Download PDF
Eur J Pediatr Surg
DOI: 10.1055/a-2767-7420
Original Article

Acquired Diaphragmatic Hernia Following Pediatric Liver Transplantation: Incidence, Risk Factors, and Surgical Outcomes

Authors

  • Nathalie Pauer

    1   Department of Pediatric and Adolescent Surgery, Hannover Medical School, Hannover, Germany

  • Nicolas Richter

    2   Department for General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany

  • Ulrich Baumann

    3   Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany

  • Norman Junge

    3   Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany

  • Caroline Fortmann 

    1   Department of Pediatric and Adolescent Surgery, Hannover Medical School, Hannover, Germany

  • Mikal Obed 

    1   Department of Pediatric and Adolescent Surgery, Hannover Medical School, Hannover, Germany

  • Jens Dingemann 

    1   Department of Pediatric and Adolescent Surgery, Hannover Medical School, Hannover, Germany

  • Rim Kiblawi 

    1   Department of Pediatric and Adolescent Surgery, Hannover Medical School, Hannover, Germany
Further Information
Also available at
   Permissions and Reprints

Abstract

Introduction

Acquired diaphragmatic hernia (ADH) is an uncommon yet relevant complication after pediatric liver transplantation (pLTx). True incidence and risk factors remain poorly defined, largely due to limited screening, heterogeneous imaging practices, and the absence of validated predictive models. This study aimed to determine the incidence, presentation, and risk factors for ADH and to compare surgical repair techniques and short-term outcomes of thoracoscopic versus open approaches.

Methods

We performed a retrospective review of all children undergoing pLTx at our institution (2014 and 2024). Demographic and transplant-related data were analyzed in patients with and without ADH. Operative approach, postoperative recovery, and 6-month follow-up were assessed. Findings were placed into context by comparison with published series.

Results

Among 246 pediatric transplant recipients, 8 children developed ADH (3.3%). Two patients had bilateral defects; each side was repaired electively in separate, staged procedures. Counting each side as a distinct repair event yielded 10 ADH repair procedures for analysis. Children who developed ADH were significantly younger at transplantation (mean 9.7 months vs. 64.0 months, p = 0.002) and had lower body weight (7.8 kg vs. 20.7 kg, p = 0.004). Prior abdominal surgery was common (five-eighths). Seven patients received a left lateral segment graft (LLS); graft-to-recipient weight ratio was 3.8% versus 3.2% in non-ADH patients (p = 0.107). Most hernias were right-sided, with presentations ranging from respiratory symptoms to incidental imaging findings. Surgical repair was performed via laparotomy in six cases and thoracoscopy in four, with one conversion to thoracotomy. Short-term outcomes were favorable in both groups, with only one recurrence (after laparotomy) and no mortality during follow-up.

Conclusion

ADH after pLTx occurred in a minority of recipients and was associated with younger age, low body weight, prior abdominal surgery, and LLS grafts. However, the specific contribution of these variables remains unclear. Persistent research gaps include the lack of standardized screening protocols, uncertainty regarding cumulative long-term risk, and the absence of predictive models to identify high-risk patients. Addressing these issues requires multicenter collaboration and prospective surveillance strategies. Thoracoscopic repair was feasible in selected patients and may be considered when suitable.

Keywords

pLTx - ADH - incidence - risk factors - thoracoscopy


Publication History

Received: 29 September 2025

Accepted: 08 December 2025

Accepted Manuscript online:
17 December 2025

Article published online:
06 January 2026

© 2026. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany