Ten Years of National Data on Chronic Diaphragmatic Hernia: Does Surgical Approach Matter?

BackgroundThe optimal surgical approach for chronic diaphragmatic hernia (CDH) remains unclear. This study aimed to compare outcomes of thoracotomy vs laparotomy vs laparoscopic repair of CDH.MethodsWe conducted a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2013-2022. Adult patients (≥18 years) with non-congenital non-hiatal CDH (with or without obstruction) who underwent thoracotomy, laparotomy, or laparoscopy were included. Outcomes assessed included postoperative complications, unplanned return to the operating room (OR), 30-day readmissions, and unfavorable discharge disposition.ResultsA total of 610 patients underwent CDH repair: 156 thoracotomies, 275 laparotomies, and 179 laparoscopies. Chronic diaphragmatic hernia complicated by obstruction was present in 35.2% of patients. On univariate analysis, rates of complications (P = 0.248), readmissions (P = 0.971), unplanned return to OR (P = 0.068), and discharge disposition (P = 0.937) did not differ significantly among groups. On multivariable regression analysis, among patients presenting with obstruction symptoms, laparoscopy was associated with higher odds of unplanned return to OR (aOR: 3.91, 95% CI: 1.91-5.57) and unfavorable discharge (aOR: 1.50, 95% CI: 1.13-4.71), whereas laparotomy was associated with lower odds of both unplanned return to OR (aOR: 0.17, 95% CI: 0.01-0.36) and unfavorable discharge disposition (aOR: 0.41, 95% CI: 0.15-0.84), compared with thoracotomy.ConclusionAcross a decade of national data, outcomes were similar among thoracotomy, laparotomy, and laparoscopy for uncomplicated CDH. In patients with obstruction, however, laparoscopy, used in nearly one in five cases, was associated with increased risks of reoperation and unfavorable discharge disposition. These findings emphasize the importance of careful patient selection and surgical expertise in tailoring operative approach to CDH.