Laparoscopic Repair of Traumatic
Diaphragmatic Hernia
Marc Zerey, MD, FRCSC, B. Todd Heniford, MD, FACS, and
Ronald F. Sing, DO, FACS, FCCP
D iaphragmatic injuries are not uncommon with rates as
high as 5% for patients hospitalized after motor vehicle
accidents, and 15% for patients after penetrating injuries to
the lower chest and upper abdomen.1-3 Left-sided rupture is
more common than right-sided rupture (68.5% vs. 24.2%,
respectively), owing to hepatic protection and increased
strength of the right hemidiaphragm.4
During the initial evaluation and hospitalization of the
trauma patient, diaphragmatic injuries from either penetrat-
ing or blunt thoracoabdominal trauma frequently are missed.
Investigative techniques to diagnose traumatic diaphrag-
matic injuries [chest roentgenogram, diagnostic peritoneal
lavage, ultrasound, and computed tomography (CT) scan]
are limited by their low sensitivity and high false-negative
rates.5,6 Reports have documented the effectiveness of lapa-
roscopy as a means to diagnose intraabdominal injury in
penetrating thoracoabdominal trauma. The surgeon may ef-
fectively visualize abnormal fluid collections as well as injury
to the peritoneum or diaphragm with the introduction of a
laparoscope. If there are no apparent signs of visceral injury it
is mandatory that the surgeon perform a systemic examina-
tion of the supra- and infracolic compartment and pelvis. The
intestines should be run using as many additional ports as
necessary and the lesser sac inspected through a defect in the
lesser omentum and gastric traction and elevation. When a
diaphragmatic laceration or hernia has been identified, repair
is mandatory. Latent repair of missed traumatic diaphrag-
matic hernias has been associated with a 20% to 36% mor-
tality rate.7,8
Over the past decade, a select group of trauma surgeons
and advanced laparoscopic surgeons have applied minimally
invasive surgical techniques for the repair of acute diaphrag-
matic lacerations and chronic traumatic diaphragmatic her-
nias.9-12 The laparoscopic repair in the acute setting is limited
by the frequent presence of concomitant injuries that reflect
Department of Trauma, Division of Gastrointestinal and Minimally Invasive
Surgery, Carolinas Medical Center, Charlotte, NC.
Address reprint requests to Ronald F Sing, DO, FACS, FCCP, Department of
Trauma, Division of Gastrointestinal and Minimally Invasive Surgery,
Carolinas Medical Center, 1000 Blythe Blvd MEB 601, Charlotte NC
28203. E-mail: Ron.Sing@carolinashealthcare.org
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2006.04.006
the severity of the traumatic event. The laparoscopic repair of
chronic diaphragmatic hernias is more difficult because of
entrapment of organs and presence of adhesions. Symptoms
of a chronic diaphragmatic hernia are related to the incarcer-
ation of abdominal contents in the defect or to impingement
of the lung, heart, or thoracic esophagus by abdominal vis-
cera and include abdominal pain, respiratory distress, and
cardiac dysfunction.
Nevertheless, with the recent increase in the proficiency in
laparoscopic technique, the number of patients having this
condition dealt with laparoscopically is increasing.
Once the diagnosis is made, operative repair is mandated.
The decision to proceed laparoscopically depends on the
hernia itself, the patient, and the surgeon. A hernia amend-
able to laparoscopic repair is one that is typically located on
the left side, that may or may not communicate with the
esophageal hiatus but that is less than 10 cm in diameter. The
surgeon must possess advanced laparoscopic skills to per-
form dissection and intracorporeal knot tying. The presence
of multiple injuries is not necessarily a contraindication to
laparoscopic repair unless the patient is unstable.
Operative Techniques
Positioning of Patient and Surgeon
The patient is placed in the supine position with legs apart
enough to accommodate the operating surgeon (see Fig. 1).
The first assistant is located to the patient’s left and second
assistant (laparoscope operator) to the patient’s right. We
favor entry into the abdominal cavity using the open Hasson
technique where a 10-mm port will be placed. Use of a 30-
degree (and occasionally a 45-degree) laparoscope is re-
quired. After CO2 insufflation, an exploratory laparoscopy is
performed to verify the presence of concomitant injuries or
conditions in addition to visualizing the hernia. Four addi-
tional 5-mm ports are placed along the subcostal margin at
the right midclavicular, subxiphoid, left midclavicular, and
left anterior axillary positions.
Primary Repair of Diaphragmatic Injury
Following visualization of the hernia defect (see Fig. 2), the
decision to repair primarily depends on the ability to approx-
27
28
Figure 1 Positioning.
imate the edges without undue tension. The standard repair
involves placement of simple, horizontal mattress (Fig. 2B,
C) or figure-of-eight zero or number one nonabsorbable
braided sutures. After the suture is placed across the defect
the needle is cut and the two free ends are kept together using
a titanium clip. This process is repeated to avoid blindingly
placing a needle across the defect and injuring structures in
the chest or mediastinum. Once all the sutures have been
placed the clip is removed and sutures are progressively tied
intracorporeally. A red rubber catheter may be placed in the
pleural cavity and the air suctioned as the final suture is tied
to minimize a postoperative pneumothorax. Alternatively, a
chest tube should be placed in the presence of lung injury.
Repair of Diaphragmatic Injury Using
Prosthetic Biomaterial
Laparoscopic visualization reveals incarcerated abdominal
viscera through diaphragmatic defect (see Fig. 3). Laparo-
scopic grasper and scissors are used to reduce hernia con-
tents. Use of electrocautery or harmonic instruments is
avoided to prevent injury to hernia contents and structures
present in thoracic cavity and mediastinum (Fig. 3B). When
it has been determined that hernia will be unable to be closed
without undue tension, prosthetic biomaterial is required
(Fig. 3C). Prosthetic repairs are performed with expanded
polytetrafluoroethylene (ePTFE) mesh (Soft Tissue Patch,
W.L. Gore & Associates, Flagstaff, AZ) secured by 0 or 1
M. Zerey, B.T. Heniford, and R.F. Sing
nonabsorbable braided suture, ensuring some overlap be-
yond the diaphragmatic defect (Fig. 3D).
Results
We recently reported on the feasibility and limitations of a
laparoscopic approach for the repair of acute traumatic dia-
phragmatic lacerations and chronic traumatic diaphragmatic
hernias.13 Thirteen traumatic diaphragmatic injuries were re-
paired laparoscopically with four (two acute and two
chronic) requiring conversion. Among the laparoscopically
repaired diaphragmatic injuries, three defects (chronic) were
repaired using ePTFE and nine were repaired primarily. The
mean length of the diaphragmatic defects was 4.6 cm (range,
1.5-12 cm). The mean operative time was 134.7 minutes
(range, 55-200 minutes). The mean estimated blood loss was
108.5 mL (range, 30-500 mL), and the postoperative length
of stay was 4.4 days (range, 1-12 days). There were no intra-
operative complications, but three patients developed pul-
monary complications (atelectasis/pneumonia). Follow-up
evaluation was available for 11 patients. There were no doc-
umented recurrences after a mean follow-up period of 7.9
months (range, 1 week to 24 months). Conversion resulted
from a reluctance or inability to perform laparoscopic suture
of transverse diaphragmatic lacerations longer than 10 cm
anterior to the esophageal hiatus and adjacent to the pericar-
dium (n ⫽ 2) or communicating with the esophageal hiatus
(n ⫽ 2). The four patients undergoing laparotomy had a
Laparoscopic repair of traumatic diaphragmatic hernia 29

Figure 2 (A) Diaphragmatic hernia seen laparoscopically; (B) placement of Ethibond suture (Ethicon Inc., Somerville,
NJ) across defect; (C) intracorporeal knot tying to close defect; (D) repaired diaphragmatic hernia.

mean postoperative discharge date of 8.7 days (range, 6-14
days).
The feasibility of repairing acute diaphragmatic lacerations
and chronic traumatic diaphragmatic hernias laparoscopi-
cally appears to be based mostly on experience but also on
location. Hernias directly communicating with the esopha-
geal hiatus or anterior to the esophageal hiatus and adjacent
to the pericardium are extremely difficult to repair using a
minimally invasive approach. Anterior to the esophageal hi-
atus the diaphragm is thin, taut, relatively immobile, and in
close proximity to the pericardium. The immobility of the
diaphragm anterior to the esophageal hiatus also impedes
visualization cephalad into the mediastinum, even with an
angled laparoscope. Sutures placed too deep in this location
30 M. Zerey, B.T. Heniford, and R.F. Sing

Figure 2 Continued
Laparoscopic repair of traumatic diaphragmatic hernia 31

Figure 3 (A) Diaphragmatic hernia with incarcerated abdominal viscera; (B) reduction of hernia contents and mobili-
zation of hernia sac; (C) placement of ePTFE mesh onto diaphragmatic defect; (D) repaired diaphragmatic hernia with
ePTFE mesh.
32 M. Zerey, B.T. Heniford, and R.F. Sing

Figure 3 Continued
Laparoscopic repair of traumatic diaphragmatic hernia
Table 1 Indications and contraindications of laparoscopic re-
pair of diaphragmatic hernia
Indications Contraindications
Presence of hernia Unstable patient (absolute)
Hernia > 10 cm (relative)
Hernia communicating with
esophageal hiatus (relative)
may violate the pericardium, and sutures placed too superfi-
cially risk hernia recurrence. The hemidiaphragm is more
mobile laterally and near the central tendon, and greater vi-
sualization is provided by retracting the edges of the defect
and placing the laparosocope into the hemithorax. Table 1
References
1. Brandt ML, Luks FI, Spigland NA, et al: Diaphragmatic injury in chil-
dren. J Trauma 32:298-301, 1992
2. Ward RE, Flynn TC, Clark WP: Diaphragmatic disruption secondary to
blunt abdominal trauma. J Trauma 21:35-38, 1981
3. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic
33
laparoscopy for penetrating abdominal trauma: A multicenter
experience. J Trauma 42:825-829, 1997; discussion 829-831
4. Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic rupture
of diaphragm. Ann Thorac Surg 60:1444-1449, 1995
5. Aronoff RJ, Reynolds J, Thal ER: Evaluation of diaphragmatic injuries.
Am J Surg 144:571-575, 1982
6. Schneider C, Tamme C, Scheidbach H, et al: Laparoscopic management
of traumatic ruptures of the diaphragm. Langenbecks Arch Surg 385:
118-123, 2000
7. Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation of
traumatic diaphragmatic hernia. Ann Surg 188:229-233, 1978
8. Madden MR, Paull DE, Finkelstein JL, et al: Occult diaphragmatic
injury from stab wounds to the lower chest and abdomen. J Trauma
29:292-298, 1989
9. Cougard P, Goudet P, Arnal E, Ferrand F: Treatment of diaphragmatic
ruptures by laparoscopic approach in the lateral position. Ann Chir
125:238-241, 2000
10. Matz A, Landau O, Alis M, et al: The role of laparoscopy in the diagnosis
and treatment of missed diaphragmatic rupture. Surg Endosc 14:537-
539, 2000
11. Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic inju-
ries: Spectrum of radiographic findings. Radiographics 18:49-59, 1998
12. Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmatic
rupture: Associated injuries and outcome. Ann R Coll Surg Engl 82:97-
100, 2000
13. Matthews BD, Bui H, Harold KL, et al: Laparoscopic repair of traumatic
diaphragmatic injuries. Surg Endosc 17:254-258, 2003