Diaphragmatic herniation after 3 years of penetrating trauma managed through laparotomy: A case report

IntroductionDiaphragmatic rupture is an uncommon trauma complication and it is associated with chronic diaphragmatic herniation, especially in the left side. Chronic diaphragmatic herniation is usually due to white weapon injury and as consequence of low suspicious and absence of proper investigation.Case reportWe report a chronic diaphragmatic herniation after three years of a stab in the left thoracoabdominal transition, managed through laparotomy.DiscussionTraumatic diaphragmatic rupture is a rare trauma consequence, most common in the left side. The herniation occurs gradually because of negative pressure of the thoracic cavity that works as a suction of the abdominal organs.ConclusionTraumatic diaphragmatic ruptures diagnosis is difficult and might go unnoticed without high suspicious and proper investigation. Chronic herniation is associated with higher morbimortality.     

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

Abstract. Diaphragmatic injury with accompanying hernia is a well-documented complication associated with both penetrating and blunt trauma. It occurs in approximately 3% of abdominal injuries with a 2:1 ratio of penetrating to blunt trauma. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress six years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and foul-smelling purulent drainage. Work-up revealed incarcerated transverse colon in a diaphragmatic hernia. Celiotomy demonstrated necrotic colon in the chest with gross fecal contamination in both the chest and abdomen. The diaphragmatic defect was closed and a Hartmann's procedure performed. The patient did well postoperatively except for the development of an empyema, which resolved with conservative management. Our patient is the eleventh reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases including the diagnostic work-up, operative approach, and expected postoperative course of this unusual condition. Electronic Publication     

Evaluation of intrapleural contrast-enhanced abdominal pelvic CT-scan in detecting diaphragm injury in stable patients with thoraco-abdominal stab wound: a preliminary study

BackgroundMany of the patients with thoraco-abdominal stab wound remain asymptomatic; in this regard, previous studies reported that 7–48% of asymptomatic patients had diaphragm injury (DI). Thoracoscopy or multidetector computed tomography (MDCT) scan is the best method to detect DI. We aimed to evaluate the role of CT scan with intrapleural contrast to rule out DI in stable thoraco-abdominal stab wounds.MethodIn a prospective study, we evaluated all haemodynamically stable patients with thoraco-abdominal stab wound, from October 2009 to 2010. Exclusion criteria included patients who needed emergency thoracotomy or laparotomy, those who were haemodynamically unstable and those with blunt trauma or gunshot injury. In the CT-scan department, 500 cc of diluted meglumine diatrozate was transfused into the pleural space via a chest tube and the CT scan was performed from the dome of the diaphragm to the pelvic cavity. In the second step, all patients were taken for thoracoscopy within 24 h after admission. The CT-scan slide was considered positive if one of the following signs was found: (1) the diaphragm was obviously injured as seen in CT-scan slides and (2) contrast agent was seen in the peritoneal cavity. Sensitivity and specificity were calculated for CT scan and thoracoscopy.ResultsFour out of 40 patients had DI according to thoracoscopy. CT scan with intrapleural contrast predicted diaphragmatic injury correctly in all four patients. Considering thoracoscopy as the gold-standard method, the CT scan had two false-positive cases. The sensitivity of the intrapleural-contrast CT scan was 100% and its specificity was 94.4%.ConclusionOur study showed that CT scan with intrapleural contrast can be an acceptable approach to rule out DI and limit the use of thoracoscopy for final diagnosis and repair of DI in cases with suspicious or positive CT-scan results, especially in trauma centres with high load of trauma patients and little accessible equipment.     

Delayed post-traumatic diaphragmatic rupture complicated by total hepato-thorax: A case report

INTRODUCTIONIntra-thoracic herniation of abdominal organs following diaphragmatic rupture represents an unusual clinical occurrence that poses great diagnostic difficulty.PRESENTATION OF CASEWe report a rare case of delayed total hepatothorax caused by a right sided post-traumatic diaphragmatic rupture in a 67 year old male. Reduction of the liver in the abdominal cavity and repair of the diaphragm was feasible via a thoraco-abdominal approach. Postoperative chest radiography showed normal position of the right diaphragmatic border.DISCUSSIONCharacteristics of right diaphragmatic rupture and subsequent complications are reviewed with the aim to reinforce physicians’ awareness of this uncommon clinical condition in order to establish a timely diagnosis and reduce the mortality related burden.CONCLUSIONSurgeons should consider this entity in the differential diagnosis of injured patients experiencing sudden respiratory distress during hospitalization as well as days or months after discharge.     

The spectrum of diaphragmatic injury in a busy metropolitan surgical service

Introduction

The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component.

Methodology

A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study.

Results

A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy.

Conclusion

If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.     

Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: A case report

BackgroundMassive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation is quite an uncommon life-threatening condition usually associated with blunt thoracoabdominal trauma. Mortality is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. Timely, and proper diagnosis is mandatory as survival depends on prompt diagnosis and treatment.Presentation of caseWe describe a case of massive left hemothorax secondary to blunt thoracoabdominal injury with left diaphragmatic and splenic rupture, gastric, greater omentum and splenic herniation into the left thoracic cavity in a 32 years old male car driver after sustaining a road traffic accident and presented with shortness of breath of 4 h’ duration. He also had zone 3 retroperitoneal hematoma and left acetabular fracture. He was treated surgically and discharged home improved.DiscussionDiaphragmatic ruptures following blunt injuries are larger leading to herniation of visceral organs into the thoracic cavity and the most common organ to herniate on the left side is the stomach followed by omentum and small intestine. Splenic rupture is a very rare cause of hemothorax and is often missed in the differential diagnosis.ConclusionMassive hemothorax following splenic and diaphragmatic rupture with visceral herniation following either blunt or penetrating trauma is rare. Delayed or missed diagnosis is associated with higher morbidity and mortality. A high index of suspicion and proper use of diagnostic studies are crucial for early and correct diagnosis.     

Late Presentation of a Traumatic Rupture of the Diaphragm with Gastric Volvulus in a Child: Report of a Case

Rupture of the diaphragm following blunt trauma is rare in children. A late presentation of a left diaphragmatic rupture with gastric volvulus is also highly exceptional. The authors report the case of a 5-year-old boy with a left diaphragmatic rupture, who presented with acute respiratory distress and volvulus of the herniated stomach 6 months after injury. The features of this uncommon entity are discussed with special emphasis on early diagnosis. It is concluded that repeated chest radiographs during hospitalization, as well as some days after discharge, should be obtained in trauma patients to detect a slowly increasing herniation.     

A new method of diagnosing diaphragmatic injury using intraperitoneal technetium: case report.

The diagnosis of diaphragmatic laceration following blunt or penetrating trauma is often difficult to establish. Delay in recognition of this injury can be life threatening, resulting in herniation of abdominal viscera with possible strangulation or respiratory embarrassment. Previous animal studies from our institution have documented that intra-abdominal instillation of technetium sulfur colloid is a sensitive method to diagnose diaphragmatic disruption. We now present a case of diaphragmatic injury where the preoperative diagnosis was accurately made using this method when other imaging studies were inconclusive.     

Review of 9 Cases of Diaphragmatic Injury Following Blunt Trauma Chest; 3 Years Experience

Diaphragmatic injuries can occur with both blunt and penetrating trauma which can be associated with herniation of abdominal viscera into the thoracic cavity. Diaphragmatic injuries can occur with blunt trauma chest in 1–7 % of patients. Retrospectively for last 3 years all cases blunt trauma chest admitted to surgery were reviewed and a study of cases of diaphragmatic rupture was done. We analysed 496 patients of blunt trauma chest retrospectively for period of three years. Nine patients have diaphragmatic injuries, all were males, six presented acutely three were chronic. In six patients laparotomy was done, four subcostal and two midline incisions were preferred. In chronic cases thoracotomy was done. Left sided injury predominates and rib fractures are most common associated finding. Diagnosis in majority of cases is made by Computerised tomography scan. Subcostal incision may be used in patients with isolated diaphragmatic injury in acute presentation while thoracotomy is preferred in late cases. Most common morbidity is pulmonary complications     

Dual mesh repair for a large diaphragmatic hernia defect: An unusual case report

IntroductionDiaphragmatic hernia secondary to traumatic rupture is a rare entity which can occur after stab wound injuries or blunt abdominal traumas. We aimed to report successfully management of dual mesh repair for a large diaphragmatic defect.Case reportA 66-year-old male was admitted with a right sided diaphragmatic hernia which occurred ten years ago due to a traffic accident. He had abdominal pain with worsened breath. Chest X-ray showed an elevated right diaphragm. Further, thoraco-abdominal computerized tomography detected herniation a part of the liver, gallbladder, stomach, and omentum to the right hemi-thorax. It was decided to diaphragmatic hernia repair. After an extended right subcostal laparotomy, a giant right sided diaphragmatic defect measuring 25 × 15 cm was found in which the liver, gallbladder, stomach and omentum were herniated. The abdominal organs were reducted to their normal anatomic position and a dual mesh graft was laid to close the diaphragmatic defect. Patients’ postoperative course was uneventful.DiscussionDiaphragmatic hernia secondary to trauma is more common on the left side of the diaphragm (left/right = 3/1). A right sided diaphragmatic hernia including liver, stomach, gallbladder and omentum is extremely rare. The main treatment of diaphragmatic hernias is primary repair after reduction of the herniated organs to their anatomical position. However, in the existence of a large hernia defect where primary repair is not possible, a dual mesh should be considered.ConclusionA dual mesh repair can be used successfully in extensive large diaphragmatic hernia defects when primary closure could not be achieved.     

Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable

BackgroundThe diagnosis of penetrating isolated diaphragmatic injuries can be challenging because they are usually asymptomatic. Diagnosis by chest X-ray (CXR) is unreliable, while CT scan is reported to be more valuable. This study evaluated the diagnostic ability of CXR and CT in patients with proven DI.MethodsSingle center retrospective study (2009–2019), including all patients with penetrating diaphragmatic injuries (pDI) documented at laparotomy or laparoscopy with preoperative CXR and/or CT evaluation. Imaging findings included hemo/pneumothorax, hemoperitoneum, pneumoperitoneum, elevated diaphragm, definitive DI, diaphragmatic hernia, and associated abdominal injuries.Results230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%).ConclusionsRadiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.     

Delayed revascularization following complete transection of left anterior descending artery after a stab wound

IntroductionPenetrating heart injury as a consequence of a stab wound is usually considered fatal. Nevertheless, there are rare lucky cases with mild symptoms which deserve clinical suspicion and proper management.Presentation of caseWe report a penetrating cardiac trauma with left anterior descending coronary artery transection after a stab wound. Successful revascularization without cardiopulmonary bypass support was performed.DiscussionCoronary artery injuries after penetrating cardiac trauma are mostly fatal. The standard approach has traditionally been coronary artery ligation with serious morbidity. We report a case of complete coronary artery transection with delayed revascularization validating the safety of off-pump approach. We add a short literature review of the management of traumatic coronary artery injury.ConclusionThis adds to the world literature on coronary artery trauma with successful off-pump revascularization. Coronary artery transection stab-wound victims can have only mild symptoms. Slightest intimation of heart injury should provoke proper clinical examination and management.     

Traumatic diaphragmatic hernia presenting as a tension fecopneumothorax

A traumatic diaphragmatic hernia is a well-known complication following blunt abdominal or penetrating thoracic trauma. Although the majority of cases are diagnosed immediately, some patients may present later with a diaphragmatic hernia. It occurs in approximately 3% of abdominal traumas. Diagnosis requires a high index of suspicion since diaphragmatic injury can only reliably be ruled out by direct visualization, i.e., laparoscopy. Hence, delayed presentation with complications secondary to the injury is not uncommon. We discuss a case of a young man who presented in respiratory distress 5 years after a stab wound to the left chest. The patient was hypoxic, with a chest X-ray (CXR) demonstrating a pneumothorax with effusion. A chest tube was placed with a rush of air and feculent drainage. CT scan revealed an incarcerated transverse colon in a diaphragmatic hernia. The laparotomy demonstrated necrotic colon in the chest with gross fecal contamination in the chest. The diaphragmatic defect was closed and a Hartmann’s procedure performed. The patient developed empyema in the postoperative period. Our patient is the twelfth reported case of a tension fecopneumothorax resulting from traumatic diaphragmatic herniation. This paper reviews all cases, including the diagnostic workup, operative approach, and expected postoperative course of this unusual condition.     

Traumatic Lesions of the Diaphragm Our Experience in 33 Cases and Review of the Literature

We reviewed 33 consecutive patients with diaphragmatic injuries. Twenty-nine were admitted in emergency conditions after blunt (22 patients) or penetrating injury, presenting shock, dyspnoea, coma or acute abdomen in 21 cases; major associated lesions were found in 23 patients. Four patients presented acute complications of visceral herniation 2, 4, 84 and 216 months after the trauma. The diagnosis was preoperative in 23 cases, intraoperative in 9; in one case it was missed at laparotomy, becoming evident the day after. The sensibility of preoperative chest x-ray and CT was 86% and 100% in presence of visceral herniation, 14% and 0% in absence of visceral hernia. The diaphragmatic repair was always obtained by direct suture, following 20 haemostatic procedures (liver, spleen, mesenterium) and two bowel resections. The mortality rate was 24.4%; the morbidity rate was 48%. Traumatic lesions of the diaphragm are generally expression of particularly severe trauma whose outcome is mainly influenced by the associated lesions. They are also correlated to specific morbidity and mortality, so the surgical exploration is mandatory whenever this injury is suspected, considering that the preoperative diagnosis relies on visceral dislocation. Associated lesions influence the surgical strategy but a direct suture is usually effective in preventing specific complications.     

Missed Diaphragmatic Rupture and Progressive Hepatothorax, 26 Years after Blunt Injury

AbstractBackground: Cases of blunt diaphragmatic rupture are not as common as other thoracoabdominal injuries and may pose a diagnostic challenge. Depending upon the size of the right hemidiaphragmatic rupture, herniation of liver may be partial, as progressive hepatothorax. The diagnosis of progressive hepatothorax coincides with the onset of the first symptoms of herniation.Case Study: In the patient presented here, the interval between the original injury and the onset of symptoms related to the herniation of the abdominal cavity organs in the thorax was 26 years. Herniation of abdominal organs into the thorax was apparently rather slow and asymptomatic. The first symptoms, 26 years after trauma, included epigastric pain, meteorism, nausea, and vomiting, and all of them were due to gastrothorax and elongated gaster. These symptoms were nonspecific and therefore interpreted as acute alcoholic gastritis. With deterioration of the patients condition, they were subsequently interpreted as subileus due to the strangulation of a portion of the elongated and dilated stomach.Conclusion: Laparoscopy proved to be the most reliable diagnostic method in this case.     

Factors Affecting Mortality and Morbidity After Traumatic Diaphragmatic Injury

Purpose We review our 11-year experience of treating diaphragmatic injury (DI), to identify the factors determining mortality and morbidity. Methods We analyzed the effects of demographic characteristics, type of injury (blunt or penetrating), number of injured organs, injury severity score (ISS), revised trauma score (RTS), Glasgow coma score, and intensive care unit and hospital stay, on complications and mortality, in 51 patients treated for DI between January 1995 and December 2005. Results Twenty-six (51%) patients suffered blunt injury and 25 (49%) suffered penetrating injury. The left diaphragm was injured in 40 (78%) patients, the right in 10 (19%), and both sides in 1 (2%). Only three (5.8%) patients had no concomitant injury. The diagnosis was made by the findings of laparotomy on 34 patients (65%), preoperative chest X-ray on 13 (25%), computed tomography on 2 (3.9%), and laparoscopy on 2 (3.9%). Complications developed in 23 (44%) patients and overall mortality was 19.6% (10/51). An ISS > 13 was found to be an independent prognostic factor for morbidity, whereas an RTS ≤ 11, age ≥ 48 years, and a major postoperative complication were independent prognostic factors for mortality. Conclusion Establishing a preoperative diagnosis of DI is still problematic. Aggressive treatment and close monitoring of patients with an ISS > 13, an RTS ≤ 11, an age ≥ 48 years, or a postoperative complication may decrease morbidity and mortality.     

Diaphragmatic hernia: an uncommon cause of dyspepsia.

Adult onset diaphragmatic hernia is a rare condition with variable clinical manifestations. The majority of adult-onset diaphragmatic hernia is associated with trauma. Blunt thoracic and abdominal trauma associated with a 5% to 7% incidence of diaphragmatic injury, and in 3% to 15% for those with penetrating injury. These injuries may be left unrecognized when they occur but often are uncovered months later during work up for related symptoms. Prompt diagnosis and surgical repair is recommended by most authorities. Traditionally, diaphragmatic hernia is repaired by laparotomy or thoracotomy, or both. Herein, we report a case of adult onset diaphragmatic hernia presented with dyspepsia that was successfully repaired via laparoscopy. Operative approach and technique of diaphragmatic defect closure is elucidated.     

Occult diaphragmatic injuries caused by stab wounds

BACKGROUND: Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries caused by stab wounds of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries. METHODS: On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation). RESULTS: In the exploration group (n = 47), four diaphragmatic injuries (9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries in left-sided thoracoabdominal stab wounds was 4 of 24 (17%), and was much lower after stab wounds of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%). CONCLUSION: In asymptomatic patients with anterior or flank stab wounds of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy or thoracoscopy, should be considered at least in left-sided stab wounds of the lower chest.     

Delayed traumatic diaphragmatic hernias presenting with strangulation

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.     

The early fecopneumothorax due to simultaneous colonic perforation and herniation through diaphragmatic laceration: within 6 days

Diaphragmatic lacerations may be due to blunt or penetrating injury. Penetrating injury is usually missed during acute phase because of small size and herniation of abdominal viscera through defect after several weeks. Here we report an unusual case of diaphragmatic and colonic injury due to stab wound. The injured abdominal viscera herniated through diaphragmatic laceration within a week.