Scholar
  16. 16.
    Swain JM, Klaus A, Achem SR, Hinder RA. Congenital diaphragmatic hernia in adults. Surg Innov. 2001;8(4):246–55.CrossRefGoogle Scholar
  17. 17.
    Bujanda L, Larrucea I, Ramos F, Muñoz C, Sánchez A, Fernández I. Bochdalek’s hernia in adults. J Clin Gastroenterol. 2001;32(2):155–7.CrossRefGoogle Scholar
  18. 18.
    Tokumoto N, Tanabe K, Yamamoto H, Suzuki T, Miyata Y, Ohdan H. Thoracoscopic-assisted repair of a bochdalek hernia in an adult: a case report. J Med Case Rep. 2010;4(1):1.CrossRefGoogle Scholar
  19. 19.
    Yamana D, Ohba S. Three-dimensional image of Bochdalek diaphragmatic hernia; a case report. Radiat Med. 1994;12:39–41.PubMedGoogle Scholar
  20. 20.
    Thanakumar J, Krishnan A, John P. Reduced port laparoscopic repair of Bochdalek hernia in an adult: a first report. J Minimal Access Surg. 2012;8(4):158. Scholar
  21. 21.
    Al-Emadi M, Helmy I, Abu Nada M, Hamad A-J. Al_Emadi_Laparoscopic repair of Bochdalek Hernia in an Adult.pdf. Surg Laparosc Endosc Percutan Tech. 1999;9(6):423–5.PubMedGoogle Scholar
  22. 22.
    Slesser AA, Ribbans H, Blunt D, Stanbridge R, Buchanan GN. A spontaneous adult right-sided Bochdalek hernia containing perforated colon. JRSM Short Rep. 2011;2(7):54. Scholar
  23. 23.
    Frantzides CT, Carlson MA, Loizides S, et al. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc. 2010;24(5):1017–24. Scholar
  24. 24.
    Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg. 2004;77(6):1956–9. Scholar
  25. 25.
    Marin-Blazquez AA, Candel MF, Parra PA, et al. Morgagni hernia: repair with a mesh using laparoscopic surgery. Hernia. 2004;8(1):70–2. Scholar
  26. 26.
    Horton JD, Hofmann LJ, Hetz SP. Presentation and management of Morgagni hernias in adults: a review of 298 cases. Surg Endosc. 2008;22(6):1413–20. Scholar
  27. 27.
    Yavuz N, Yigitbasi R, Sunamak O, As A, Oral C, Erguney S. Laparoscopic repair of Morgagni hernia. Surg Laparosc Endosc Percutan Tech. 2006;16(3):173–6.CrossRefGoogle Scholar
  28. 28.
    Bortul M, Calligaris L, Gheller P. Laparoscopic repair of a Morgagni-Larrey hernia. J Laparoendosc Adv Surg Tech Part A. 1998;8(5):309–13.CrossRefGoogle Scholar
  29. 29.
    Fagelman D, Caridi J. Fagelman_CT diagnosis of hernia of morgagni.pdf. Gastrointest Radiol. 1984;9(1):153–5. Scholar
  30. 30.
    Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair case report. J Laparoendosc Surg. 1992;2(2):93–100.CrossRefGoogle Scholar
  31. 31.
    Orita M, Okino M, Yamashita K, Morita N, Esato K. Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni. Surg Endosc. 1997;11(6):668–70.CrossRefGoogle Scholar
  32. 32.
    Ackroyd R, Watson D. Ackroyd_Laparoscopic repair of a hernia of Morgagni using a suture technique.pdf. J R Coll Surg Edinb. 2000;45(6):400–2.PubMedGoogle Scholar
  33. 33.
    Ramachandran M, Dip M, Arora V. Ramchandran_Laparoscopic transabdominal repair of hernia of Morgagni-Larrey.pdf. Surg Laparosc Endoscpy Percutaneous Tech. 1999;9(5):358–61.Google Scholar
  34. 34.
    Thoman DS, Hui T, Phillips EH. Laparoscopic diaphragmatic hernia repair. Surg Endosc Interv Tech. 2002;16(9):1345–9.CrossRefGoogle Scholar
  35. 35.
    Nguyen T, Eubanks PJ, Nguyen D, Klein SR. The laparoscopic approach for repair of Morgagni hernias. JSLS. 1998;2(1):85–8.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Godazandeh G, Mortazian M. Laparoscopic repair of Morgagni hernia using polyvinylidene fluoride (PVDF) mesh. Middle East J Dig Dis MEJDD. 2012;4(4):232–5.PubMedGoogle Scholar
  37. 37.
    Li S, Liu X, Shen Y, Wang H, Feng M, Tan L. Laparoscopic repair of Morgagni hernia by artificial pericardium patch in an adult obese patient. J Thorac Dis. 2015;7(4):754.PubMedPubMedCentralGoogle Scholar
  38. 38.
    Percivale A, Stella M, Durante V, et al. Laparoscopic treatment of Morgagni-Larrey hernia: technical details and report of a series. J Laparoendosc Adv Surg Tech. 2005;15(3):303–7.CrossRefGoogle Scholar
  39. 39.
    Shah R, Sabanathan S, Mearns A, Choudhury A. Traumatic rupture of diaphragm. Ann Thorac Surg. 1995;60(5):1444–9. Scholar
  40. 40.
    Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg. 2001;20(1):53–7.CrossRefGoogle Scholar
  41. 41.
    Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 2003;17(2):254–8. Scholar
  42. 42.
    Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85(3):1044–8. Scholar
  43. 43.
    Thiam O, Konate I, Gueye ML, et al. Traumatic diaphragmatic injuries: epidemiological, diagnostic and therapeutic aspects. Springerplus. 2016;5(1)
  44. 44.
    Dirican A, Yilmaz M, Unal B, Piskin T, Ersan V, Yilmaz S. Acute traumatic diaphragmatic ruptures: a retrospective study of 48 cases. Surg Today. 2011;41(10):1352–6. Scholar
  45. 45.
    Ali S, PS MHK, Lins M. Update on managing diaphragmatic rupture in blunt trauma: a review of 208 consecutive cases. Can J Surg. 2009;52(3):177.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Sangster G, Ventura VP, Carbo A, Gates T, Garayburu J, D’Agostino H. Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients. Emerg Radiol. 2007;13(5):225–30. Scholar
  47. 47.
    Shapiro M, Heiberg E, Durham R, Luchtefeld W, Mazuski J. The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture. Clin Radiol. 1995;51:27–30.CrossRefGoogle Scholar
  48. 48.
    Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the diaphragm: experience with 65 patients. Injury. 2003;34(3):169–72.CrossRefGoogle Scholar
  49. 49.
    Magu S, Agarwal S, Singla S. Computed tomography in the evaluation of diaphragmatic hernia following blunt trauma. Indian J Surg. 2012;74(4):288–93. Scholar
  50. 50.
    Murray JG, Caoili E, Gruden JF, Evans SJ, Halvorsen RA Jr, Mackersie RC. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol. 1996;166(5):1035–9.CrossRefGoogle Scholar
  51. 51.
    Peer SM, Devaraddeppa PM, Buggi S. Traumatic diaphragmatic hernia-our experience. Int J Surg. 2009;7(6):547–9. Scholar
  52. 52.
    Murray JA, Demetriades D, Asensio JA, et al. Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest. J Am Coll Surg. 1998;187(6):626–30.CrossRefGoogle Scholar
  53. 53.
    Siow SL, Wong CM, Hardin M, Sohail M. Successful laparoscopic management of combined traumatic diaphragmatic rupture and abdominal wall hernia: a case report. J Med Case Rep. 2016;10(1)
  54. 54.
    Kishore GSB, Gupta V, Doley RP, et al. Traumatic diaphragmatic hernia: tertiary centre experience. Hernia. 2010;14(2):159–64. Scholar
  55. 55.
    Zerey M, Heniford BT, Sing RF. Laparoscopic repair of traumatic diaphragmatic hernia. Oper Tech Gen Surg. 2006;8(1):27–33. Scholar
  56. 56.
    Simpson J, Lobo DN, Shah AB, Rowlands BJ. Traumatic diaphragmatic rupture: associated injuries and outcome. Ann R Coll Surg Engl. 2000;82(2):97.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Reina A, Vidana E, Soriano P, et al. Traumatic intrapericardial diaphragmatic hernia: case report and literature review. Injury. 2001;32(2):153–6.CrossRefGoogle Scholar
  58. 58.
    McCutcheon BL, Chin UY, Hogan GJ, Todd JC, Johnson RB, Grimm CP. Laparoscopic repair of traumatic intrapericardial diaphragmatic hernia. Hernia. 2010;14(6):647–9. Scholar
  59. 59.
    Carlson MA. Brief clinical report laparoscopic repair of a penetrating injury to the diaphragm: a case report. J Laparoendosc Surg 1994;4(2):153–6.Google Scholar
  60. 60.
    Frantzides C, Madan A, O’Leary P, Losurdo J. Frantzides Laparoscopic repair of a recurrent chronic traumatic diaphragmatic hernia.pdf. February 2003.Google Scholar
  61. 61.
    Zhong T, Janis JE, Ahmad J, Hofer SOP. Outcomes after abdominal wall reconstruction using acellular dermal matrix: a systematic review. J Plast Reconstr Aesthet Surg. 2011;64(12):1562–71. Scholar
  62. 62.
    Garvey PB, Martinez RA, Baumann DP, Liu J, Butler CE. Outcomes of Abdominal Wall reconstruction with acellular dermal matrix are not affected by wound contamination. J Am Coll Surg. 2014;219(5):853–64. Scholar
  63. 63.
    Rodriguez-Morales G, Rodriguez A, Shatney C. Acute rupture of the diaphragm in blunt trauma: analysis of 60 patients. J Trauma. 1986;26(5):438–44.CrossRefGoogle Scholar
  64. 64.
    Liao C-H, Chu C-H, Wu Y-T, et al. The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literature review. Hernia. 2016;20(2):303–9. Scholar
  65. 65.
    Sharma O. Sharma_Traumatic diaphragmatic rupture_not an uncommon entity.pdf. J Trauma. 1989;29(5):678–82.CrossRefGoogle Scholar
  66. 66.
    Matz A, Alis M, Charuzi I, Kyzer S. The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture. Surg Endosc. 2000;14(6):537–9. Scholar
  67. 67.
    Schneider C, Tamme C, Scheidbach H, Delker-Wegener S, Köckerling F. Laparoscopic management of traumatic ruptures of the diaphragm. Langenbeck’s Arch Surg. 2000;385(2):118–23.CrossRefGoogle Scholar
  68. 68.
    Meyer G, Hüttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc. 2000;14(11):1010–4. Scholar

Copyright information

© SAGES 2019

Authors and Affiliations

  • Taher Gulamhusein
    • 1
  • Nabeel R. Obeid
    • 2
  • Aurora D. Pryor
    • 1
    Email author
  1. 1.Department of Surgery, Stony Brook MedicineStony Brook University HospitalStony BrookUSA
  2. 2.Department of SurgeryStony Brook MedicineStony BrookUSA

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