Diaphragmatic Hernia

DIAPHRAGMATIC HERNIA
Ruli Sakarozi
CASE 1
Tn. M/50 th Trauma score:
RTS : 7,55
Mechanism ISS : 9
TTSS : 4
• The patient was stabbed on the lower left chest with a keris,
(approximately 10 cm long) while he was walking. The keris was
withdrawn immediately by perpetrator.
• The patient was fully conscious and had no history of hematemesis,
hemoptoe. There was no history of shock
• Then the patient was brought to the Primary Healthcare Center
(Puskesmas) where the wound was sutured  referred to the Sampang
hospital, the chest tube was inserted to the left hemithorax  referred
to the Dr Soetomo General Hospital.
ToAc : 05/08/2020 (14.00)

ToAr : 06/08/2020 (02.00)
Injury
• Sutured penetrating wound at Left hemithorax (ICS 7-8
anterior axillary line)
Chest X-Ray Sampang hospital (05/08/2020)
Sign
• BP = 120/90 mmHg
• HR = 95 bpm
• RR= 30 times/min
• T= 36,7oC
• SpO2 = 98% with nasal cannula 3 lpm
Treatment at sampang hospital
• Chest tube insertion #20 Fr hemithorax S  initial prod. 100 mL,
blood at Sampang Hospital
• O2 nasal canule 3 lpm
• IVFD PZ 20 dpm
• Inj. ATS 1500 IU im
• Inj. Ketorolac 30 mg iv
• Inj. Ceftriaxone 1 gr iv
Primary Survey (06/08/2020 02.00 am)
Airway : clear, spontaneous breath
C-spine stable
Additional breath sound (-), wound in airways area
and maxillofacial (-)
Breathing :
Simple Interrupted Sutured penetrating wound at Left
hemithorax (ICS 7-8), chest tube 20 Fr at left lower chest,
undulation (+), prod 100 mL, blood
RR 30 x/min, SpO2 98% with nasal cannula 3 lpm
symmetrical chest movement (+), retraction (-), crepitation
(-), tenderness (+) at left lower chest, sonor +|+
Vesicular |Vesicular, rhonchi -|-, wheezing -|-, bowel sound
(-)
• Circulation :
Perfusion warm, dry, red, CRT <2”
BP = 120/82 mmHg, without support, MAP 94.6 mmHg
Pulse = 90 bpm regular, strong
No active bleeding
Catheter no 16 Fr, urine production 600ml/7 hour, yellow,
clear
 Local Status at Abdomen :
I : flat (+), No injury was found in abdomen, inserted NGT
Feeding (no retention)
A: normal bowel sound
P: sign of free fluid (-), left hypochondrium tenderness (+)
P: tympani, liver dullness (+)
• Disability :
 GCS = E4 V5 M6
 pupil isochoric, 3 mm|3 mm, light reflexes +|+,
lateralization -|-
• Environment :
Simple interrupted sutured left hemithorax vulnus ichtum
(ICS 7-8)
DRE: Normal anal sphincter tone, smooth mucosa, blood
(-)
PROBLEMS
 Penetrating Thoracoabdominal Injury ICS 7-8 Left hemithorax
 Left Hematothorax on WSD
 Suspect rupture left diaphragm
Adjunct to Primary Survey (14/02/2020 02.45 AM)
• Hb= 15,7
• FAST = negative
• NGT production : No retention
Chest X-Ray Dr Soetomo BOF erect Dr Soetomo General Hospital
(06/08/2020 pk 03.00 AM)
General Hospital (06/08/2020
03.00 AM)
INITIAL ASSESSMENT (03.10)
 Penetrating Thoracoabdominal Injury stable HD
 Left Hematothorax on WSD
 Suspect left diaphragm rupture
Thoracoabdominal CT 08.00 am (6/8/2020)
 Rupture of the left anterior hemidiaphragm at the level of the 9th-11th thoracal vertebral, with a defect of
4.3 cm that causes herniation of the bowel and omentum into the left inferior thoracic cavity, with
hematopneumoperitoneum from epigastric to left hypochondriaca.
 No solid organ defects
 Laterobasal consolidation, posterobasal segment of the left inferior lobe and posterobasal segment of the
inferior lobe of the right lung can constitute contusion of the right lung and pneumonia.
 Left hematopneumothorax attached chest tube entry point ICS 5-6
 Emphysema subcutis left hemitorax lower lateral side
Adjuct to secondary survey Pk 03.00 (06/8/2020)
• Hb :15.7
• Wbc :7.090 • pH : 7,4
• Plt :244.000 • PCO2 : 35
• Na :143
• K :3,6 • Po2 : 152
• Cl :106 • Hco3 : 21.7
• BUN :17
• SK :0,9 • BE : -3.1
• SGOT :32 • SaO2 : 99%
• SGPT :37
• Alb :3,5 • PF Ratio : 475
• Glukosa :169
• PPT :15.4
• APTT :23.4
• HbsAg :Reactive
• Rapid covid-19 : Non reactive
ASSESSMENT
• Primary Dx : Penetrating thoracoabdominal injury
• Secondary Dx : HBsAg reactive
• Complication Dx : Left Hematothorax on WSD + Left

Diaphragm Rupture
Planning
Digestive:
• Immediate exploratory laparotomy
Cardiothoracic vascular surgery :

• Revised chest tube # 28 Fr left hemithorax , active suction -20cmH20
• Evaluation of durante Op Laparotomy  Exploratory thoracotomy
DURANTE OF LAPAROTOMY OP 03.00 PM
Findings:
• Minimal peritoneal fluid is turbid, mixed with gastric content
• Rupture of the Left diaphragm in the anterolateral area with a defect size of +/- 5x4
cm with herniation of the left transverse colon and part of the omentum in the left
thorax cavity
• Gastric rupture in the corpus with size +/- 2x2cm
• Gastric content spill into left hemithorax (+)
• Solid organ, small bowel, large bowel intact
Perform :
• Re-position of intra-abdominal organs (transverse colon and omentum) from thorax
cavity
• Primary gastric repair + omental patch
• Primary diaphragm repair
• Wash the abdominal cavity with normal saline 10 Lt
• Install a drain in subdiaphragm
• Suture layer by layer
• Operation continued by CTV
CRANIAL
Durante Op
DEXTRA
SINISTRA
• Left Diaphragm
Rupture on the
anterolateral Side
CAUDAL
Durante Op
CRANIAL
DEXTRA SINISTRA
Stomach
rupture
CAUDAL
Durante Op thoracotomy 07.30 pm (06/08/2020)
Findings:
• Gastric content, fibrin in the diaphragm and no lung
lacerations, fibrin on the basal side of the inferior lobe of
the left lung
Perform:
• Wash the thoracic cavity, drain insertion 28 #Fr
Durante Op (Thoracotomy) (06/08/2020)
CRANIAL
SINISTRA
DEXTRA
CAUDAL
Foto klinis
Traumatic Diaphragmatic Hernia
Introduction
• Congenital Diaphragmatic Hernia (CDH)
• Bochdalek hernia: most common (95%), located
posterolaterally (side and back) and usually present in
infancy
• Morgagni hernia: smaller, anterior and presents later in
life, through the sternocostal angles
• Acquired
• Traumatic diaphragmatic rupture through either
penetrating injury (65%) or blunt trauma (35%)
• Hiatus hernia
• Iatrogenic
Leslie V. Simon; Richard A. Lopez; Bracken Burns. 2020. Diaphragm Rupture. NCBI StatPearls Publishing LLC.
Anatomy & Physiology
B C
A
Mallory Williams. 2020. Recognition and Management of Diaphragmatic Injury in Adult. https://teksmedik.com/uptodate20/d/topic.htm?path=recognition-and-
management-of-diaphragmatic-injury-in-adults
PATOPHYSIOLOGY
Penetrating Diaphragmatic Injury
• The location can be quite variable, from the T4 through T12 dermatome anteriorly
and the L3 region posteriorly should be potentially caused the diaphragmatic
injury. Penetrating injuries most measuring less than 2 cm so it can be more
delayed in diagnosis. Penetrating injuries are most commonly associated with liver,
hollow viscous, and splenic injuries.
Blunt Diaphragmatic Injury
• Rupture of the diaphragm occurs when intra-abdominal pressure suddenly rises
above the tensile strength of the diaphragmatic tissue. Like penetrating injury,
blunt diaphragmatic injuries occur most frequently on the left side which may be
due to a congenital area of weakness in the diaphragm or because the liver
attenuates some of the compressive force.
• Diaphragmatic injuries rarely occur alone and most patients have concomitant
abdominal, head or thoracic injuries.
Ernest E. More. Mattox Kenneth L. et all. 2017. Trauma 8 ed. Mac Graw Hill. USA
History and Physical Examination
• Clinical presentation varies widely 1

based on the mechanism of injury,
2
• Gimes Calssification, three phase : 4
acute, latent, obstruction. 3
• A physical exam should focus on
the airway, breathing, and
circulation.
https://www.google.com/url?sa=i&url=https%3A%2F%2Ffetus.ucsf.edu
%2Fcdh&psig=AOvVaw08I2QpAfKbhRP6bqzrrw5U&ust=1612409790309000&source=im
ages&cd=vfe&ved=2ahUKEwiykcXX5MzuAhXfgEsFHTIyCJEQjRx6BAgAEAc
Con’t
• 10-50% delayed diagnostic for days or weeks  visceral or

bowel herniation into the chest cavity  Strangulation,
incarceration and even cardiac tamponade
• In the setting of acute trauma, many patients cannot relate
their symptoms or medical history due to altered mental status
(eg, neurologic injury, intoxication) or because they are
intubated and sedated.
Evaluation & Diagnostic
• Clinically Asymtomatic
• Ultrasonography  EFAST
• CBC, ABG.
• Chest X-Ray (sens 27-62%
left side, 18-33% right
side)  malposition
NGT/OGT
• CT scan (sens 71-100%,
spec 75-100%, improved
78-100% if only left side)
Algorithms of TDI
Management
Technique for two-layer repair of diaphragmatic defect

Repair of acute diaphragmatic Rupture
• The two principles are complete reduction of the herniated organs back into the abdominal
cavity and watertight closure of the defect to prevent recurrence.
• Best performed via an exploratory laparotomy
• The right hemidiaphragm is best inspected after transection of the falciform ligament and
downward traction of the liver. The left hemidiaphragm can be inspected by applying gentle
downward retraction of the spleen and greater curvature of the stomach.
• Larger defects, maybe repaired in a number of different ways, including interrupted figure of
eight or horizontal mattress sutures, a running hemostatic suture line, or a double layer
repair, using a combination of the two methods. Generally, a no. 1-nonabsorbable
monofilament placed in an interrupted fashion for the repair of traumatic diaphragmatic
defects.
• For integrity of the suture line may be tested by increasing intrathoracic pressure with the
administration of large tidal volumes and assessment of diaphragmatic motion. This
maneuver is repeated with the field flooded with sterile saline to determine if there is escape
of air
Ernest through
E. More. theL. etsuture
Mattox Kenneth line.8 ed. Mac Graw Hill. USA
all. 2017. Trauma
Amy A. McDonald, MD, Bryce R.H. Robinson. 2018. Evaluation and management of traumatic diaphragmatic injuries: A PracticeManagement Guideline from the
Eastern Association for the Surgery of Trauma. J Trauma Acute Care SurgVolume 85, Number 1
Repair of Chronic diaphragmatic Injury
• Patients who small, undetected, diaphragmatic
lacerations may remain asymptomatic or may
experience a progressive increase in visceral herniation
of the omentum or all or a portion of a hollow viscus.
• Can be repaired either transabdominally or
transthoracically (to allow for lysis of intrathoracic
adhesions). Combined approach may be indicated to
complete the procedure safely and effectively.
• If the procedure cannot be completed at laparotomy, 
patient repositioned for a posterolateral thoracotomy
(more easy to visualized posterior diaphragm than an
anterolateral approach).
• Deffect < 8 cm can be primary repair, >8 cm repair with
prosthetic material (PTFE) (running suture with no. 0 Technique for repair of the diaphragm using a prosthetic.
nonasorbable.
Algorithm for repair of an acute or chronic diaphragmatic defect.
Use of Mesh ??
• In the rare instance that primary repair is not possible due to
excess diaphragmatic tissue loss or chronic expansion of the
defect (Grade IV or V injury), nonabsorbable prosthetic materials
(eg, polytetrafluoroethylene, polyethylene) can be used,
provided no colonic contamination is present.
• When contamination is present, the abdomen is copiously
irrigated and an autologous tissue flap (eg, omentum, latissimus
dorsi flap) or a bioprosthesis should be used.
Debatabel, how and when to
thoracotomy on diapghragmatic
rupture???
Kapan dilakukan thoracotomy?
CASE 2
An. MR/16 tahun/BB 40 kg
RIWAYAT PERJALANAN PENYAKIT
27 NOV 2020 5-15 DESEMBER 17-28 DESEMBER
10 JANUARI 2021 16 JANUARI 2021
2020 2020
-Nyeri -hematemesis
-Muntah 3-4x/hari isi -Nyeri kolik abdomen -rujuk
kolik -muntah hijau
makanan yg dimakan -Muntah 3-4x/hari isi RSDS
abdomen -belum bab 1
makanan yg dimakan
minggu
-pola bab berubah
-bisa flatus
2-3x/minggu
Lab hb 8,6
-BB turun 8 kg
Kalium 2,6
USG abdomen: dilatasi
intestine
MRS DI RS SAKINAH MOJOKERTO

THORAX FOTO
13 JANUARI
16 JANUARI
Tip NGT
13 JANUARI 16 JANUARI
USG MARKER TGL 17/1/2021
Tampak intensitas echo cairan bebas minimal di mid axillary

line dan midscapulare line hemithorax kiri di sertai gambaran
bowel hingga setingga subscapula kiri
CT THORACOABDOMINAL 17/1/2021
OPERASI
Ileum adhesi
Defek pada diafragma
terhadap pulmo
diameter 8 cm Jahit tutup defek
lobus superior
Congenital Diaphragmatic Hernia (CDH)
• Bochdalek hernia: most common (95%), located posterolaterally (side

and back) and usually present in infancy
• Morgagni hernia: smaller, anterior and presents later in life, through
the sternocostal angles
Locicero Joseph., 2019. H.Feins Richard. Shield General Thoracic Surgery 8ed. Walter Kluwer. USA
Embryology
• Prior to week 4 of gestation the coelomic cavity comprises the entire
span of the embryo without separation into a thorax and abdomen 
embryologic development the diaphragmatic precursors of the
mesoderm become defined and mobilized—lateral extension of the
septum transversum toward the lateral margins of the
pleuroperitoneal fold (PPF) bridge the coelomic gap to form the
membranous (central tendon) and the muscular diaphragm.
• The developing lung occupying that space above the developing
diaphragm is thought to provide the “sealant” for all of the above
contributors to the diaphragm. The process is complete by the end of
the first trimester. In this model, it is believed that Bochdalek hernias
arise from failure of the PPF and mesenchyme to give rise to the
central tendon and the muscular diaphragm.
Patophysiology
• The most significant anatomic feature of Bochdalek CDH is the
posterolateral diaphragmatic defect. Most life-threatening feature of
Bochdalek and agenesis CDH is respiratory insufficiency and pulmonary
hypertension from underlying pulmonary hypoplasia.
• Pulmonary hypoplasia associated with CDH is the single leading factor
of CDH mortality and morbidity but it appears to be different from
other congenital conditions associated with pulmonary hypoplasia such
as omphalocele or Potter syndrome.
• Pulmonary hypoplasia associated with CDH can affect both lungs and
ranges from mild to a level of severity that is incompatible with life.
Pulmonary hypertension remains one of the leading causes of death in
CDH neonates.
Barrel-shaped chest Scaphoid abdomen
Associated Syndromes And Conditions
• CDH infants present at birth with other anomalies including
cardiac, urogenital, pulmonary, and brain or spinal cord defects.
• CDH is seen with chromosomal aneuploidy such as Trisomy 13,
18, and 21. Known genetic syndromes variably associated with
CDH include Cornelia de Lange syndrome, Fryns syndrome,
Matthew-Wood syndrome, Denys–Drash syndrome, and
Donnai–Barrow syndrome.1
Management
1. Perinatal resuscitation
2. Respiratory management insertion of a nasogastric tube for
bowel decompression, intravenous access and application of
oxygen by noninvasive means, or invasive endotracheal
intubation if respiratory compromise is apparent. Use of
noninvasive positive-pressure respiratory support (i.e., nasal or
bag-mask CPAP) must be avoided, as it leads to further
gaseous distension of the herniated viscera that may further
exacerbate cardiorespiratory compromise
• Chest X-ray
Con’t
3. Ventilator management  not only support the pulmonary

insufficiency of the CDH infant but also to minimize right-to-
left shunting through the patent ductus arteriosus (PDA).
• No Hyperventilation, PEEP <5 mmHg  prevent ventilator-induced
lung injury
4. Pulmonary hypertension management  remain a chalanges
(prostaglandin E1 (PGE1) for PDA can be sufficient to reverse
the hemodynamic instability but not improve OS  ECMO +
iNO.
Con’t
• ECMO (raised OS) :
Indication
• Inability to maintain preductal oxygen saturations >85%
• Peak inspiratory pressure >28 cm H2O, mean airway pressure >15
• Pressure-resistant hypotension
• Inadequate oxygen delivery based on persistent metabolic acidosis or
rising serum lactate level
• Inability to wean from FiO2 100% in the first 48 hours of life.
• Birth weight >2 kg, gestational age >34 weeks, absence of intracranial
hemorrhage >grade I, and absence of other congenital or
chromosomal anomalies
Late Presentation
• All clinicians involved in the care of CDH infants recognized that

those Bochdalek CDH infants who present after the neonatal
period are significantly different physiologically from those who
present prenatally or in the immediate neonatal period.
• CDH Study Group reported that infants who present with CDH
after age 30 days were likely to present with respiratory or
gastrointestinal symptoms, unlikely to require patch repair and
have excellent (100%) survival to discharge
Operative Management
• The goal of surgical treatment of CDH is the reduction of the herniated

contents and closure of the diaphragmatic defect—either primarily or
with a patch, using nonabsorbable sutures.
• Increased incidence of patch infection, bowel obstruction, diaphragmatic
hernia recurrence, and development of chest and abdominal wall
deformities)
• Today, optimal management includes delay in operative repair, which is
no longer urgently anticipated after the infant arrives in the intensive care
unit, as was practiced up to the early 1990s, until cardiorespiratory
stabilization is achieved.
• Delayed repair has the potential advantage of improving outcome
CASE 3
Anamnesa (P/52 th)
• Keluhan utama: Sesak nafas sejak 7 hari yang lalu
• Riwayat penyakit sekarang: pasien datang rujukan dari RS RKZ IGD dengan
diagnosis Hernia Diafragmatika (S) pasien APS pindah rumah sakit karena
punya BPJS. Awalnya 7 hari yang lalu, pasien mengeluhkan tiba-tiba sesak
nafas, tidak ada batuk, mual & muntah banyak, sehari bisa > 5 kali. Diikuti
dengan tidak bisa BAB dan kentut sejak 7 hari yang lalu. Perut tidak
kembung, makan dan minum terasa sulit karena setiap kali makan minum
selang beberapa saat pasien muntah-muntah.
• Pasien tidak ada riwayat terbentur di perut (trauma/kecelakaan) sebelumnya,
tidak ada riwayat change of bowel habit dalam 3 bulan terakhir ini.
• Pasien sebelumnya langsung berobat ke RS RKZ ke dokter penyakit dalam,
dikatakan ada penyakit gastritis kronis ec GERD, diberikan obat-obatan,
namua keluhan tidak kunjung membaik
Anamnesa
RPD :
• DM disangkal
• HT disangkal
• Riwayat sakit keganasan keluarga disangkal pasien
RPK
• Tidak ada anggota keluarga mengeluh sakit serupa dengan pasien
70
Pemeriksaan Fisik
• Keadaan Umum : cukup
• Vital Sign : TD 1113/87mmHg , N: 90x/menit, RR: 20-22x/m, SpO2 99% free air
• Status Generalis :
– Kepala/Leher : tidak anemis dan ikterik
– Thoraks : cor: S1S2 tunggal, reguler murmur(-), gallop(-)
pulmo: vesikuler/vesikuler, rhonki -, wheezing -.
terdengar suara peristaltic usus di Hemithorax (S)
– Abdomen:
I : fatty, darm contour (-), darm steifung (-)
A: Bising usus ada - lemah
P: supel, defans tidak ada
P: Timpani, pekak hepar ada
– Ektremitas : akral Hangat Kering Merah, CRT < 2’
Hasil Laboratorium (9/12/2020)
Lab 9/12/2020 11/12/2020 13/12/2020 BGA 9/12/2020
Hb/Leu/PLT 14/5.79/304 13,1/6,06/3 PH 7,46
18 PCO2 35
CRP 1,7 PO2 70
Bil D/T 0,13 HCO3 24,9
Albumin/GDA 3,4/113 BE 1,1
Na/K/Cl 137/4,8/96 P/F ratio 371
BUN/SK 28/0,7 FiO2 21
SGOT/SGPT 42/11
PTT/APTT
HbsAg
Rapid Covid
HIV
Swab covid 19 Negatif
Thorax RS Bhayangkara (04/12/2020)
Thorax RS Katolik (08/12/2020)
BOF/LLD RS Katolik (08/12/2020)
BOF/LLD RS Katolik (08/12/2020)
CT Scan abdomen RSDS (9/12/20)
• Hernia diafragmatika kiri sisi posterior

dengan luas defek AP +/- 10,3 cm,
setinggin VTh 9 disertai volvulus gaster
mesentero-axial dengan herniasi phylorus
dan sebagian duodenum yang masuk ke
cavum thorax melalui defek tersebut
menyempitkan phylorus dan sebagian
duodenum yang menyebabkan dilatasi
dari corpus gaster
• Lymphnode subcentimeter di mesenterium
• Bekas keradangan paru
• Spondilosis lumbalis
KESAN
• Saat ini secara radiologis, cor dan
paru tak tampak kelainan
• Hernia diafragmatika kiri
Dx primer: Hernia paraesofageal sinistra (K44)
Diagnosa Dx sekunder: -
Dx komplikasi: -
Tindakan Endoscopy (melihat pilorus) + Repair Hernia Hialoplasti Per Laparotomi (53.7)
Deskripsi Didapatkan :
• Defek pada hiatus ukuran 5x2 cm
• Isi kantong bagian corpus dan omentum
• gaster dialtasi + , massa -
• EGD : preop : tak bisa masuk
• EGD : post op : cardia, corpus, antrum, pilorus, duodenum, mukosa licin +, massa -
Dilakukan :
• kembalikan isi hernia ke cavum abdomen
• identifikasi defek > herniotomy + hialoplasty
• fundoplikasi toupet
Diagnosa Dx primer: Hernia paraesofageal sinistra (K44)

Dx sekunder: -
post op Dx komplikasi: -
EGD Pre op
EGD Pre op
EGD Durante op
EGD Durante op
Durante Op
Durante Op
Durante Op
Durante Op
Hiatal Hernia
• Type I or sliding hiatus hernia is characterized by the displacement of the gastroesophageal
junction above the diaphragm. The stomach remains in its usual longitudinal alignment, and the
fundus remains below the gastroesophageal junction.
• Type II or "true" paraesophageal hernia results from a localized defect in the phrenoesophageal
membrane where the gastric fundus serves as a lead point of herniation, while the gastroesophageal
junction remains fixed to the preaortic fascia and the median arcuate ligament
• Type III or "mixed" paraesophageal hernias have elements of both types I and II hernias and are
characterized by both the gastroesophageal junction and the fundus herniating through the hiatus.
The fundus lies above the gastroesophageal junction.
• Type IV paraesophageal hernia is associated with a large defect in the phrenoesophageal
membrane and is characterized by the presence of organs other than the stomach in the hernia sac
(eg, colon, spleen, pancreas, or small intestine).
Abhishek Chaturvedi.,Prabhakar Rajiah. 2018. Imaging of thoracic hernias: types and complications. https://doi.org/10.1007/s13244-018-0670-x
Difference Thoracic Hernia, Their Finding, mimics and
Treatment
Abhishek Chaturvedi.,Prabhakar Rajiah. 2018. Imaging of thoracic hernias: types and complications. https://doi.org/10.1007/s13244-018-0670-x
REFFERENCES
• Ernest E. More. Mattox Kenneth L. et all. 2017. Trauma 8 ed. Mac Graw Hill. USA
• Locicero Joseph., 2019. H.Feins Richard. Shield General Thoracic Surgery 8ed. Walter
Kluwer. USA
• Abhishek Chaturvedi.,Prabhakar Rajiah. 2018. Imaging of thoracic hernias: types and
complications. https://doi.org/10.1007/s13244-018-0670-x.
• Amy A. McDonald, MD, Bryce R.H. Robinson. 2018. Evaluation and management of
traumatic diaphragmatic injuries: A PracticeManagement Guideline from the Eastern
Association for the Surgery of Trauma. J Trauma Acute Care SurgVolume 85, Number 1
• Leslie V. Simon; Richard A. Lopez; Bracken Burns. 2020. Diaphragm Rupture. NCBI
StatPearls Publishing LLC.
• Mallory Williams. 2020. Recognition and Management of Diaphragmatic Injury in Adult.
https://teksmedik.com/uptodate20/d/topic.htm?path=recognition-and-management-of-
diaphragmatic-injury-in-adults

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Diaphragmatic Hernia

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DIAPHRAGMATIC HERNIA

ToAc : 05/08/2020 (14.00)

• Primary Dx : Penetrating thoracoabdominal injury

• Secondary Dx : HBsAg reactive

• Complication Dx : Left Hematothorax on WSD + Left

Cardiothoracic vascular surgery :

• Clinical presentation varies widely 1

• 10-50% delayed diagnostic for days or weeks  visceral or

Technique for two-layer repair of diaphragmatic defect

MRS DI RS SAKINAH MOJOKERTO

Tampak intensitas echo cairan bebas minimal di mid axillary

• Bochdalek hernia: most common (95%), located posterolaterally (side

3. Ventilator management  not only support the pulmonary

• All clinicians involved in the care of CDH infants recognized that

• The goal of surgical treatment of CDH is the reduction of the herniated

• Hernia diafragmatika kiri sisi posterior

Diagnosa Dx primer: Hernia paraesofageal sinistra (K44)

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