Luke presented to Asheville Veterinary Specialists for evaluation of what appeared to be a chronic diaphragmatic hernia, as well as concurrent heartworm disease. The diaphragm is the muscular separation between the chest and abdominal cavities that functions as a barrier and assists in respiration. Diaphragmatic hernia is disruption of the diaphragm which allows abdominal organs to migrate into the chest cavity, which can cause collapse of the lungs due to the displaced organs or fluid production.. Most dogs and cats that suffer diaphragmatic hernias have been hit by a car or have experienced some other type of trauma, although some are born with congenital defects of the diaphragm. As he had other signs of chronic injury it was likely that Luke’s hernia was due had some form of previous trauma. Radiographs taken at referring veterinarian revealed increased soft tissue density of the thoracic cavity (more on the left side than right) consistent with a probable diaphragmatic hernia (See Images 1a and 1b).
Luke was placed under general anesthesia and an abdominal surgery was performed on 4/8/13. There was a large chronic traumatic defect in the central portion of the diaphragm with multiple scar tissue adhesions present. Abdominal organs that had herniated into the chest cavity included several liver lobes, the spleen and a large amount of the small intestines. As a result of the severe scar tissue formation and attachments of the abdominal organs within the chest cavity an approach to the back portion of the thoracic cavity had to be made ( partial caudal sternotomy) as well as the defect in the diaphragm was enlarged to be able to break down the adhesions and remove the incarcerated organs without excessive tension/damage. The abdominal contents were retracted into the abdomen and the defect was reconstructed A temporary thoracostomy tube (chest tube) was placed prior to closure. The remainder of the abdominal exploratory was with normal limits. A routine closure was performed.
Post-op operative radiographs revealed an intact diaphragm repair and mild changes to the lung fields likely related to being underinflated for a long period of time. There was also an increased in the vascular pattern consistent with the previous heartworm positive diagnosis. The remainder of the lung fields appeared to be inflating and the thoracostomy tube is in place and exiting the abdominal wall. (See Images 2a and 2b). After surgery Luke was kept on a continuous pain medication IV and given supplemental oxygen initially. By the net morning Luke was comfortable, breathing well on room air and had minimal air or fluid production from the chest tube so it was removed. After staying at AVD/REAVCH for another 24 hours for observation Luke was doing very well on oral medications, eating/drinking and was discharged for home care.
Luke returned to AVS for recheck evaluation 9 days after his surgery. Luke appeared comfortable and was breathing well in the post-operative time frame. He was eating/drinking normally. There were no signs of abdominal wall healing problems. The superficial staples were removed at that time and it was recommended that he have several weeks to fully recover prior to treating his concurrent heartworm disease.
The prognosis for animals presenting with a traumatic diaphragmatic hernia is variable depending on other injuries incurred. It is estimated that roughly 15% of animals suffering traumatic diaphragmatic hernia will die before presentation. Of the patients that survive to presentation, the timing of surgery will also affect prognosis. Animals that have surgery greater than 24 hours after trauma have a lower mortality rate than those having surgery within the first 24 hours owing to resolution of shock and proper pre-operative stabilization. Animals having surgery greater than 1 year after the initial insult can carry a poorer prognosis due to the presence of adhesions, and careful removal of the abdominal organs from the thoracic cavity by an experienced surgeon, along with good anesthesia management of the patient are factors paramount to success in these patients.
Thank you Laurie Johnson Photography for the use of the beautiful photographs of Luke!
To see more photos of Luke during his recovery, visit Luke's very own Facebook page by clicking here.