CHAPTER 83 — Diaphragmatic Hernia 625

CHAPTER 83

Diaphragmatic Hernia
Dale E. Bjorling • Gretchen K. Sicard

T he diaphragm structurally separates the thorax from

the abdomen and also takes an active role in respiration.
Pars sternalis

Despite the passive and active roles of the diaphragm,

loss of continuity of the diaphragm itself does not neces- Pars costalis
sary result in the clinical signs commonly associated with
a diaphragmatic hernia. Taber’s Cyclopedic Medical Dic- Caval foramen
tionary defines a diaphragmatic hernia as the “. . . protru-
sion of abdominal contents through the diaphragm.”1
Consequently, it is the displacement of viscera that re-
sults in morbidity and mortality.
Diaphragmatic hernias can be congenital or acquired.
Congenital diaphragmatic hernias result from abnormal Esophageal
embryogenesis. Acquired diaphragmatic hernias are hiatus
more common than congenital hernias and are usually
traumatic in origin.2 Knowledge of normal anatomy and Pars lumbalis
embryogenesis is important in understanding the patho-
genesis of the occurrence and the effects of diaphrag-
matic hernia. Aortic hiatus

Anatomy
The diaphragm has two major components: tendinous
and muscular.3,4 The tendinous portion consists of the Y-
shaped central tendon, which attaches to the thirteenth Figure 83-1. Anatomy of the diaphragm. The ventral portion of
rib on either side.4 It has two layers of concentric fibers the diaphragm is at the top of the illustration.
that surround the caval foramen.4 The muscular portion
of the diaphragm includes the pars lumbalis, the pars
costalis, and the pars sternalis. 4 The pars lumbalis is di-
vided into the medial, intermediate, and lateral portions Embryology
on each side of the esophageal and aortic hiatus.4 The
tendons of the pars lumbalis arise from vertebral bodies In the embryo, the diaphragm originates as a connective
L3 and L4.4 The pars costalis and sternalis circumvent tissue membrane lying opposite the midcervical seg-
the central tendon laterally and ventrally.4 Blood is sup- ments.8 Myoblasts from the caudal cervical myotomes of
plied to the diaphragm by the phrenic arteries, and mo- cervical segments 4 through 7 migrate onto the di-
tor innervation is provided by the phrenic nerves.4 The aphragmatic membrane to form the muscular portion of
phrenic nerves arise from spinal cord segments C5 to C7 the diaphragm.8 The origin of the embryonic diaphrag-
in the dog and segments C4 to C6 in the cat.4-6 matic membrane near the cervical segments gives rise to
The normal diaphragm has three circular openings the phrenic nerve as the major nerve supply of the mus-
(Figure 83-1).7 The caudal vena cava passes through the culature of the diaphragm.
caval foramen. The esophageal hiatus contains the cau- Three embryonic structures are the major active con-
dal esophagus, and support from the diaphragmatic tributors to the diaphragmatic membrane.8 The septum
crura and suspensory apparatus forms the caudal transversum is the ventral component and develops
esophageal sphincter. The aortic hiatus allows passage into the central tendon of the diaphragm.8 The pleu-
of the aorta, azygous vein, hemiazygous vein, and tho- roperitoneal membranes are ingrowths of the body wall
racic duct across the diaphragm. that fuse with the mesoesophagus, body walls, and the
626 PART FIVE — Disorders of the Respiratory Tract: E. Pleura, Diaphragm, and Chest Wall

septum transversum.8 Fusion of these membranes al- although the sex distribution in cats is equal.13
lows closure of the pleuroperitoneal canals and forma- Concurrent congenital anomalies are often present, in-
tion of the pleural cavity.8 The body wall is thought to cluding sternal defects, intracardiac defects, and pul-
allow growth of the diaphragm by incorporation of its monary vascular disease.12,16-19 Concurrent prognathism,
tissues circumferentially, although the extent of its con- portosystemic shunt, and umbilical hernias have also
tribution is not entirely known.8 Passive contributors to been reported.16-19
the diaphragm include the mesoesophagus, the Viscera that are commonly displaced through a perito-
mesonephric remnant with its mesentery, and the mes- neopericardial hernia include the liver, falciform liga-
enchyme around the aorta.8 These structures contribute ment, omentum, spleen, small intestine, and stom-
to the diaphragm simply because of their proximity to ach.12,13 One study reported that the liver and the
the major components. intestines herniate most commonly.13 Clinical signs asso-
ciated with peritoneopericardial hernia may be nonspe-
cific, including weight loss, abdominal pain, ascites, ex-
Congenital Diaphragmatic Hernias ercise intolerance, collapse, or shock.12 Gastrointestinal
involvement may result in vomiting, diarrhea, and
There are three types of congenital diaphragmatic her- anorexia or polyphagia.13,16 Respiratory signs such as
nia: pleuroperitoneal, peritoneopericardial, and hiatal.2 coughing, tachypnea, or dyspnea may occur if lung ex-
A pleuroperitoneal hernia involves the dorsal tendinous pansion is restricted.12 Tachypnea and muffled heart
portion of the diaphragm and likely results from incom- sounds were the most common physical examination
plete closure of the pleuroperitoneal membranes.9 findings in dogs and cats with peritoneopericardial her-
Peritoneopericardial hernias result from a defect in the nia.13 This hernia is diagnosed most often as an inciden-
septum transversum in conjunction with anomalous de- tal finding, and one study reported that 60% of cases
velopment of the pleuroperitoneal membranes.8 A hiatal were found incidentally on routine examination.13
hernia occurs at the point where the esophagus passes Useful diagnostic tools for evaluation of peritoneoperi-
through the diaphragm and may result from either in- cardial hernia include thoracic radiography, contrast radi-
complete fusion of the pleuroperitoneal membranes and ography, angiography, ultrasonography, and computed to-
the mesoesophagus, or from an esophageal defect.8 mography.12,13,16 Thoracic radiographs may reveal an
enlarged, round cardiac silhouette or, more specifically, in-
testinal loops within the cardiac shadow.12 Although radi-
PLEUROPERITONEAL HERNIA
ography may be useful in diagnosis of the hernia, it is not
Since pleuroperitoneal hernias result from incomplete particularly helpful in determining which organs have her-
fusion of the pleuroperitoneal membranes, they create a niated.16 Nonselective angiography may differentiate car-
dorsolateral diaphragmatic defect. The intermediate por- diomyopathy or pericardial effusion from a peritoneoperi-
tion of the left lumbar musculature may be absent, the cardial hernia.12 Peritoneography or a positive contrast
crura may be absent, and the central tendon may or may study of the upper gastrointestinal tract is often helpful to
not be involved.10,11 This condition is reported to follow confirm displacement of the stomach or intestines (Figure
an autosomal recessive mode of inheritance.11,12 83-2, A and B).12 Thoracic ultrasound, performed subster-
Pleuroperitoneal hernias are uncommonly diagnosed, nally or through the right fifth intercostal space, is highly
possibly because of a high neonatal mortality rate.10 useful and allows differentiation of fluid and solid struc-
Death often results from fatal respiratory insufficiency as tures, with concurrent evaluation of cardiac function.12,13
a result of displacement of the stomach, spleen, or small Evidence of incarceration of the liver in a perito-
intestine into the thorax.10 neopericardial hernia warrants further diagnostic evalu-
ation, including liver function tests and a coagulation
panel, before surgical correction. Fibrinolysis and asso-
PERITONEOPERICARDIAL HERNIA
ciated hepatic hypoxia have been reported in association
The peritoneopericardial hernia is the most common con- with incarceration of the liver, and irreversible liver dam-
genital diaphragmatic hernia in dogs and cats.12 It in- age is associated with a guarded prognosis.16
volves herniation of abdominal viscera into the pericar- Early surgical repair of congenital peritoneopericar-
dial sac through a ventral diaphragmatic defect.13 It is dial hernias is recommended.13 Clinical outcome of con-
thought that incomplete closure of the septum transver- servatively managed cases, although not widely re-
sum occurs prenatally between days 24 and 28 of gesta- ported, has been poor.13 Surgical correction is relatively
tion in animals because of a genetic defect or a terato- easy, is associated with few complications, and results in
gen.14,15 Peritoneopericardial hernia must be congenital in a high rate of success in dogs and cats.13 The effect of
dogs and cats but can be congenital or traumatic in peo- age of the animal on the outcome of surgery is un-
ple.13 Peritoneopericardial hernia can be traumatic in hu- known. Adhesions of abdominal viscera to the peri-
mans because the diaphragm forms one wall of the peri- cardium or epicardium are uncommon, and a sufficient
cardial cavity, but there is no direct communication amount of diaphragmatic tissue is usually available for
between the peritoneal and pericardial cavities in dogs primary repair. A ventral midline incision is made in the
and cats.13,16 An increased incidence of peritoneopericar- abdomen beginning at the xyphoid and continuing cau-
dial hernia has been reported in weimaraners.16 There is dally. The edges of the defect are debrided, and the di-
also a higher incidence in male dogs than in female dogs, aphragm is closed with mononfilament absorbable or
 CHAPTER 83 — Diaphragmatic Hernia 627

tion of sliding and paraesophageal hiatal hernia, has also

been suggested in humans, dogs, and cats.22
Sliding hiatal hernias are the most common and in-
volve displacement of the gastroesophageal junction
through the hiatus and into the caudal mediastinum.20 In
animals with paraesophageal hiatal hernia, the esopha-
gogastric junction remains fixed and the stomach herni-
ates through a defect in the hiatus along the esophagus.20
The majority (approximately 60%) of hiatal hernias in
A
dogs and cats occur in animals less than 1 year of age
and are considered congenital.23 A breed predilection has
been reported in the Chinese shar-pei.12,24,25
Congenital hiatal hernia is thought to result from an
inherent weakness of the phrenoesophageal suspensory
apparatus, which is the fascial reflection of the di-
aphragm around the circumference of the esophagus.26
Although the hernia itself rarely causes clinical signs di-
rectly, it may play a major role in the development of
gastroesophageal reflux and esophagitis, resulting in
clinical signs associated with secondary megaesophagus
and esophageal hypomotility.
Hiatal hernia and gastroesophageal reflux often coex-
ist, but hernias are probably an aggravating factor rather
than the inciting cause of gastroesophageal reflux. The
pathogenesis of gastroesophageal reflux disease is com-
plex but may relate to any of the following factors: func-
B tion of the caudal esophageal sphincter, esophageal peri-
stalsis, esophageal clearance, composition of the
refluxed material, and gastric function.23,27 Hiatal hernia
is assumed to contribute to gastroesophageal reflux by
promoting incompetence of the gastroesophageal
sphincter.28 It is thought that the caudal esophagus and
the diaphragmatic crura work together to prevent
esophageal reflux.29 Hiatal hernia alters this anatomic re-
lationship, resulting in incompetence of the gastro-
Figure 83-2. A, Ventrodorsal and B, lateral thoracic radio- esophageal sphincter.28
graphs of a cat with a peritoneopericardial hernia. Water-soluble Clinical signs associated with hiatal hernia can vary
contrast material was placed in the abdominal cavity, and the greatly depending on the severity of the esophageal hi-
hindquarters of the cat were elevated to allow the contrast mate- atal hernia, and they are usually more severe in animals
rial to migrate into the pericardial sac. with a congenital defect. One study of 16 cases of con-
genital hiatal hernia reported that 7 animals were symp-
tomatic.23 It is thought that a large number of cases of hi-
atal hernia remain undetected because they lack clinical
nonabsorbable suture in a continuous pattern beginning signs. If they have clinical signs, most commonly the an-
at the most dorsal aspect of the defect. Separate closure imals suffer episodes of anorexia, coughing, dysphagia,
of the pericardium is not required, and it may be possi- hypersalivation, and regurgitation.12,21 Clinical signs may
ble in some animals to close the defect without entering progress to vomiting, hematemesis, and dyspnea. Death
the thoracic cavity.13 If the thoracic cavity is entered, a can occur secondary to cardiopulmonary compromise or
thoracostomy tube should be placed before completion gastric necrosis. Differential diagnoses based on clinical
of the surgery. signs should include megaesophagus, esophageal diver-
ticulum, gastroesophageal intussusception, esophageal
foreign body, neoplasia, or granuloma.
HIATAL HERNIA
The diagnosis of hiatal hernia is usually made radio-
A hiatal hernia results from protrusion of abdominal graphically (Figure 83-3, A and B). Thoracic radiographs
contents through the esophageal hiatus of the dia- should be evaluated carefully for the presence of mega-
phragm.12 Although this particular defect is fairly com- esophagus or aspiration pneumonia. If a sliding hiatal
mon in man, it is considered rare in the dog and cat.20,21 hernia results in intermittent signs, positive abdominal
The three types of hiatal hernia described in humans pressure may be necessary to induce herniation.12
(i.e., sliding hiatal hernia, paraesophageal hiatal hernia, Diagnosis of hiatal hernia may require a positive contrast
and shortened esophagus) have also been reported in radiographic study of the esophagus and stomach. Done
animals.12,20 A fourth type of hiatal hernia, a combina- in conjunction with fluoroscopy, this may allow assess-
 628 PART FIVE — Disorders of the Respiratory Tract: E. Pleura, Diaphragm, and Chest Wall

monitoring, and manometry. These modalities are not

widely used in clinical veterinary medicine.
Animals with small sliding hiatal hernias and those
with mild clinical signs may benefit from conservative
management. Medical therapy is directed at reflux
esophagitis, the proposed cause of clinical signs. A low-
fat, soft diet may enhance gastric emptying and thereby
reduce reflux.28 Small, frequent (three to five times
daily), elevated feedings are recommended if mega-
esophagus is present.21 Neutralization and suppression
of gastric acid secretion, increased caudal esophageal
sphincter tone, and esophageal prokinesis are the goals
A of drug therapy.21 H2-receptor antagonists (e.g., cimeti-
dine, ranitidine, and famotidine) decrease gastric acid,
and an increase in gastric pH also increases caudal
esophageal sphincter pressure.21 Metoclopramide in-
creases caudal esophageal sphincter pressure via proki-
nesis and reduces intragastric pressure by promoting
gastric emptying.28 Sucralfate has been used as a diffu-
sion barrier for peptic digestion and is cytoprotective
against acid-induced mucosal injury.21,28 Omeprazole, a
drug used to treat esophagitis in humans, inhibits ATP-
dependent exchange of extracellular potassium for intra-
cellular hydrogen ions in the parietal cell.21 This drug
may be useful in animals that do not respond to the an-
tisecretory effects of the H2-receptor antagonists. Medical
therapy alone resulted in improvement of signs in 8 of 15
dogs with hiatal hernia, and complete resolution of clin-
ical signs was observed in some dogs after 30 days of
treatment.21 These results suggest that conservative ther-
apy should be instituted for at least 30 days before con-
sideration of surgical correction of hiatal hernia.
Animals with a paraesophageal hiatal hernia, those
B
with a permanently displaced stomach, and those that
fail to respond to conservative management are all can-
didates for surgical correction.28 Primary goals of surgi-
cal treatment consist of replacement of the stomach and
esophagus caudal to the diaphragm, reduction of an en-
larged hiatus (hiatal plication), and fixation of the stom-
ach and/or caudal esophageal sphincter within the ab-
domen (esophagopexy or gastropexy).28 Antireflux
Figure 83-3. A, Ventrodorsal and B, lateral radiographs of a procedures (fundoplication) have also been used to re-
dog with a paraesophageal hiatal hernia. The stomach is filled store caudal esophageal sphincter pressure.28
with food and displaced into the thorax. Surgery is performed using a cranial ventral midline
abdominal incision. Hiatal plication is performed by in-
cising the ventral phrenoesophageal ligament circumfer-
entially while avoiding the ventral vagal trunk. The cau-
ment of esophageal motility, esophageal diameter, and dal esophageal sphincter is retracted into the abdomen,
caudal esophageal sphincter function. However, observa- and the diaphragmatic crura are sutured in approxima-
tion of gastroesophageal reflux by radiology or fluo- tion with 3-0 or 2-0 monofilament nonabsorbable suture
roscopy may not correlate with clinical signs.12 to reduce the hiatus to a diameter of 1 to 2 cm. An
Endoscopy may allow evaluation of the caudal esophagopexy can be performed by suturing the abdom-
esophageal sphincter and facilitates detection of lesions inal esophagus to the diaphragm using the same suture
consistent with reflux esophagitis (e.g., mucosal hyper- material in an interrupted pattern. Sutures should not
emia, erosion, and ulceration); it is performed routinely penetrate the lumen of the esophagus. A fundic gas-
in humans to determine the severity of disease and, tropexy can be performed using any of the described
therefore, the course of therapy.21 However, endoscopy techniques (e.g., incisional, belt loop, circumcostal, or
may not be particularly useful for identifying the pres- tube gastropexy).12 Current antireflux procedures per-
ence of hiatal hernia or for distinguishing this defect from formed in dogs are modifications of techniques that have
gastroesophageal intussusception. Other diagnostic tests been used in humans (e.g., Nissen fundoplication and
used in humans include acid clearing tests, 24-hour pH Belsey fundoplication) and entail wrapping the stomach
 CHAPTER 83 — Diaphragmatic Hernia 629

around the esophagus. Nissen fundoplication is the sim- during quiet inspiration to over 100 cm H2O during
plest procedure and the one most commonly used in maximum inspiration.32 Indirect trauma resulting in a
small animals. A large-bore stomach tube is placed sudden increase in intraabdominal pressure, in con-
through the esophagus before fundoplication, and um- junction with an open glottis, may dramatically in-
bilical tape or a Penrose drain is used to pull the caudal crease the pleuroperitoneal pressure gradient and lead
esophagus into the abdomen. A fold of the cranial wall to a tear in the diaphragm.31,32 Iatrogenic diaphrag-
of the fundus is passed around the esophagus on the matic trauma can occur during thoracocentesis, chest
right side of the abdomen. Sutures (3-0 or 2-0 monofila- drain placement, or while making an abdominal inci-
ment nonabsorbable) are placed, incorporating the sion.12 Abdominal viscera do not usually pass into the
esophagus, to approximate the fundus and form a cuff thoracic cavity through a small laceration, and these
around the caudal 3 to 4 cm of the esophagus. often heal unremarkably.
Hiatal plication alone has not been sufficient for hu- Traumatic diaphragmatic tears generally involve the
mans with an incompetent lower esophageal sphincter. muscular rather than the tendinous portion of the di-
Therefore gastropexy or an antireflux procedure is gen- aphragm because of the relative weakness of muscle.33,34
erally combined with hiatal plication. The accepted ap- Muscular diaphragmatic tears are divided into three
proach to surgical repair of a symptomatic hiatal hernia general categories based on the location of the damage:
consists of a combination of hiatal plication, gastropexy, circumferential, radial, or a combination of circumferen-
and Nissen fundoplication. However, a study by Prymak tial and radial (Figure 83-4). Two studies reported that
and colleagues reported good to excellent results in ani- approximately 40% of tears were located circumferen-
mals following hiatal plication plus esophageal or gas- tially, 40% were located radially, and 20% were com-
tropexy alone.24 They advocated the use of an antireflux bined.33,34 In a review of 406 cases of diaphragmatic her-
procedure only if there is primary incompetence of the nia in dogs and cats, right costomuscular tears were
caudal esophageal sphincter.24 In a more recent study, observed in 51% of the cases, and left costal tears oc-
Lorinson and Bright reported similar results:21 they curred in 24% of cases.7 The right diaphragm was lacer-
found that 8 of 10 dogs had resolution of signs following ated in 13% of the cases, and multiple lacerations were
hiatal plication, esophagopexy, and gastropexy, whereas seen in 4% of the cases.7 The least common lesions in-
fundoplication alone was successful in only 1 of 4 dogs.21 volved the central tendon and crura, which made up
Based on these results, fundoplication was only recom- only 3% of the cases.7 The decreased incidence of left-
mended in animals that did not respond favorably to sided diaphragmatic hernia may result from the cush-
esophagopexy.21 ioning effect of a gas-filled stomach on the left side of
Potential complications of surgical repair include her- the abdomen because the stomach may act to disperse
niation, esophagitis, vomiting, regurgitation, aspiration the intraabdominal forces at impact.7
pneumonia, dyspnea, and gastric tympani. Development The contents of a diaphragmatic hernia generally
of gastric bloat syndrome (gastric tympani) has specifi- correspond to the location of the tear and may signifi-
cally been associated with fundoplication. A reduction cantly impact the clinical outcome of the case. The
in the complication rate can be accomplished by using most common organs found to herniate through a trau-
modified fundoplication techniques (loose 360-degree matic diaphragmatic hernia were the liver (78% to
fundoplication) and placement of a gastrostomy tube for 88%), the small intestine (64% to 73%), and the stom-
decompression. However, the most important factor in ach (47% to 53%).7,35 Other organs reported to herni-
reducing complication rate may be careful selection of ate include the spleen, omentum, pancreas, colon, gall
surgical candidates. bladder, cecum, kidney, and uterus.7,12,33 Left-sided
traumatic diaphragmatic hernias most commonly con-
tained stomach, spleen, or small intestine, whereas
Traumatic Diaphragmatic Hernias right-sided hernias commonly contained liver, small in-
testine, and/or pancreas.33 Because of the force re-
The majority of diaphragmatic hernias are traumatic quired to create a traumatic diaphragmatic hernia,
in origin. In a review of 406 dogs and cats diagnosed other injuries are often found.7 Wilson and Hayes re-
with diaphragmatic hernia, 85% were traumatic, ported that 38% of animals with traumatic diaphrag-
whereas 15% were developmental, peritoneopericar- matic hernia had concomitant traumatic injuries,7 in-
dial, or esophageal hiatal hernias.7 Three types of trau- cluding hernias at other locations, myocardial and
matic diaphragmatic hernia have been described: di- pulmonary contusions, hip luxations, hematomas, and
rect, indirect, and iatrogenic.12 Direct diaphragmatic damage to the liver and urinary bladder. Fractured
hernias are caused by direct trauma to the diaphragm bones are also common, specifically caudal rib frac-
(e.g., bite, stab, or gunshot wounds).12,30 Diaphragmatic tures and fractures of the pelvis and femur.12
hernias caused by direct trauma are relatively rare.
Indirect diaphragmatic hernias are more common and
CLINICAL CONSEQUENCES OF TRAUMATIC
are the result of blunt trauma to the abdominal cav-
DIAPHRAGMATIC HERNIA
ity.31 Automobile accidents are the most common
cause of this type of injury, but indirect trauma may The clinical signs of a diaphragmatic hernia are a sum-
also occur from a kick, fall, or fight.7 Normal pleu- mation of the effects of the location of the lesion and the
roperitoneal pressure gradients vary from 7 cm H2O organs that have herniated, as well as accumulation of
630 PART FIVE — Disorders of the Respiratory Tract: E. Pleura, Diaphragm, and Chest Wall

Circumferential Radial Combination

Figure 83-4. Diagram depicting the common locations of muscular diaphragmatic tears.

fluid within the thoracic cavity and damage to visceral

DIAGNOSIS
organs. Respiratory signs including dyspnea and cyanosis
are often seen, although the cause of respiratory impair- When obvious signs of respiratory distress or enteric
ment is not necessarily loss of diaphragm continuity.2 pathology are not observed, physical examination may
The cause of dyspnea is often multifactorial and may re- reveal subtle indications of diaphragmatic hernia. The
late to a combination of shock, chest wall dysfunction, animal may appear gaunt, and abdominal palpation may
decreased pulmonary compliance, pulmonary contu- suggest a lack of viscera within the abdomen. Thoracic
sions, pleural effusion, and cardiovascular dysfunction.2 auscultation may reveal borborygmus, an apparent lack
Depending on the contents of the hernia, enteric signs of lung sounds, or a muffled heartbeat. Thoracic percus-
may occur alone or in conjunction with respiratory signs. sion is dull over areas of pleural fluid or displaced ab-
Displacement of enteric organs often results in vomiting, dominal viscera.
hematemesis, diarrhea, constipation, or anorexia. The diagnosis of diaphragmatic hernia is made most
Entrapment of the stomach within the hernia can result often by thoracic radiography. If the animal is stable
in gastric dilation that can further compromise respira- enough, thoracic radiographs should be made with the
tory function. Prolonged distention of the stomach can animal positioned in dorsal recumbency and both right
result in obstruction of the blood supply leading to gas- and left lateral recumbency. A high percentage of ani-
tric necrosis. Other signs reported in conjunction with di- mals with a diaphragmatic tear have an incomplete di-
aphragmatic hernia include exercise intolerance, dyspha- aphragmatic outline on lateral thoracic radiographs
gia, weight loss, and depression. (97%), and 67% of these animals have air-filled intesti-
Although the liver is the most common organ found nal loops within the thorax (Figure 83-5, A and B).36 Less
in the thorax as a result of traumatic diaphragmatic her- specific roentgen signs of diaphragmatic hernia include
nia, the consequences of its displacement are generally an obscure cardiac outline, increased opacity of the ven-
limited.7 However, if intrahepatic pressure is elevated by tral lung fields, pleural fluid, and atelectasis.33 It may be
5 to 10 mm Hg, hemorrhagic fluid may exude through necessary to remove pleural fluid and obtain additional
the hepatic capsule, resulting in life-threatening fluid ac- thoracic radiographs to more clearly differentiate the
cumulation in the thorax or abdomen.7 There is also the presence of displaced abdominal viscera from intratho-
possibility of hepatic infection as a result of colonization racic pathology. Ultrasound is often useful to identify ab-
with anaerobic and gram-negative aerobic organisms as dominal contents within the thorax, especially in the
a result of decreased hepatic bloodflow.7 On rare occa- presence of pleural fluid.37 A positive contrast study of
sions, the liver may be strangulated within the hernia, the upper gastrointestinal tract or positive-contrast peri-
resulting in hepatic necrosis or biliary obstruction, and toneography may be useful if a diaphragmatic hernia is
resection of devitalized liver tissue may be necessary suspected and thoracic radiography and ultrasound are
during hernia repair. nondiagnostic.
 CHAPTER 83 — Diaphragmatic Hernia 631

Figure 83-6. Gastric necrosis is apparent during necropsy of this

dog, which had displacement of the stomach through a trau-
matic diaphragmatic hernia.

Acute hemorrhage can occur because of organ trauma

(particularly from the spleen or liver), and pulmonary
compliance may be compromised because of thoracic
wall trauma or the presence of fluid or viscera within the
thorax. Pulmonary contusions are essentially bruises of
the lung and can result in significant ventilation/perfu-
sion mismatch. The full extent of pulmonary contusions
may not be apparent for several hours, and arrhythmias
resulting from poor myocardial perfusion or contusions
may not develop for 24 to 48 hours after trauma. If the
animal cannot be stabilized, however, emergency
B surgery should be performed.39 Emergency surgery is
definitely indicated in animals with acute dilation of a
herniated stomach or with strangulated intestines.2
Whenever the stomach herniates through a diaphrag-
matic hernia there is a significant risk that it could be-
come severely distended at any time, resulting in acute
decompensation of the patient. A distended stomach can
compress the caudal vena cava, resulting in decreased
Figure 83-5. A, Ventrodorsal and B, lateral thoracic radiographs venous return, and strangulation can result in bowel
of a cat with a traumatic diaphragmatic hernia. Note the loss of necrosis and peritonitis (Figure 83-6).
a distinct outline of the diaphragm. Gas-filled bowel loops are ap- The goal of herniorrhaphy is to atraumatically reduce
parent within the thorax. the displaced viscera, followed by repair of the di-
aphragmatic defect.7 Surgical approaches that have been
described for herniorrhaphy include the lateral thoracic,
transthoracic, abdominal, and paracostal. Each approach
MANAGEMENT has its own limitations, emphasizing the need for care-
ful planning before surgery. The lateral thoracic ap-
Surgical intervention is necessary for resolution of signs. proach prevents abdominal viscera from interfering with
Cardiovascular and pulmonary stabilization is warranted the closure7; however, this approach limits exposure to
for approximately 1 to 3 days before herniorrhaphy.38 the ventral midline, the crus, and the costomuscular ori-
One report indicates that the mortality rate is highest gins of the diaphragm, and it does not allow thorough
when surgery takes place within the first 24 hours after exploration of the abdomen.7 The transthoracic ap-
diaphragmatic injury.7 However, this observation may be proach allows greater exposure of the ventrolateral di-
biased by the fact that surgery is usually performed on aphragm but exposure of the costal diaphragm is lim-
the most critically injured animals during this time. ited.7 In addition to the anatomical limitations, thoracic
Perioperative treatment of pulmonary contusions and approaches can seriously compromise thoracic wall
pneumothorax can greatly reduce the risks of anesthesia compliance and are therefore not recommended. The ab-
in critically injured hernia patients.2 It is important that dominal approach is used most commonly and allows
the patient is carefully monitored while being stabilized. thorough exploration of the abdomen and good exposure
632 PART FIVE — Disorders of the Respiratory Tract: E. Pleura, Diaphragm, and Chest Wall

of all aspects of the diaphragm.7 The incision can be con- monary edema was the most common cause of death
tinued cranially with a median sternotomy or a paracostal following diaphragmatic hernia repair.12
incision to provide even greater exposure if necessary. The most critical intervals during diaphragmatic hernia
Thorough examination of the diaphragm during repair are anesthesia induction and the immediate post-
surgery is important to search for multiple diaphrag- operative period. Some degree of hypoxia is often present
matic defects. All abdominal organs should be examined in animals with diaphragmatic hernia because of de-
to identify concurrent traumatic injuries. Contraction of creased compliance and/or ventilation-perfusion mis-
the diaphragmatic defect may make repositioning organs match.12 Animals should be sedated with cardiovascular
difficult, especially in chronic cases. Abdominal organs sparing drugs to ensure that minimal physical restraint is
should be gently repositioned into the abdomen without required during induction of anesthesia.12 Preoxygenation
tugging or pulling, and the surgeon should not hesitate for at least 2 to 3 minutes before induction is recom-
to enlarge the primary defect to allow atraumatic re- mended.12 Minimal doses of induction agents should be
placement of abdominal viscera. In some animals with used to avoid the hypotensive and respiratory depressant
chronic diaphragmatic hernia, adhesions form between effects of these drugs, and intubation should proceed
the lungs and abdominal viscera. These can usually be rapidly after induction, followed by ventilation with oxy-
gently broken down with digital pressure. The lungs gen and gas anesthesia.12
should be inspected for lacerations that may have oc- Reexpansion pulmonary edema can occur in animals
curred during the inciting trauma or as adhesions were with diaphragmatic hernia, particularly when chronic
divided. Small (i.e., 5 mm or less) superficial lacerations atelectasis is present. The most common cause of reex-
will heal spontaneously, but larger defects should be pansion pulmonary edema in humans is rapid genera-
closed with staples or sutures. Nonviable tissue should tion of negative intrapleural pressure, resulting in leak-
be identified and resected if possible. age of protein-rich fluid into the alveoli of reexpanded
Debridement of the diaphragm is only necessary if lungs.41 The pathogenesis is thought to involve the acti-
mature scar tissue covers the edges of the defect. Care vation of neutrophils and, potentially, the generation of
must be taken to avoid damage to the caudal vena cava, free radicals that leads to increased microvascular per-
both as the hernia opening is enlarged or debrided and meability.42-46 The rapidity with which lungs are rein-
as sutures are placed during closure. It is usually possi- flated is thought to be more important than the duration
ble to close diaphragmatic defects with available tissue; of collapse.41 During surgery, peak airway pressures dur-
however, muscle flaps, omentum, autologous fascia, or ing assisted ventilation should not exceed 20 cm H2O,
synthetic materials can be used to close large defects.2 and increased end-expiratory pressure should be
These procedures should be used judiciously because avoided. As long as the animal is adequately oxy-
they may result in additional hemorrhage and increased genated, it is not critical that the lungs are fully inflated
anesthetic time. Before closure of the defect, a thoracos- during surgery, and intrapleural air or fluid can be evac-
tomy tube should be placed for evacuation of the chest. uated slowly over 12 hours via the thoracostomy
Closure should begin at the most dorsal aspect (usually tube.7,41 Fortunately, reexpansion pulmonary edema
the most difficult to reach) of the diaphragmatic defect. does not occur commonly after diaphragmatic hernia re-
The defect in the diaphragm is closed with monofila- pair. If pulmonary edema develops, prompt treatment
ment absorbable or nonabsorbable suture in a continu- should be initiated including oxygen supplementation;
ous pattern. positive-pressure ventilation, if necessary; and judicious
According to one study, approximately 15% of di- use of diuretics.41 The thoracostomy tube should be
aphragmatic hernia cases die before examination.34 Of maintained for at least 12 to 24 hours, and the patient
the cases treated for traumatic diaphragmatic hernia, should be monitored carefully postoperatively.7 The
survival rates as high as 78% for dogs and 92% for cats thoracostomy tube is removed when no further air is
have been reported.34 In a study comparing survival obtained and the volume of fluid has declined to less
rates for acute and chronic traumatic diaphragmatic her- than 5 ml/kg/24 hours.
nia cases, similar survival rates were observed after
treatment of acute and chronic diaphragmatic hernias in
dogs (72% and 74%, respectively), whereas the survival REFERENCES
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 CHAPTER 83 — Diaphragmatic Hernia 633

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