The Altemeier Procedure: Surgical Repair of Large Diaphragmatic Hernias

The Altemeier procedure—described by German surgeon Walter Altemeier in 1948—is a transthoracic or transabdominal approach to repair large diaphragmatic hernias via primary fascial closure, often reinforced with prosthetic mesh.

Indications

• Large congenital diaphragmatic hernia (Bochdalek, Morgagni) in adolescents/adults
• Traumatic diaphragmatic rupture with tissue loss
• Recurrent hernia after prior primary repair
• Giant hiatal hernia with intrathoracic stomach (>50% volume)

Surgical Technique

1. Approach: Left thoracotomy (8th–9th intercostal space) for posterolateral defects; laparotomy for anterior/central defects; VATS/robotic for selected cases
2. Reduction: Herniated viscera reduced; adhesions lysed; bowel viability assessed
3. Defect assessment: Measure gap; if <3–4 cm tension-free primary closure possible
4. Closure strategy:
   • Primary: Interrupted or continuous non-absorbable sutures (polypropylene, polyester) — U-stitches or horizontal mattress for strength
   • Reinforced: Onlay/underlay/underlay-onlay mesh (polypropylene, PTFE, composite, biologic) — reduces recurrence from 20–40% to <5%
   • Bridging: Mesh alone if primary closure impossible (higher recurrence, seroma risk)
5. Chest tube placement: For thoracotomy; water seal, monitor air leak
6. Optional: Fundoplication (Nissen/Toupet) if concurrent GERD or hiatal hernia

Mesh Considerations

• Synthetic (PP, ePTFE): Durable, low cost; risk of adhesions, erosion, infection
• Composite (absorbable barrier + permanent): Reduces visceral adhesions (Parietex, Proceed, Symbotex)
• Biologic (acellular dermal matrix, porcine SIS): Remodels to host tissue; resistant to infection; high cost; variable durability

Outcomes and Follow-Up

• Recurrence: 5–15% with mesh reinforcement; higher without
• Pulmonary function improvement: FVC, FEV₁ typically increase 15–25%
• GERD resolution: 80–90% if fundoplication added
• Chronic pain: 10–20% (intercostal neuralgia, mesh-related)

The Altemeier procedure remains a foundational technique for large diaphragmatic defects, with mesh reinforcement now standard for durable repair. Multidisciplinary evaluation (thoracic surgery, GI, pulmonology) optimizes patient selection and outcomes.