Unusual varieties of diaphragmatic herniae.

Abstract

Unusual varieties of diaphragmatic herniae can be classified into two major groups, congenital and acquired. The late-presenting Bochdalek herniae often present difficulties in diagnosis which may lead to inappropriate treatment. The prime example is the herniated stomach, which is mistaken for a tension pneumothorax. Strangulation is a rare, but an important, complication of Bochdalek herniae. A number of techniques for closure of large diaphragmatic defects are described with recommendation of those procedures which can be performed rapidly and effectively in a critically ill infant. The literature concerning eventration is confusing due to different definitions of the condition by different authors. It may be difficult to distinguish preoperatively between this condition and congenital diaphragmatic hernia with a sac. Such distinction is often not important as the decision for intervention is based on evaluation of clinical and radiological considerations. The majority of Morgagni herniae are asymptomatic and only rarely does strangulation supervene. There is a small group of infants with Morgagni hernias who present in early infancy with respiratory symptoms. Paralysis of the diaphragm due to phrenic nerve palsy recovers spontaneously in the majority of patients. The selective use of diaphragmatic plication for this condition is widely accepted, but the decision and appropriate timing for surgical intervention is often difficult. The results of surgery are very good both in the early postoperative period and also on long-term follow-up. The diagnosis of traumatic diaphragmatic hernia is often overlooked in the presence of other major injuries. The danger of strangulation of contents of this hernia is ever present and repair should be undertaken without delay once the diagnosis is made.