Saudi Surgical Journal

: 2019  |  Volume : 7  |  Issue : 3  |  Page : 128--132

Laparoscopic versus open repair of posttraumatic diaphragmatic hernia (Saudi experience)

Abdulrahman Ashy, Hamed Hussien Abousteit, Yasser Ahmed Salem, Essam Badr, Mosab Ibrahim Hassan 
 Department of Surgery, King Abdulaziz University Hospital and Andalusia Hai Al-Jamea Hospital, Jeddah, Saudi Arabia

Correspondence Address:
Abdulrahman Ashy
Andalusia Hai Al-Jamea Hospital, Jeddah
Saudi Arabia


The aim behind this study is to evaluate the feasibility and efficacy of laparoscopic versus open repair of acute and chronic posttraumatic diaphragmatic hernia in three patients treated in our institute in Jeddah, Saudi Arabia.

How to cite this article:
Ashy A, Abousteit HH, Salem YA, Badr E, Hassan MI. Laparoscopic versus open repair of posttraumatic diaphragmatic hernia (Saudi experience).Saudi Surg J 2019;7:128-132

How to cite this URL:
Ashy A, Abousteit HH, Salem YA, Badr E, Hassan MI. Laparoscopic versus open repair of posttraumatic diaphragmatic hernia (Saudi experience). Saudi Surg J [serial online] 2019 [cited 2020 Oct 31 ];7:128-132
Available from:

Full Text


Post-traumatic rupture of the diaphragm is not an uncommon entity all around the world.

In Saudi Arabia, road traffic accidents rate is high with multiple chest, bone and abdominal injuries seen, but traumatic diaphragmatic injuries are not commonly seen. The involvement of the central tendon of the diaphragm is also rare.

The protective effects of the liver and the right kidney make the trauma of the left copula of the diaphragm more common 90% than the right copula 10%.

Our case of post-traumatic rupture of the diaphragm involving the central tendon was the first case managed surgically in our King Abdulaziz University hospital, Jeddah, Saudi Arabia and published in the Saudi Heart Bulletin journal in 1989 Vol. 1, P61.

 Patients and Methods

We had three patients treated in our hospitals in Jeddah, Saudi Arabia (King Abdulaziz University Hospital and Andalusia Hai Al-Jamea Hospital) in 1989, 2013, and 2019 after they have been exposed to different types of trauma several years before the rupture diaphragmatic hernia is diagnosed. There were two males and one female of different nationalities. All of them were treated surgically using one-lung anesthesia technique: The first one through a left thoracoabdominal incision, whereas the other two were repaired laparoscopically with success.[1],[2],[3],[4],[5] All literatures were reviewed.


Posttraumatic diaphragmatic hernia is not an un-common event. It occurs more commonly in the left dome (90%) than in the right dome (10%) because of the protective effect of the liver and right kidney,[6],[7] while rupture of the central tendon of the diaphragm and pericardium is rare. Our case published in the Saudi Heart Bulletin Journal Vol. 1, No. 1, October 1989, was the first case seen in Saudi Arabia since that time up to date.[8] A few cases were reported worldwide.[9],[10],[11]

Hereby, we present our Saudi experience in the diagnosis and management of three cases of posttraumatic diaphragmatic hernia underwent repair in our hospitals in Jeddah, Saudi Arabia, by the first author.

The first case was in October 1989. The patient was a 56-year-old Yemeni Male, with a history of road traffic accident in 1969 and treated conservatively in a hospital in Yemen. He came to the emergency department having epigastric pain, flatulence, vomiting, and dyspnea for 3 days before admission.

Chest x-ray showed a large air shadow in the left hemi-thorax with shift of the mediastinum and heart to the right. The patient was admitted and prepared for surgery after he was resuscitated. The operation was carried out through a long left thoracoabdominal incision. The stomach the part of the small bowel and colon with the omentum were found in the left pleural cavity with complete lung collapse. The defect was seen involving the central tendon extending to the pericardium.[8] All the viscera were returned to the abdominal cavity, and the defect in the diaphragm was closed using a biological Lyodura mesh,[12] While the hole in the pericardium was left open to avoid cardiac tamponade as a possible complication.[8],[11] The lung was inflated fully, and two chest tubes were inserted. The abdomen was closed with an intra-abdominal drain. The patient was kept in the intensive care unit (ICU) for 2 days and in the ward for 2 weeks and then discharged home in good condition. The patient went back to his country 2 years later and no more follow-up.

The second case was a 46-year-old Egyptian woman, who had an intragastric balloon in 2009 to get rid of her excess weight, but failed. She then had laparoscopic adjustable gastric banding somewhere and sustained an anterior iatrogenic perforation of the stomach during the dissection in 2011. The operation was aborted and the perforation was sutured laparoscopically and the abdomen was closed with intra-abdominal drain. In June 2013, she came to our hospital with abdominal pain, vomiting, and severe dyspnea. The chest X-ray findings were the same as of the case seen in 1989. She was taken to the operation theater after resuscitation, and laparoscopic exploration revealed a giant left diaphragmatic hernia with the stomach and bowel found in the left hemithorax. The viscera were retuned back to the abdomen, and the large defect was closed laparoscopically using Marlex mesh.[12] The patient was transferred to the ICU for 2 days and then to the ward for 5 days and discharged home in good condition. She is living a normal life without symptoms of recurrence until now.

Our third case was seen recently in February 2019. He is a 48-year-old Bangladeshi male working as a car electrician. He gave a history of blunt abdominal trauma 4 years ago, which was neglected at that time. He came to our hospital with epigastric pain, vomiting, abdominal distention, and dyspnea for 1 month, increased during the last few days and could not lie supine comfortably. Chest X-ray and computed tomography scan revealed a large black shadow in the left hemithorax with complete lung collapse and shift of the mediastinum and heart to the right [Figure 1] and [Figure 2]. The patient was admitted and resuscitated and prepared for laparoscopic exploration. Nasogastric tube and urinary catheter were inserted. Intravenous fluids and antibiotic with anti-emetic and proton pump inhibitor were given. Laparoscopy revealed herniation of the stomach, part of small and large bowel, and omentum into the left chest cavity with adhesions which were released and the viscera were pulled down into the abdominal cavity with care. A few small patches of the omentum were seen dark and so resected, whereas the stomach and bowel were viable. The left lung was completely collapsed, and a small amount of bloody pleural effusion was sucked, and the lung was fully inflated. An intercostal tube was inserted and connected to the underwater seal [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d, [Figure 3]e, [Figure 3]f, [Figure 3]g, [Figure 3]h. Gastrografin meal through the nasogastric tube was done intraoperatively and showed a massively dilated stomach [Figure 4]. A J-Vacuum drain was left intraperitoneally and the wounds were closed as usual. The patient was transferred to the ICU for overnight, and the postoperative chest X-ray was clear. All the drains were removed, and the patient was transferred to the ward. Gastrografin meal done on the 2nd postoperative day showed about 60% shrinkage of the stomach size with good passage of the contrast to the bowel, and the chest X-ray was clear [Figure 5] and [Figure 6]. The patient opened his bowel on the fourth postoperative day and discharged home on the 5th postoperative day in good condition.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

Anesthetic consideration

Providing anesthesia for cases with posttraumatic diaphragmatic hernia is challenging with extreme potential complications. The challenge starts from the preoperative assessment, which includes pulmonary function evaluation, electrolyte disturbances, and hemodynamic status. Our patients presented with severe pulmonary disease pattern with no or little improvement postmedication. They show more or less stable hemodynamics preoperatively.

All patients with diaphragmatic hernia should be considered as having full and dilated stomach. Traditionally, it was believed that awake intubation with spontaneous ventilation is a must to keep negative intrathoracic pressure and avoid positive pressure compression of the mediastinum, leading to major hemodynamic collapse.[12] Afterward, regional anesthesia is considered the most common method by rescue anesthesia team during serious complications of awake tracheal intubation, especially diaphragmatic rupture, but it is suggested that high regional anesthesia increases the workload of the diaphragm and could lead to the same complication.[13]

Recently, almost the reverse theory is adopted regarding spontaneous ventilation as total diaphragmatic relaxation considered being more protective.[14] Nevertheless, crush induction remains the gold standard in induction of anesthesia for such pathology.

In our cases, crush induction was done using propofol, fentanyl, and rocuronium as a muscle relaxant at a dose of 1 mg/kg to mimic succinylcholine effect. Intubation was done using a left bronchial double-lumen endotracheal tube size 37F for males and size 34F for females. Verification of the site was done using fiberoptic bronchoscope. Invasive blood pressure monitoring was done using left radial arterial cannulation. Central venous catheter (central venous pressure [CVP]) was inserted via the right internal jugular vein for continuous measurement of the CVP.

In laparoscopic approach, careful initial peritoneal insufflation using gradual ascending pressure was performed guided by blood pressure and CVP. Finally, intraperitoneal pressure of 12 mmHg was usually satisfactory for the surgeon and the anesthesiologist. One-lung ventilation was performed till reduction of the herniated abdominal contents. Later, the interior of the thoracic cavity was examined during which the left lung was inflated under vision to check if there is any apparent lung collapse. Inflation should be slow, controlled, and sustained with occlusion of the contralateral (right) lung to prevent its overinflation. Usually, the abdominal pressure is increased during inflation as the peritoneum and left pleura behave as one cavity. After the completion of the repair and insertion of the intercostal tube and connected to the under-water seal, mechanical ventilation was resumed using both lungs with gradual ascending positive end-expiratory pressure (PEEP) up to 10 cm water. Gas bubbling from the intrapleural tube was noted and then gradually decreased and eventually ceased with good oscillation indicating full lung expansion. At this point, the PEEP is dropped to 6 cm water and maintained till extubation.

In open approach, the same steps were done without taking intraperitoneal insufflation precautions. Stoppage of gas bubbling and full-lung expansion was noted only in laparoscopic cases. In open cases, air leak continued beyond the operation and recovery time frame. In open approach, thoracic epidural injection of Marcaine was mandatory to control the postoperative pain. No major hemodynamic instability was noted as the patient was preloaded with 1 l of crystalloids in the form of Ringer's lactate and 500 ml of colloid expander. No major hypotension was recorded. CVP reading was increased by 10–14 cm water during the peritoneal insufflation and dropped back to normal after deflation. Full muscle relaxation was mandatory during the whole procedure in both approaches.


Traumatic rupture of the diaphragm is a not an uncommon entity. It can be easily misdiagnosed in its acute stage. It usually involves the left copula (90%) than the right one (10%) of the diaphragm because of the protective effect of the liver and right kidney. On the other hand, rupture of the central tendon extending to the pericardium is rare. A few reported cases were found in the literature worldwide. Our patient with central tendon rupture extended to the pericardium (pericardiophrenic rupture) was the only reported case in Saudi Arabia. Different etiologies can cause the problem, but blunt abdominal trauma and road traffic accidents are on the top of the list. Iatrogenic causes such as difficult dissection around the angle of hiss or during creation of pericardiophrenic window are also considered.

The usual repair of the hernia is commonly performed through a thoracoabdominal incision in the acute and chronic cases, but laparoscopic approach is also feasible in the hands of the expertise. It is a safe and relatively quick procedure and can explore the right and left domes of the diaphragm as well as the abdominal organs. It is of great benefits, especially in the treatment of the chronic cases, while still debatable in the acute ones.[15]

From the anesthetic point of view, laparoscopic approach for repair of chronic posttraumatic diaphragmatic hernia is anesthetically feasible and even more preferable with no major intraoperative hemodynamic or respiratory derangements. More practice is needed to prove that it is recommended. Moreover, it offers the patient a better postoperative course regarding pain management, pulmonary complications, and hospital stay. Concomitantly, vigilant monitoring and carefully targeted hemodynamic and respiratory management should be committed to ensure patient's safety.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, et al. Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 2003;17:254-8.
2Nguyen P, Davis B, Tran DD. Laparoscopic repair of diaphragmatic rupture: A Case report with radiological and surgical correlation. Case Rep Surg 2017;2017:4159108.
3Pojarliev T, Tzvetkov I, Blagov J, Radionov M. Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh. Surg Endosc 2003;17:660.
4Xenaki S, Lasithiotakis K, Andreou A, Chrysos E, Chalkiadakis G. Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases. Int J Surg Case Rep 2014;5:601-4.
5Latic F, Delibegovic S, Latic A, Samardzic J, Zerem E, Miskic D, et al. Laparoscopic repair of traumatic diaphragmatic hernia. Med Arh 2010;64:121-2.
6Estrera AS, Landay MJ, McClelland RN. Blunt traumatic rupture of the right hemidiaphragm: Experience in 12 patients. Ann Thorac Surg 1985;39:525-30.
7Hood RM. Traumatic diaphragm hernia (collective review) ann. Thorac Surg 1971;12:311.
8Meccawy A, Ashy A. Traumatic rupture of the central tendon of the diaphragm and the pericardium (case report). Saudi Heart Bull J 1989;1:61.
9Larrieu AJ, Wiener I, Alexander R, Wolma FJ. Pericardiodiaphragmatic hernia. Am J Surg 1980;139:436-40.
10Adamthwaite DN, Snyders DC, Mirwis J. Traumatic pericardiophrenic hernia: A report of 3 cases. Br J Surg 1983;70:117-9.
11Ames MD, Kaczmarski CJ, Sahar DI, Lattes CG. Pericardiophrenic hernia secondary to a surgically created peritoneal and pericardial window. Ann Thorac Surg 1986;41:449-50.
12Waldhausen JA, Kilman JW, Helman CH, Battersby JS. The diagnosis and management of traumatic injuries of the diaphragm including the use of marlex prostheses. J Trauma 1966;6:332-43.
13Faheem M, Fayad A. Diaphragmatic rupture after epidural anaesthesia in a patient with diaphragmatic eventration. Eur J Anaesthesiol 1999;16:574-6.
14Nama RK, Butala BP, Shah VR, Patel HR. Anesthetic management of morgagni hernia repair in an elderly woman. Anesth Essays Res 2015;9:413-6.
15Bala M, Faroja M. Laparoscopic repair of acute traumatic diaphragmatic hernia: Is proximity to esophageal hiatus a contraindication? Austin J Trauma Treat 2015;2:1005.