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Do not confuse with: [[Hiatal Hernia]], [[Hernia, Peritoneopericardial Diaphragmatic|Peritoneopericardial Hernia]], [[Hernia, Pleuroperitoneal Diaphragmatic|Pleuroperitoneal Hernia]], Congenital Diaphragmatic Hernia

| Do not confuse with:

|'''[[Hiatal Hernia]]<br>

'''[[Hernia, Peritoneopericardial Diaphragmatic|Peritoneopericardial Hernia]]<br>

'''[[Hernia, Pleuroperitoneal Diaphragmatic|Pleuroperitoneal Hernia]]<br>

'''Congenital Diaphragmatic Hernia'''

==Description==

==Description==

[[Image:stomach diaphragmatic hernia.jpg|thumb|right|150px|Post-mortem image of displacement of the stomach into the thorax through a diaphragmatic rupture (Copyright BioMed Image Archive, all rights reserved)]]

[[Image:stomach diaphragmatic hernia.jpg|thumb|right|150px|Post-mortem image of displacement of the stomach into the thorax through a diaphragmatic rupture (Sourced from BioMed Image Archive)]]

Rupture of the diaphragm is an acquired condition that often has a traumatic origin in small animals.  The rupture is not a true hernia as the parietal peritoneum is disrupted and displaced organs are not contained within a defined hernial sac.  Most cases occur in animals which have suffered blunt abdominal trauma with an open glottis, most commonly during a road traffic accident (RTA).  If the animal has a closed glottis at the moment of impact, the lung parenchyma is more likely to rupture.  Any of the peritoneal abdominal organs may move into the thorax, of which the most commonly herniated are the liver and small intestine.  In some cases, the stomach may be displaced into the thorax and, as its outflow is disrupted, it may become dilated and filled with gas.  This situation requires urgent surgical intervention.  Affected animals often have other injuries associated with the traumatic event, including:

Rupture of the diaphragm is an acquired condition that often has a traumatic origin in small animals.  The rupture is not a true [[Hernia|hernia]] as the parietal peritoneum is disrupted and displaced organs are not contained within a defined hernial sac.  Most cases occur in animals which have suffered blunt abdominal trauma with an open glottis, most commonly during a road traffic accident (RTA).  If the animal has a closed glottis at the moment of impact, the lung parenchyma is more likely to rupture.  Any of the peritoneal abdominal organs may move into the thorax, of which the most commonly herniated are the liver and small intestine.  In some cases, the stomach may be displaced into the thorax and, as its outflow is disrupted, it may become dilated and filled with gas.  This situation requires urgent surgical intervention.  Affected animals often have other injuries associated with the traumatic event, including:

*'''Thoracic injuries'''

*'''Thoracic injuries'''

**Pulmonary contusion

**Pulmonary contusion

*'''Broken claws'''

*'''Broken claws'''

*'''Fractured mandibular symphysis'''

*'''Fractured mandibular symphysis'''

*'''Pelvic, spinal or appendicular fractures''

*'''Pelvic, spinal or appendicular fractures'''

*'''Tail pull injuries'''

*'''Tail pull injuries'''

*'''Wounds'''

*'''Wounds'''

In most acute cases, animals must be stabilised before the tear in the diaphragm can be repaired surgically.  This may involve the following steps:

In most acute cases, animals must be stabilised before the tear in the diaphragm can be repaired surgically.  This may involve the following steps:

*Provision of '''oxygen''' to dyspnoeic animals, using a mask, flow-by or intra-nasal catheter.

*Provision of '''oxygen''' to dyspnoeic animals, using a mask, flow-by or intra-nasal catheter.

*'''Pleurocentesis''' if pleural effusion or pneumothorax are suspected.

*'''[[Pleurocentesis]]''' if pleural effusion or pneumothorax are suspected.

*Keeping the animal in '''sternal recumbency''' to allow more efficient thoracic excursion.

*Keeping the animal in '''sternal recumbency''' to allow more efficient thoracic excursion.

*'''Gastric decompression''' by orogastric tube or percutaneously if the stomach is though to be dilated.

*'''Gastric decompression''' by orogastric tube or percutaneously if the stomach is though to be dilated.

===Surgical Repair===

===Surgical Repair===

Traditionally, it was recommended that at least 24 hours elapse from the traumatic event until the rupture was repaired to reduce perioperative mortality but newer evidence suggests that, if animals are adequately stabilised before this, surgical repair may still be successful.  If possible, the repair should be conducted in the first week after rupture as fibrous adhesions begin to form after this time.  Post-operative mortality is also higher if the rupture is repaired after a very long interval (more than 1 year) due to the formation of extensive fibrous adhesions.  

Traditionally, it was recommended that at least 24 hours elapse from the traumatic event until the rupture was repaired to reduce perioperative mortality but newer evidence suggests that, if animals are adequately stabilised before this, surgical repair may still be successful <ref> Gibson TW, Brisson A and Sears W (2005): '''Perioperative survival rates after surgery for diaphragmatic hernia in dogs and cats: 92 cases''' J of the Am Vet Med Assoc '''227''' 105-109.</ref>.  If possible, the repair should be conducted in the first week after rupture as fibrous adhesions begin to form after this time.  Post-operative mortality is also higher if the rupture is repaired after a very long interval (more than 1 year) due to the formation of extensive fibrous adhesions.  

The defect is approached by a ventral midline coeliotomy (which may be extended cranially beside the xiphisternum or into a median sternotomy) and the abdominal organs are retracted.  Fibrinous adhesions can be easily separated but strangulated organs (such as torsed liver lobes or loops of small intestine) should be sacrificed and resected.  If the rupture has been present for a long period, its fibrous edges may be debrided before suturing using polydioxanone in a continuous pattern.  If there is a large defect that cannot be closed without tension, the following approaches may be used:

The defect is approached by a ventral midline coeliotomy (which may be extended cranially beside the xiphisternum or into a median sternotomy) and the abdominal organs are retracted.  Fibrinous adhesions can be easily separated but strangulated organs (such as torsed liver lobes or loops of small intestine) should be sacrificed and resected.  If the rupture has been present for a long period, its fibrous edges may be debrided before suturing using polydioxanone in a continuous pattern.  If there is a large defect that cannot be closed without tension, the following approaches may be used:

==Prognosis==

==Prognosis==

Patients that undergo surgical repair of a rupture have a favourable prognosis, with around 90% being discharged after treatment.  Animals that survive the first 24 hours after surgical repair are generally considered to do well subsequently.

Patients that undergo surgical repair of a rupture have a favourable prognosis, with around 90% being discharged after treatment.  Animals that survive the first 24 hours after surgical repair are generally considered to do well subsequently.

==References==

==References==

[http://w3.vet.cornell.edu/nst/nst.asp?Fun=Image&imgID=11491 Image of traumatic diaphragmatic hernia with displaced intestine in a dog by Cornell Veterinary Medicine]

[http://w3.vet.cornell.edu/nst/nst.asp?Fun=Image&imgID=11491 Image of traumatic diaphragmatic hernia with displaced intestine in a dog by Cornell Veterinary Medicine]

Fossum, T. W. et. al. (2007) Small Animal Surgery (Third Edition) Mosby Elsevier

Fossum, T. W. et. al. (2007) Small Animal Surgery (Third Edition) Mosby Elsevier

[[Category:Stomach_and_Abomasum_-_Pathology]]

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