Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.     

Minimally invasive diagnosis and treatment of traumatic rupture of the right hemidiaphragm with liver hermiation

We report a case of blunt traumatic rupture of the right hemidiaphragm with liver herniation. A 57-year-old man admitted in an emergency after a traffic accident was suspected from chest radiography and computed tomography to have traumatic diaphragmatic rupture. Magnetic resonance imaging was helpful in the final diagnosis. Thoracoscopy was useful in planning surgery and surgically repairing the ruptured diaphragm.     

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.     

Congenital Intercostal Lung Herniation Combined with an Unusual Morgagni's Hernia

A 70-year-old male visited urgent care due to coughing for 1 month and left chest pain. He had no history of trauma. The initial chest computed tomography (CT) showed the 7th left intercostal lung herniation. A follow-up CT showed an intercostal lung herniation combined with a bowl herniation, which had developed due to a Morgagni's hernia. An emergency operation was performed due to the incarceration of the bowl and lung. The primary repair of the diaphragm was performed and the direct approximation of the 7th intercostal space was determined. We concluded that the defect of the diaphragm and the intercostal muscle was a congenital lesion, and the recurrent coughing was the aggravating factor of herniation.     

The impact of positive pressure ventilation on the diagnosis of traumatic diaphragmatic injury

Initial chest radiography (CXR) has been noted to have limited diagnostic sensitivity to detect acute diaphragmatic injury (ADI). A further confounding variable may be intubation and positive pressure ventilation which may prevent herniation of abdominal organs until weaning is achieved. We sought to determine the impact of positive pressure ventilation on the sensitivity of the initial CXR to identify ADI as well as to document the incidence of late herniation occurring as positive pressure ventilation is weaned. A retrospective chart review of 166 patients over an 8-year period in whom diagnosis of ADI was made on the same admission was performed. Etiology was penetrating trauma in 91 (55%). Eighty-five (51%) patients were intubated and ventilated with positive pressure before the initial chest radiograph. Diagnosis was made within 24 hours in 144 (87%) cases. The ability to correctly identify ADI by CXR was affected by whether or not the patient was intubated (intubated 12% vs nonintubated 27%; P = 0.001), side (right 10% vs left 27%; p = 0.04), and injury size (> 5 cm 81% vs < or = 5 cm 3%, P = 0.02). Late diagnosis was made in 22 cases: eight during surgery, six because of persistent radiographic abnormalities, and six when high levels of ventilator support were decreased with subsequent herniation of stomach above the diaphragm. Two cases were described at autopsy. Diaphragmatic injuries cannot be excluded if patients are intubated. Late diagnosis can be facilitated if chest radiographs are reviewed in sequence as ventilator support is decreased.     

Delayed diagnosis of traumatic diaphragmatic rupture

We report a case of late presentation of traumatic rupture of the diaphragm discovered incidentally on chest radiography (CXR) during an annual medical checkup. A 60-year-old man suffered severe blunt trauma from heavy steel frames collapsing against his back, resulting in pelvic and femoral fractures as well as pulmonary contusions. The patient recovered, but 10 months later CXR performed for lung cancer surveillance during an annual medical checkup revealed a traumatic rupture of the diaphragm. Video-assisted thoracic surgery was performed with reduction of the intestine and primary closure of the diaphragmatic defect. The patient recovered uneventfully. This report serves as a useful reminder that a medical history of severe blunt trauma should provoke a high index of suspicion for diaphragmatic rupture during annual medical surveillance.     

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.     

Repair of right sided Traumatic Diaphragmatic Hernia with intrathoracic herniation of liver and a segment of ruptured jejunum—a case report and review of literature

We present this rare case of a 24 year old male who was knocked down by a slowly backing truck when the rear wheels climbed on to the right side of the abdomen and on hearing the shouts of people rolled forwards causing a partial run over injury. He was resuscitated and treated conservatively. An X Ray Chest done 24 h later showed right sided chest wall fracture, right basilar opacity suggesting chest injury with localized haemothorax/pulmonary contusion and a chest tube was inserted through Rt. 5th intercostal space. Initially some blood came out. But on the third day bile was seen coming out of the intercostal drain prompting a diagnosis of traumatic rupture of diaphragm with liver injury. A Magnetic Resonance Imaging (MRI) scan was done when the diagnosis of ruptured right dome of diaphragm with Traumatic Diaphragmatic Hernia (TDH) with herniation of liver into the right hemithorax was made. Surgical exploration on the 4th day through right thoraco- abdominal approach confirmed TDH with herniated liver into the right hemithorax without any injury to the liver, hepatic blood vessels or the bile ducts but an unsuspected rupture in a herniated loop of jejunum wedged into the right hemithorax anterior to the liver with biliary discharge into the right hemithorax but without any peritoneal soiling. Repair was done by resection anastomosis of the ruptured jejunum, reduction of the liver into the abdomen, suturing of the torn diaphragm effectively obliterating the hernia orifice and reinforcing it with a polypropylene mesh anchored to the chest wall. There was a stormy post operative phase involving burst thorax which was corrected by re-exploration of the thoracic portion of the thoraco abdominal wound, wound toileting and resutured. The wound healed after 2 months. The patient is doing well after 20 months of follow up.     

Dislocation of three segments of the liver due to hernia of the right diaphragm

Right diaphragmatic hernia is a rare injury (0.25–1%) following blunt abdominal trauma. The diagnosis may be delayed and achieved years after the trauma during laparotomies for other reasons. A 75-year-old male fell 6 years before, and was symptom-free since then. He was admitted to the hospital for abdominal pain, and chest X-rays revealed intestinal gas in the lower right thoracal region. Abdominal ultrasonography showed agenesis of the gallbladder, and computed tomography demonstrated that the right upper abdominal viscera were located in the vicinity of the heart. The patient underwent a laparotomy for right diaphragmatic hernia, and the right hepatic lobe and the medial segment of the left lobe, the gall bladder, the proximal part of the transverse colon, the omentum and some segments of the intestine were dislocated into the thoracal cavity by a tear in the right diaphragm. The organs were returned to the abdominal cavity uneventfully and the defect in the diaphragm, measuring 10 × 5 cm, was repaired by unabsorbable sutures. The diagnosis, surgical treatment and postoperative course of the right diaphragmatic hernia is discussed with a review of the literature.     

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.     

Colobronchial Fistula Complicating a Traumatic Right Diaphragmatic Hernia: A Case Report

Abstract The delayed presentation of traumatic diaphragmatic hernia is associated with high morbidity and mortality. Acute colobronchial fistula complicating delayed presentation of traumatic diaphragmatic hernia is previously unreported. A 52-year-old woman presented with a 4-day history of dyspnoea, feculent sputum and chest and abdominal pain 3 months after a road traffic accident. The diagnosis of Chilaiditi's syndrome, diaphragmatic hernia and colobronchial fistula was confirmed with computed tomography (CT) and treated by chest drain, primary hernia repair and right hemicolectomy. Spontaneous decompression through the bronchus had prevented tension fecopneumathorax. The diagnosis of diaphragmatic hernia is difficult but delay is associated with increased mortality. Symptoms include dyspnoea, chest and abdominal pain, with decreased respiratory sounds and visceral sounds in the thorax. Abdominal visceral structures or gas on CXR, CT or contrast studies will confirm the diagnosis. The initial operative approach is laparotomy but thoracotomy must be considered as abdominal viscera may be adherent to thoracic structures.     

A case of traumatic hernia of right diaphragma

A patient with traumatic diaphragmatic hernia at right side was treated surgically. He was 63-year-old male. His illness was caused by a traffic accident one year ago. The major symptoms due to the injury were short breathness and pain at right lateral chest wall. One year later he complained of the nausea and abdominal discomfort. At the right thoracotomy, the herniation of liver and colon through the ruptured diaphragma was found. After the return of herniated organ into the abdominal space, ruptured diaphragma was closed directly.     

右侧肝膈疝合并肺内异位肝一例并文献复习

目的探讨肝膈疝合并肺内异位肝的诊疗方案。 方法回顾性分析1例右侧肝膈疝合并肺内异位肝患者的临床表现、影像学特征、手术治疗方案及病理，对异位肝进行相关的探讨及文献复习。 结果患者接受胸腔镜肺楔形切除术＋膈疝修补术，术中发现右肺下叶肿物，与疝入胸腔组织不连续。病理结果提示为异位肝组织。患者术后一年复查胸部CT未见异常，随访无特殊不适。 结论异位肝在临床上极为少见，病例结合相关文献复习，以提高对该病的认识，且腔镜微创手术不仅直观观察，也可直接切除明确诊断且治愈该病。     

Giant primary liposarcoma of the chest

Liposarcomas are the most common soft tissue sarcomas in adults, although liposarcomas of the chest are uncommon. We report two cases of giant liposarcoma in the mediastinum and chest wall, respectively. An 82-year-old man presented with a mass in the right upper mediastinum, as seen by computed tomography (CT). He had a past history of subcutaneous lipoma resection on his back (19 years previously). The patient underwent tumor resection with a right thoracotomy. A 58-year-old woman presented with an enlarging mass of the right lateral chest, involving the diaphragm and ribs, as seen by CT. She had a past history of subcutaneous lipoma resection of the right chest (18 years previously). The patient underwent an en bloc resection that included the tumor and a part of the right diaphragm and ribs. Histological examination of both patients’ tumors revealed a well-differentiated liposarcoma, with no pathological relation to the previous lipoma resected in either case.     

Pulmonary typical carcinoid tumor and liver metastasis with hypermetabolism on 18-fluorodeoxyglucose PET: a case report.

Pulmonary carcinoid tumors are generally hypometabolic on 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET). We experienced a case of pulmonary typical carcinoid that showed rapid growth and high FDG uptake at the primary site and liver metastasis. A 56-year-old man with hemosputum had a medical examination by his family physician. A roentgenogram and computed tomography of the chest showed a solitary solid mass on the right lower lung field. However, he had not been shown an abnormal shadow on a roentgenogram taken 8 months earlier. He had undergone fiber-optic bronchoscopy, but the cytological diagnosis showed no evidence of malignancy. After that, FDG-PET was examined and revealed hot spots in the pulmonary tumor and liver mass. A standard uptake value of this pulmonary tumor was 32.9 mg/mL, and that of the liver mass was almost the same value of pulmonary lesion. He had undergone a right lower lobectomy diagnosed as a typical carcinoid. Thereafter he underwent partial resection of he liver mass, and the histology was metastasis from pulmonary carcinoid. We first reported a typical pulmonary carcinoid that showed high FDG uptake at the primary site and liver metastasis.     

Delayed hepatothorax due to right-sided traumatic diaphragmatic rupture

We present a 48-year-old man with delayed hepatothorax due to right-sided traumatic diaphragmatic rupture. An initial chest radiograph showed no specific signs except elevation of the right diaphragmatic border. The diagnosis was confirmed by coronal reformatted helical computed tomography (CT) imaging, which revealed intrathoracic displacement of the liver. A follow-up chest radiograph revealed gradual elevation of the right diaphragmatic border, suggesting worsening of the diaphragmatic rupture and progression of hepatothorax, resulting in severe atelectasis of the right lung. Therefore, surgical repair of the diaphragmatic rupture was performed. Impaction of the liver through the diaphragmatic ruptured region was observed. Chest radiographic examination after the operation revealed a more normal position of the right diaphragmatic border and resolution of the right lung atelectasis. The problems associated with the diagnosis and operative treatment of hepatothorax with right-sided traumatic diaphragmatic ruptures are discussed in the light of this case report.     

Penetrating lung and diaphragmatic injuries with no abnormal finding of chest X-ray: a case report

A case of penetrating lung and diaphragmatic injuries with no abnormal findings of chest X-ray is reported. A 76-year-old man was admitted to our hospital due to penetrating chest trauma. A simple X-ray film of the chest on admission revealed no abnormal finding. An emergency operation was performed. On exploring the back open wound, we found a laceration of 7 cm in diameter in the right diaphragm and lung laceration. Then we repaired primarily with absorbable material. The postoperative course was uneventful, and the patient was discharged 12 days later. Penetrating truncal traumas can result in diaphragmatic injury. Sometimes the clinical and roentgenographic findings are unreliable. If the diagnosis is missed, a diaphragmatic injury may occur delayed diaphragmatic hernias within hours to years. Accordingly, initial wound exploration are important for the diagnosis of diaphragmatic injury in avoiding serious complications.     

Minimally invasive procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct diagnosis in selected patients

Traumatic rupture of the diaphragm is no longer uncommon. Because of the increasing frequency of motor vehicle accidents, the rate of blunt trauma to the chest and abdomen, which are the most common causes of diaphragmatic rupture, is increased as well. However, the diagnosis is frequently missed or delayed because of the lack of sensitivity and specificity of imaging modalities. Diagnostic laparoscopy is considered a standard tool for penetrating injuries to the left diaphragm and is widely practiced in selected cases. Right diaphragmatic tears, however, are more difficult to diagnose because of the sealing effect of the liver. Blunt abdominal trauma can cause large right diaphragmatic tears, causing liver incarcerations and respiratory compromise, therefore demanding the need for a comparable diagnostic tool. A high index of suspicion, together with knowledge of the mechanism of trauma, is the key factor for the correct diagnosis. Once the diagnosis has been considered, diagnostic laparoscopy and/or diagnostic thoracoscopy should be performed to confirm or rule out this injury. Factors suggestive of a right diaphragmatic tear include newly or progressive elevation of the right diaphragm and respiratory distress without underlining lung injury. The timing of the procedure should be in accordance with the hemodynamic and respiratory status of the patient. This procedure should be performed semielectively if there are no other indications for surgical intervention.     

Gunshot wound of the left chest and Bochdalek hernia

A 16-year-old male presented with a hemopneumothorax following a gunshot wound to the left chest. He was treated effectively with closed suction drainage for 48 hours when he suddenly complained of severe left chest pain. Preoperative diagnosis was suggestive of a traumatic diaphragmatic hernia but operative findings were confirmatory of a rare hernia through the foramen of Bochdalek. Chest X-ray showing a gas-filled viscus above the diaphragm is diagnostic. Increased abdominal pressure generated when he was first hit by the bullet and aggravated by increased negative intrapleural pressure resulting from suction drainage of the hemothorax is the probable mechanism of the herniation.     

Right-sided diaphragmatic hernia following group B streptococcal pneumonia and sepsis.

A case of right-sided diaphragmatic hernia following group B streptococcal pneumonia and sepsis is reported herein. The clinical course was characteristic. The position of the right hemidiaphragm was initially normal. After an antecedent group B streptococcal infection, an abnormal shadow indicating either pneumonia or a pleural effusion on the chest x-ray was recognized and an elevation of the bowel and liver into the right hemithorax gradually appeared. Repair of the hernia was indicated and the postoperative result was excellent. The relationship between a delayed-onset diaphragmatic hernia and a group B streptococcal infection is still unknown. Increased intrathoracic pressure caused by mechanical ventilation coupled with an abnormal lung compliance due to inflammation may have resulted in the delayed herniation. Among various methods for diagnosis applied, chest x-ray and ultrasonography were noninvasive and useful.