Diaphragmatic Hernia Medical Slides

Present the gentle ventilation paradigm: CDH lungs are hypoplastic and vulnerable to barotrauma. Peak inspiratory pressure (PIP) ≤25 cmH2O (permissive hypercapnia: accept pCO2 45-65 mmHg if pH >7.25). Pre-ductal SpO2 target >85% (do NOT chase normal saturations with aggressive ventilation). Conventional ventilation first → HFOV if failing conventional → ECMO if failing HFOV (ECMO criteria: OI >40 or inability to maintain preductal SpO2 >85% or pH <7.15). CDH-EURO consortium data shows survival >70% at experienced centers using gentle ventilation. Key teaching point: intubate immediately at birth (do NOT bag-mask — inflates stomach and compresses lungs further), place OG tube for gastric decompression. Delay surgical repair until hemodynamically stable — repair does NOT fix pulmonary hypoplasia.

Present the diagnostic pitfalls: acute blunt TDH — CXR sensitivity only 27-62% (left-sided: elevated hemidiaphragm, intrathoracic bowel gas, NGT above diaphragm; right-sided: often occult, diaphragm elevation mimics atelectasis). CT sensitivity improves to 78-100% (sagittal/coronal reconstructions essential — "dependent viscera sign" and "collar sign" are specific). Left-sided injuries are 3× more common clinically (right-sided may be protected by liver). Penetrating TDH — small diaphragmatic lacerations often missed on initial imaging, may present months/years later with incarceration/strangulation. Diagnostic laparoscopy or thoracoscopy is definitive for penetrating thoracoabdominal wounds with suspected diaphragmatic injury. All diagnosed TDH require surgical repair — no role for observation due to progressive herniation risk.

Present the giant paraesophageal hernia (PEH, type II-IV): >30% of stomach herniated into chest. Indications for repair: symptomatic (dysphagia, regurgitation, chest pain, anemia), acute presentation (gastric volvulus with strangulation is a surgical emergency — mortality 30-50% if not addressed). Laparoscopic repair is standard: complete sac excision, hernia reduction, crural closure (often with mesh reinforcement — biologic mesh preferred due to erosion risk with synthetic mesh at the hiatus, though evidence is mixed — Oelschlager 2006 showed mesh reduced recurrence from 24% to 9% at 6 months). Add fundoplication (Nissen or Toupet) to prevent GERD. Gastropexy (Boerema anterior gastropexy) may reduce recurrence. Recurrence rate remains the challenge: 15-40% radiographically, though most recurrences are small and asymptomatic.