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.     

Blunt Diaphragmatic Injuries: Pericardial Ruptures

Blunt traumatic diaphragmatic injuries (BTDIs) can be misdiagnosed. Careful evaluation of associated injuries in BTDI is important. In this study, we evaluated treatment options and difficulties in the diagnosis of patients with BTDI. We evaluated ten patients retrospectively with BTDI admitted to our departments, between January 2004 and 2015. Age, gender, trauma type, symptoms, radiological findings, diagnosis time, location and grade of the diaphragmatic injury, surgical type of repair, associated injuries and pericardial rupture, and morbidity and mortality rates were recorded. The mean age of the patients was 46.7 years, and all were males. Ninety percent of BTDI was left sided, and 10 % was on the right side. The diagnosis was confirmed with chest radiograph in 50 % and computed tomography in 70 %. Radiological examination revealed hemothorax in 80 %, the loss of diaphragmatic shadow in 60 %, and visceral organ herniation to the thorax in 60 %. Multiple organ injuries were present in 90 % of cases. Pericardial rupture seen in 30 % was remarkable. Early surgery was performed for eight patients and late surgery for two patients. There were six patients with grade 4 or 5 central diaphragmatic injuries (CDIs). Multiorgan injury was present in all patients developing acute CDI. Multiple organ injury is much higher in patients with severe acute blunt trauma with CDI. Pericardial rupture rate is high in cases with acute BTDI and CDI. Proper diagnosis and early surgical management reduce morbidity and mortality.     

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.     

Traumatic diaphragmatic hernia

Thirty-four patients with traumatic diaphragmatic hernia treated between 1941 and 1972 were reviewed. The patients were analyzed as to the mode of trauma, location of the diaphragmatic injury and associated injuries, and the time and methods of diagnosis. The mortality rate was 23%, and deaths were due primarily to the severity of associated injuries, especially in patients sustaining blunt trauma. The necessity of immediate laparotomy in patients with acute diaphragmatic hernia appears indicated by the high incidence of associated intraabdominal injuries that required surgical management. Thoracotomy was employed primarily in patients undergoing delayed repair and was rarely necessary for control of acute associated intrathoracic injuries.     

Surgical management of diaphragmatic injuries

Background Traumatic diaphragmatic lesions have variable presentations and need a high index of suspicion to be diagnosed in the acute phase. Delayed diagnosis is frequently associated with considerable comorbidity. Material and Methods The present retrospective study aims to evaluate the radiological findings and discuss the surgical approach for the repair of the injured diaphragm. This study includes fifteen cases with diaphragmatic injuries, which were surgically managed between 1994 and 2005. Injuries resulted from violent blunt trauma in twelve patients and three patients had penetrating injuries. Patients presented with hypotension, respiratory insufficiency, acute abdomen and hemothorax. Preoperative diagnosis was established in 12/15 (80%) patients depending on the clinical and the chest skiagram findings. Intra-operative diagnosis was made in the rest. Injuries were more common on the left side (11/15, 73.33%). All these patients underwent repair of the defect by direct closure in double layer using monofilament polypropylene suture. In addition, laparotomy was performed in four patients who had liver and spleen injury. Concomitant procedures included lobectomy, segmentectomy, repair of lung laceration, spleenectomy, spleenorraphy, repair of gastric perforation, intestinal perforation and mesenteric tear. Results One patient died (1/15, 6.66%) of associated injuries. Two patients with major liver injuries had prolonged drainage and repeated subdiaphragmatic collections. Conclusions Associated lesions particularly influence the outcome after traumatic lesions of the diaphragm. Surgical exploration is mandatory whenever diaphragmatic injuries are suspected. Right-sided injuries are best exposed and managed through the right thoracotomy. Direct suture is effective in preventing future specific complications.     

Traumatic rupture of diaphragm: surgical reconstruction with special reference to delayed closure.

Thirteen cases of diaphragmatic rupture following blunt trauma or gunshot wounds are presented. In 10 cases the diagnosis of diaphragmatic rupture was made immediately following the injury, and the defect was closed by primary diaphragmatic suture. In three cases, the diagnosis was delayed for 3 to 16 years after the initial trauma. In all of them, abdominal organs such as the colon or liver had migrated into the thoracic cavity. One of them had acute intestinal obstruction and died following several unsuccessful operations. The remaining two patients required plastic repair of the diaphragmatic hernia by a Dacron patch, and both recovered. The clinical and pathological aspects of diaphragmatic rupture, the importance of early diagnosis and surgical correction, and the surgical approach to this entity are considered. The use of Dacron fabric in delayed closure of diaphragmatic defects is described.     

Blunt traumatic rupture of the diaphragm

Lesions of the diaphragm are uncommon but important complications of blunt thoraco-abdominal traumas. Their incidence is increasing over the last decades as a consequence of the increase of the road traumatology. Preoperative diagnosis is often difficult especially when the diaphragmatic lesion is associated with other skeletal or visceral injuries that may mask the clinical or radiological signs. The Authors report 12 cases of traumatic lesions of the diaphragm due to blunt trauma observed from 1980 to 1997 and that underwent surgery. In particular they discuss about the importance of an early diagnosis and a correct surgical approach to reduce morbidity and mortality. Nine patients were operated by laparotomy; thoracotomy was performed in one case and the combined approach in the last two patients.     

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.     

Strangulated traumatic hernia of the diaphragm. A report of two cases

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.     

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     

Computed Tomography in the Evaluation of Diaphragmatic Hernia following Blunt Trauma

Diagnosis of traumatic diaphragmatic hernia due to blunt abdominal trauma requires a high index of suspicion. This study was conducted to assess the accuracy of multidetector computed tomogram (MDCT) in the diagnosis of traumatic diaphragmatic hernia. All patients with thoracoabdominal blunt trauma with diaphragmatic hernia diagnosed on radiologic evaluation during a 3-year period (i.e., from June 2004 to June 2007) were analyzed. Nineteen patients with diaphragmatic injuries in 117 patients with blunt thoracoabdominal injury (16.23%) were studied. Age range was 8?C60?years (mean 34?years). Male?Cfemale ratio was 18:1. Various features seen on CT scan were diaphragmatic discontinuity in 13 (68.42%), thickened diaphragm in 10 (52.63%), ??collar sign?? in 8 (42.10%), visceral herniation in 12 (63.15%), dependent viscera sign in 8 (42.10%), and segmental nonrecognition of the diaphragm in 1 patient (5.88%). Two patients presented with delayed rupture. In the rest mean duration between time of injury and performance of CT scan was 44.35?h (range 3?C288?h). Fourteen patients underwent operative management. Sensitivity, specificity, and accuracy of MDCT scan were 100, 93, and 95%, respectively. Three patients (15.78%) expired. MDCT is a highly accurate modality for detecting traumatic diaphragmatic hernia.     

Traumatic lesions of the diaphragm

The Authors studied 30 cases of diaphragmatic traumatisms from 1972 to 2003 to stress the difficulty to achieve an early diagnosis and the need of their immediate treatment: 26 of these patients were male and 4 female (6.5:1); the pathogenesis was in 50% of cases an open trauma and in 50% a closed trauma. The mean age was 36.6 years (33.4 in the open trauma and 41.4 in the closed). The left hemi-diaphragm was affected more frequently (63%) than the right (37%). The associated lesions were mainly of the parenchymatous abdominal organs (spleen 43.3% and liver 49%), while in the thorax lung was involved in 20% of cases and heart in 3.3%. All patients underwent plastic surgical intervention of the diaphragm. In only one case, particularly severe, the operation consisted in placing a pleuric drain and death occured a few hours later. Mean mortality was 30% (33.3% in open and 26.6% in closed traumas) and mean hospital stay was 36.2 days. Accurate diagnosis in emergency is difficult because of the frequent associated lesions, typical of these patients. Despite of the optimisation of the rescue and the new imaging technologies, the gold standard for treatment is not yet reached. There is still a considerable amount of misdiagnosis, a relevant mean hospitalization, a high mortality and a very high morbidity. The best approach to thoraco-abdominal traumas is still to fear a diaphragmatic lesion up to contrary demonstration, in order to achieve precocious diagnosis and surgical treatment, to avoid complications of delayed treatment.     

Traumatic rupture of the right hemidiaphragm: case report of an unusual means of diagnosis

It has been reported that 10 to 20% of all traumatic diaphragmatic ruptures are missed on initial evaluation, only to be discovered at a later date (1). In the chronic state an abnormal chest X-ray, symptomatic visceral incarceration, or barium contrast studies often lead to the correct diagnosis. This is a case of chronic diaphragmatic injury secondary to trauma being discovered when a diagnostic thoracentesis yielded viscous bile. With the needle left in situ a dye study was performed which demonstrated not only a normal cholangiogram, but also a chronic diaphragmatic rupture with partial herniation of the liver. We feel that this case represents a very unusual presentation of an uncommon injury.     

Laparoscopic repair of intrathoracic liver herniation after traumatic rupture of the diaphragm

Right diaphragmatic hernia after abdominal trauma is a rare injury. Most patients can be asymptomatic, and the diagnosis may be delayed for several years. The treatment of choice involves surgical repair via laparotomy. The authors treated a young patient with transdiaphragmatic herniation of the right hepatic lobe and delayed diagnosis using a laparoscopic approach and accomplished a successful complete repair. The 6-month radiologic follow-up assessment confirmed good results.     

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.     

Traumatic diaphragmatic hernia: a continuing challenge

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. From 1957 to 1982, we treated 41 patients with traumatic diaphragmatic hernias. In 39 patients (95%), diaphragmatic hernia followed blunt trauma. The herniation occurred on the right side in 14 patients and on the left side in 29; it was bilateral in 2. Twenty-four patients had diagnostic chest radiographs, and an additional 11 had abnormal but nondiagnostic studies. Peritoneal lavage was of little value in making the preoperative diagnosis. Twenty-three patients underwent laparotomy only, 13 required thoracotomy alone, and 5 had combined laparotomy and thoracotomy. There were 7 deaths (17%) from associated injuries. Only one missed injury was encountered; a second delayed hernia, initially treated elsewhere, was repaired 45 years after the original trauma. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. Right-sided injuries occur more commonly than previously thought and often require dual incisions (laparotomy and thoracotomy) for diagnosis and treatment. The organization of emergency care for such patients is critical in avoiding the potential of long-term sequelae.     

Lateral approach to laparoscopic repair of left diaphragmatic ruptures

Video-assisted repairs of traumatic diaphragmatic ruptures have been described where thoracoscopy or laparoscopy in the supine position were used. This study aims to validate a new lateral laparoscopic approach for left diaphragmatic repairs. Six consecutive patients were operated on for left diaphragmatic rupture using a lateral approach (Gagner's position). A series of 362 consecutive patients presenting with abdominal or thoracic trauma with or without diaphragmatic rupture over a 2-year period were reviewed retrospectively. Contraindications for immediate or delayed lateral laparoscopic approach were studied. The lateral approach provided complete visibility of the subdiaphragmatic space, easy reduction of herniated organs, easy thoracic inspection and cleaning, the use of low peritoneal pressure, full range of instrumental motion, and rapid diaphragmatic repair. No operative mortality or morbidity was noted. Altogether, 14% to 50% of the patients with diaphragmatic ruptures were candidates for immediate lateral laparoscopic repair. Associated spleen injury in 50% of the cases was the main contraindication. The lateral laparoscopic approach provides better exposure of the diaphragm on the left side and facilitates the diaphragmatic repair especially with a large herniation. Immediate repair is possible in selected cases (14-50%). There is no contraindication in case of delayed diagnosis.     

Post-traumatic tension faecopneumothorax in a young male: case report

Diaphragmatic rupture due to trauma is both well recognised and uncommon. The difficulties in diagnosing traumatic diaphragmatic rupture at the first admission are the most common causes of latent morbidity and mortality. Herniation of the abdominal viscera is the most common sequel with strangulation and perforation the most serious complication. This case outlines the delayed presentation of diaphragmatic rupture and herniation presenting as an acute tension faecopneumothorax. We review the relevant literature, with particular emphasis on the difficulties in diagnosis at presentation.