Case Report
Volume 8 Issue 3 - 2021
Congenital Diaphragmatic Hernia with Massive Abdominal Contents
José Alberto Martinez Valdes1*, Xóchitl Serna Velazquez2, Héctor Armando Miranda Blasnich1, Paul Ernesto Charis Trujillo1, Jennifer Itzel Jacobo Godínez1, Manuel Cornish Estrada1, Alfredo Leonardo Ortiz Nieto1, Leslie Azarel Callejas Reyes1 and Ivan Hernadez Cuevas1
1General Surgeon, Department of General Surgery in “Hospital General Ticomán” General Hospital of Mexico City’s Health Secretariat, Universidad Nacional Autónoma de México, Mexico City, Mexico
2Perioperative Nurse, Hospital General de México, Universidad Nacional Autónoma de México, Mexico City, Mexico
*Corresponding Author: José Alberto Martinez Valdes, General Surgeon, Department of General Surgery in “Hospital General Ticomán” General Hospital of Mexico City’s Health Secretariat, Universidad Nacional Autónoma de México, Mexico City, Mexico.
Received: February 03, 2021; Published: February 11, 2021


Introduction: Congenital diaphragmatic hernia (CDH) is a congenital defect that occurs in about 1: 3000 to 5000 live births leading to communication between the abdominal and thoracic cavities during critical stages of development. The displacement of abdominal contents into the thoracic space during this time can cause pulmonary hypoplasia due to the mass effect of abdominal contents. The lung not only suffers from hypoplasia, but also lacks a normal vascular and bronchial branching pattern. This abnormal development leads to increased pulmonary vascular resistance and subsequent significant pulmonary hypertension. These two pathological conditions are the main source of morbidity and mortality in patients with CDH.

CDH can occur either on the right side of the diaphragm, on the left side or even in the least of cases may be bilateral. Within the most frequent hernias are left-sided and there are two main types: Morgani (anteromedial) and Bochdalek (posterolateral). Bochdalek hernias occur much more often and are usually associated with physiological disorders in the newborn.

While open surgery (thoracotomy or laparotomy) has traditionally been performed for patients with CDH, minimally invasive surgery (laparoscopy or thoracoscopy) has emerged as a safe and feasible alternative. Each technique has advantages and disadvantages. Minimally invasive surgery has a shorter duration of postoperative ventilation, less pain and short-term use of narcotics, faster recovery, shorter hospitalization, and less morbidity, such as thoracic wall deformities and small bowel obstruction unlike open surgery.

Purpose: Presentation of a clinical case at the Pediatric Hospital of Peralvillo, of the Health Secretariat in Mexico City, on a case of congenital diaphragmatic hernia with massive abdominal contents to the surgical community.

Results: We present a clinical case of a male patient with 35 weeks of pregnancy who experiences respiratory distress, having at physical examination, absence of respiratory noise in left hemithorax, heart noises predominantly in right hemithorax, as well as concave abdomen without auscultating peristaltic noises, is taken a chest X-ray, in which is evidenced a diaphragmatic hernia, as well as displacement of the cardiac silhouette to the right, and abdomen with ground glass image, so surgical management is decided, having as a finding a hernial defect in the posterolateral left face of the diaphragm with massive abdominal content, diaphragmatic plasty with tension is performed. Post surgery, its postoperative period is carried out in the neonatal ICU where gasometry is taken in which severe respiratory acidosis is reported, requiring invasive mechanical ventilation with increase in ventilatory parameters, use of aminergics and life support with drug products, with death 15 hours after surgery.

Discussion: Congenital diaphragmatic hernia (CDH) is a condition in which partial or complete agenesis of the diaphragm occurs, resulting in continuity between the chest and abdominal cavities, usually more common in males, occurs in about 1: 3,000 to 5000 live births. Left side CDH is more common than on the right side. The posterolateral left side of the diaphragm is the most common localization in 75 to 90% of cases (Bochdaleck's hernia) and 10% occurs in the anteromedial portion (Morgani's hernia); the defect on the right side occurs in 10 to 15%, it can even be bilateral in 1 to 2% of cases. The prevalence of CDH does not appear to be associated with maternal age.

The pathogenesis of CDH is not fully understood, however, the most accepted theory is failure in the closure of the pleuroperitoneal membrane or environmental factors altering the differentiation of mesenchymal cells during the formation of the diaphragm and other somatic structures.

Prenatal diagnosis of CDH is based on ultrasound. Usually, diagnosis is based on the presence of a mediastinal displacement and a fluid-filled stomach next to or just behind the heart. In some cases, the fetal liver may herniate into the chest and appear as an intrathoracic homogeneous mass at heart level. The defect in the right hemidiaphragm is more difficult to diagnose since on ultrasound the liver is similar in appearance to the fetal lung.

Patients with CDH management before surgery may take several different forms, but all maintain several basic principles: permissive hypercapnia (PaCO2, 45 - 60 mm Hg), maintaining oxygen saturation between 85% - 95%, minimizing the volutrauma index and barotrauma with conventional ventilatory strategies aimed at maintaining a positive inspiratory pressure less than 25 cm H2O with a positive pressure at the end of expiration between 2 and 5 cm H2O. The addition of inhaled nitric oxide can further decompress the pulmonary vascular bed. If these goals cannot be achieved with maximum medical therapy, extracorporeal membrane oxygenation (ECMO) is required to deliver oxygen and eliminate CO2. However, in terms of hernia repair surgically, it has several modalities, with an open or minimally invasive technique, with or without mesh and approached from the abdomen or chest.

Conclusion: Congenital diaphragmatic hernia is a rare entity, whose clinical presentation varies from mild symptoms to incompatible with life, depending on the degree of pulmonary hypoplasia and concomitant diseases. One of the main problems related to anesthetic management of these patients is ventilation. According to the severity of symptoms, it is used from pressure-controlled respiratory assistance to high-frequency oscillatory respiratory assistance and extracorporeal membrane oxygenation. Congenital diaphragmatic hernia remains a challenging condition with a little-known etiology and pathogenesis.

Keywords: Hernia; Congenital; Massive; Viscera; Bochdalek; Morgani; ECMO; FETO


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Citation: José Alberto Martinez Valdes., et al. “Congenital Diaphragmatic Hernia with Massive Abdominal Contents". EC Gastroenterology and Digestive System 8.3 (2021): 94-102.

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