Recurrent Diaphragmatic Hernia

By Douglas Cohen and lan S. Reid Sydney, Australia

�9 There are 109 cases of congenital diaphrag- mat ic hernia rev iewed. There w e r e 58 survivors in this group. There w e r e 13 recurrences among these 58 cases, an incidence of 22.4%. One can recognize minor and major recurrences. Minor recurrences are usually stable and nonprogressive and, in general, do not require fu r ther surgery. The technique of inter- costal flap repair of recurrent d iaphragmat ic hernia is described. This technique has been used in f ive cases of recurrent d iaphragmat ic hernia and has proved sat isfactory in every instance. It is recom- mended as the technique of choice in most cases of recurrent d iaphragmat ic hernia.

INDEX WORDS: Recurrent d iaphragmat ic hernia.

D UR ING the 20 yr up to June, 1974, 124 infants presented at the Royal Alexandra

Hospital for Children with congenital diaphrag- matic hernias. Of these, 15 were anterior (Mor- gagni) hernias and will not be discussed further.

Most of the remaining 109 cases had postero- lateral defects; in 8, the hernia was stated to be through the dome of the diaphragm and 8 had aplasia of the hemidiaphragm associated, as is invariably the case, with gross pulmonary hypo- plasma.

One family had 2 siblings with left Bochdalek hernias and 2 infants had bilateral hernias.

There were 58 survivors and it has been possi- ble to review 30 of these children. It was found that three of them had marked mental retarda- tion requiring special schooling. ~ The relatively high mortality rate is related to the large number of infants in this series who presented in the first 24 hr of l i feY

All of the survivors had their diaphragmatic defect repaired by direct closure with inter- rupted nonabsorbable sutures. There were 13 recurrent diaphragmatic hernias among the 58 surviving children, an incidence of 22.4%.

From The Department of Surgery and The Children's Medical Research Foundation, Royal Alexandra Hospital for Children, Camperdown, N.S. IV., Australia.

Address reprint requests to Douglas Cohen, Department of Surgery, Royal Alexandra Hospital for Children, Camperdown, N.S.W., Australia.

�9 1981 by Grune & Stratton, Inc. 00 2 2-3468/81/1601~9009501.00/0

There are two types of recurrent diaphrag- matic hernia: (1) Minor-- in which there is mini- mal intrusion of abdominal contents into the thorax. Five children with minor recurrences have all been observed regularly for from 10 to over 20 yr with no evidence of progression and without any significant symptoms or complica- tions and (2) Major recurrence--in these cases, the defect reopens allowing numerous loops of bowel to find their way up into the thorax again. These cases clearly require further surgery.

DISCUSSION

In dealing with major recurrence, an abdomi- nal approach is best avoided because of the risk of damage to abdominal viscera, particularly the spleen, and because further recurrence is very likely to ensue. Dense adhesions will invariably be found on this aspect of the diaphragm.

A thoracic approach usually achieves a satis- factory result provided that the recurrent defect is amenable to direct suture. However, when the residual defect is large enough to require a patch to allow it to be closed without tension, further recurrence is very likely unless the patch is constructed from living vascularized tissue. Various ways of achieving this have been described. Repositioning of the diaphragm to a higher level has been recommended) The liver 5 and even the diaphragmatic surface of the lung 6 have been used to occlude defects. The lower chest wall, previously prepared by a first stage thoracoplasty, has been employed] There are obvious disadvantages to each of these proce- dures. Several surgeons have described the use of free autogenous grafts of fascia 8 or skin 9 and many have recommended synthetic material, n~ Other surgeons have used flaps of endo-thoracic fascia, jj renal fascia, ~2 sliding muscle flaps from the transversus abdominus? 3 the latissimus dorsi, ~" or a pedicle flap of abdominal muscle.15

Over 40 yr ago, Bettman and Hess 16 reported a single stage operation involving division of appropriate ribs and the use of the chest wall to close a large posterior diaphragmatic hernia. Provenzale ~7 has also described the use of a flap of intercostal muscle.

42 Journal of Pediatric Surgery, Vol. 16, No. 1 (February), 1981

RECURRENT DIAPHRAGMATIC HERNIA 43

We have found an intercostal flap satisfactory in every instance in which it has been employed.

TECHNIQUE OF INTERCOSTAL FLAP REPAIR

The diaphragmat ic defect is approached via the ninth interspace and cleared in the usual way. Once the edges have been defined, the abdominal viscera are replaced and it will be found that there is a tr iangular defect with fibromuscular edges extending to the chest wall posterolaterally.

The 10th rib is removed subperiosteally f rom well behind the posterior margin of the defect to the costochondral junction and an intercostal flap is fashioned, hinged inferiorly (Fig. 1).

This is turned inwards and it will be found that it can be sutured without any tension to completely fill the defect. In the most recent case in this series, it was found possible to fashion the intercostal flap in the way described by freeing the periosteum without removal of the rib. This is a further refinement of the technique.

The chest wall can be closed by strong nonab- sorbable pericostal sutures. This closure, which will be under some tension, is reinforced by the superficial muscle layers of the chest wall and has proved satisfactory in every instance.

Five cases have been dealt with in the way described. In each instance, the child had had one or more at tempts to close the defect, prior to the use of the intercostal flap technique.

All of these children have now remained well without any evidence of further recurrence for 2 -5 yr.

~ J - , ......... !

Fig. 1. Technique of intercostal flap repair. The flap is hinged inferiorly and is turned inwards and sutured to the edges of the defect.

We would now recommend the use of this technique in all cases of recurrent d iaphragmat ic hernia unless it is found possible to co-apt the edges of the defect throughout their full length without any evidence of tension.

REFERENCES

1. Reid I, Hutcherson RJ: Long-term follow-up of patients with congenital diaphragmatic hernia. J Pediatr Surg 11:939, 1976

2. Brown JH, Davey RB: Congenital postero-lateral diaphragmatic hernia. Aust NZ J Surg 40:30, 1970

3. Butler N, Claireaux AE: Lancet 1:659, 1962 4. Belsey R, Apley J: Congenital rightsided diaphrag-

matic hernia. Arch Dis Child 24:129, 1949 5. Neville WE, Clowes GHA: Congenital absence of

hemidiaphragm and use of a lobe of liver in its surgical correction. Arch Surg 69:282, 1954

6. Bonilla-Naar, Corredor AM, Savogal F: Un cas de hernie diaphragmatique plastic due diaphragme avec le poumon atelectaaique. J Franc Med Chir Thorac 6:244, 1952

7. Harrington SW: Diaphragmatic hernia. JAMA 101:987, 1933

8. Singteton AO, Stehou,~,er OW: The fascia-patch transplant in the repair of hernia. Surg Gynaecol Obstet 80:243, 1945

9. Geever ED, Merendino KA: The repair of diaphrag- matic defects with cutis grafts. Surg Gynaecol Obstet 95:308, 1952

10. Harrison JH: A teflon weave for replacing tissue defects. Surg Gynaecol Obstet 104:584, 1957

11. Benjamin HB: Agenesis of the left hemidiaphragm. J Thorac Cardiovasc Surg 46:265, 1963

12. Weinberg J: Diaphragmatic hernia in infants; surgical treatment with use of renal fascia. Surgery 3:78, 1938

13. Parrella GS, Hurwitz A: Repair of anterior subcosto- sternal hernia of the diaphragm (Hernia of Morgagni) using a flap of transversalis fasica. Arch Surg 59:1327, 1949

14. Chisholm TC: Transthoracic repair of large diaphrag- matic hernias. J Thorac Surg 16:200, 1947

44 COHEN AND REID

15. Wieting: Ueber die hernia diaphragmatica nament- lich ihre chronische form. Deutsche Ztschr Chir 82:315, 1906

16. Bettman B, Hess J H : Incarcerated diaphragmatic

hernia in an infant with operation and recovery. JAMA 92:2014, 1929

17. Provenzale L: The surgical treatment of the diaphrag- matic eventrations by intercostal muscle-periosteal pedicled flaps with bony evolution. Sci Med Ital (Eng) 6:485; 1958