Late bilateral diaphragmatic rupture: Challenging diagnostic and surgical repair

The role of video-assisted thoracoscopy in chest trauma: a retrospective monocentric experience

Video-assisted thoracoscopy (VAT) plays an essential role in the exploration of pleural cavity after thoracic trauma, although some doubts about the precise and specific indications persist. This study examines the eligibility criteria for videothoracoscopy and establishes the ideal timing for VAT. Between January 2011 and November 2022, we observed 923 polytraumatized patients. All patients underwent computed tomography (CT) scan total body with and without contrast enhancement. Two hundred and nine patients carried out VAT within 10 ± 2 h of injury while 8 patients after 20 ± 1 h. The Injury Severity Score (ISS) was 31 ± 1 and the Glasgow Coma Scale was 14.1 ± 0.3 upon arrival at the hospital. One hundred and nineteen patients displayed hemothorax (55%), 62 hemopneumothorax (28.5%), 21 penetrating wound (9.6%), 10 pneumothorax (4.6%) and 5 chylothorax (2.3%). In 18 patients (8.3%) without vascular, diaphragmatic, or parenchymal lesion the treatment consisted in chest tube placement. VAT was converted to video-assisted thoracoscopic surgery (VATS) in 190 patients (87.5%), to open surgery in 8 (3.7%) and to laparoscopy in 1 (0.5%). Twelve patients (5.5%) with diaphragm ruptures < 5 cm in diameter were treated by separate stitches suture in VATS. Only eight postoperative complications (4 pneumonia, three atelectasis and one pulmonary embolism) out of 217 VAT, positively resolved with medical treatment, were noted exclusively in patients undergoing minimally invasive approach 20 ± 1 h after trauma. Early VAT in selected patients is a safe and easy procedure that ensure a quick diagnosis of lesions and an accurate management of the most thoracic injuries among trauma patients. The prompt identification of injuries, to avoid life-threatening conditions requiring rapid intervention, responds to medico-legal needs to which VAT fulfills.

Angiotensin converting enzyme inhibitor associated spontaneous herniation of liver mimicking a pleural mass: A case report

BACKGROUND

Spontaneous diaphragmatic herniation of the liver is a rare entity. It may mimic pulmonary mass especially in the absence of trauma. Cough is a common side effect of angiotensin converting enzyme (ACE) inhibitors that may cause diaphragmatic rupture due to a sudden increase in trans-diaphragmatic pressure. We present a case of ACE-inhibitor associated spontaneous herniation of the liver mimicking pleural mass.

CASE SUMMARY

An 80-year-old woman presented with dry cough for 1 mo and sudden onset of cramping abdominal pain for 1 d. She denied history of trauma, prior surgeries, smoking, alcohol or illicit drug use. She has a history of diabetes and was started on an ACE inhibitor 6 mo ago for the management of hypertension. Examination was remarkable for right upper quadrant tenderness. Lab work-up was unremarkable. Chest X-ray showed a right lower lung opacity suspecting right pleural mass. Chest computed tomography scan ruled out pleural mass, however, revealed herniated right lobe of the liver (3.9 cm × 3.6 cm × 3.4 cm) into the thoracic cavity through the posterolateral diaphragmatic defect. Laparoscopic repair of the diaphragmatic defect was performed and the ACE inhibitor was stopped. Patients' symptoms had completely resolved on follow-up.

CONCLUSION

ACE inhibitor-associated cough may cause diaphragmatic liver herniation mimicking pleural mass. Early diagnosis, surgical repair and addressing the triggering factors improve patients' outcomes.

Surgical management of traumatic diaphragmatic hernia: a single institutional experience of more than two decades

Background

We present here our experience with surgical management of traumatic diaphragmatic hernia, trying to find out the era impact of different periods on the outcome and risk factors of mortality.

Methods

A series of 63 patients with traumatic diaphragmatic hernia were referred to us and operated on during March, 1990-August, 2017. The patient records were reviewed and statistically analyzed to demonstrate injury characteristics and to find out optimal treatment strategy, risk factors of death as well as the difference between two periods (1990–2005, 2005–2017) divided by introduction of computed tomography at our institution.

Results

The overall mean age was 31.2 ± 16.3 years old with a female to male ratio of 11/52. The mechanism was penetrating trauma in 19 cases (30.2%), and blunt trauma in 44 cases (69.9%). Two thirds of the patients in the second group (2005–2017) yet none in the first group (1990–2005) underwent computed tomography. Ten patients (15.9%), of which 8 in the first and the other 2 in the second group (p = .042), had late diagnoses. The most commonly used incision was a thoracotomy (n = 43, 89.6%). There was no statistical difference in etiology or mortality between the two periods. Univariate analysis showed survivors were younger, and had lesser injury severity scores (ISS) and lower American Association for the Surgery of Trauma (AAST) grade than non-survivors. By multivariate logistic regression analysis, increased age (odds ratio, 1.275; p = .013) and greater ISS (OR, 1.174; p = .028) were risk factors of death in all patients.

Conclusions

High-definition computed tomography has significantly improved the preoperative diagnosis rate. The transthoracic approach could be used in selected cases with traumatic diaphragmatic hernia with good outcomes. Patients with greater ISS and advanced ages are at a higher risk of death.

Delayed presentation of traumatic diaphragmatic rupture with tension colothorax and strangulation of the transverse colon

A 26-year-old man presented to emergency department with respiratory distress. The initial diagnosis after chest X-ray was massive haemothorax, after insertion of a chest drain and further investigations, it turned up to be a rare case of a delay presentation of traumatic diaphragmatic rupture (DR) (after 1 year of the initial trauma). After excessive resuscitation of the patient in the emergency department, the patient underwent an emergency laparotomy which revealed ischaemic transverse colon herniated into the chest through a 7 cm diaphragmatic defect. Resection of the ischaemic bowel had been done, and the patient admitted to Intensive Therapy Unit (ITU) postoperatively. The patient had an uneventful recovery and discharged home on postoperative day 9. As DR after thoracoabdominal trauma is a rare condition that can be missed at initial presentation, we would like to highlight the main challenges in diagnosing and managing similar cases after reviewing related cases in the literature.

Video-assisted thoracoscopic surgery in trauma: pros and cons

Thoracic injuries account for 60% of all trauma presentations. These patients often have extra-thoracic injuries adding to the complexity of their management. Morbidity and the associated mortality are significantly increased in the elderly. The majority of cases will comprise of simple rib fractures, requiring adequate analgesia. In those that require surgical intervention, the use of video-assisted thoracoscopic surgery (VATS) is becoming increasingly more popular. VATS can often provide greater visualisation of the intra-thoracic structures, whilst limiting the burden of injury to smaller non-rib spreading incisions. It is therefore becoming increasingly used as a diagnostic tool to identify the extend of the injuries whilst also allowing for therapeutic intervention. These benefits translate into decreased rate of post-operative complications and a shorter length of inpatient stay. We also discuss the relative contra-indications and cautions to the use of VATS in the setting of trauma.

[Diaphragmatic hernia in elective thoracic surgery]

AIM

To clarify the indications for reconstructive surgery in patients with diaphragmatic hernia.

MATERIAL AND METHODS

Retrospective trial has included 36 patients with diaphragmatic hernia for the period 1963-2017. There were 23 (63.9%) women and 13 (36.1%) men. The majority of patients (83%) underwent surgery at able-bodied age (18-60 years). 27 (75%) patients had hernia of weak diaphragmatic zones, 9 (25%) - posttraumatic hernia. Diaphragm repair was performed with primary suture. In 2 cases of posttraumatic hernia mesh endoprosthesis was used.

RESULTS

All patients were discharged. Postoperative complications arose in 4 (11.1%) patients, including 2 cases of mesh endoprosthesis deployment. Long-term outcome was followed-up in 15 patients from 6 months to 17 years. Recurrent hernia was absent in all cases.

CONCLUSION

Primary suture is acceptable for diaphragmatic hernia repair. Alloplastic repair is indicated for large defect, when primary suture is impossible or risk of its failure is high.

A Case of Unusual Occurrence of Nasogastric Tube Feed Coming Through the Chest Tube in a 27-Year-Old Polytrauma Patient

The provision of early and adequate nutritional support is vital for the successful recovery from the trauma in any form. Nutritional support is enteral unless specified otherwise as dictated by various benefits of the former. Nasogastric tubes provide effective and common mode of enteral feed due to the ease of placement and maintenance. To our knowledge, the late presentation of diaphragmatic hernia with gastric perforation in a trauma patient leading to feed coming through chest tube is very rare of the complications.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Does a Negative Emergency Celiotomy Exclude the Possibility of Significant Diaphragmatic Injury? A Case Report and Review of the Literature

Introduction

Diaphragmatic rupture (DR) is an uncommon, potentially serious complication following blunt or penetrating abdominal trauma. Even with a high index of suspicion, the diagnosis of DR can easily be missed for a long period post injury. Delayed or missed diagnosis [delayed diagnosis of diaphragmatic rupture (DDDR)] and delayed diaphragmatic rupture (DDR) are possible explanations in cases where the initial operative exploration fails to show the diaphragmatic damage.

Case Presentation

Here we present a patient with suspected DR that was not seen on initial open abdominal exploration, but was suggested by subsequent serial imaging. This injury was ultimately identified on laparoscopic exploration. The procedure was converted to open (celiotomy) due to poor tolerance of the pneumoperitoneum required for laparoscopy, and the laceration was primarily repaired. We propose that DDR and DDDR be considered as a differential diagnosis in patients with a previous thoraco-abdominal trauma when presenting with radiologic/clinical signs suspicious for DR, even when the immediate post traumatic exploration failed to demonstrate a DR.

Conclusions

A high index of suspicion is essential for early detection of DDR and DDDR. Patients with high impact injuries or surrounding organ damage should be followed with serial clinical examinations, follow-up radiologic assessments, and even re-exploration in situations highly suspicious for diaphragmatic injuries.

Diaphragmatic rupture precipitated by intercostal chest tube drainage in a patient of blunt thoraco-abdominal trauma

Blunt thoraco-abdominal trauma in collision injuries in road traffic accident (RTA) occasionally results in diaphragmatic injury and rupture besides other serious multisystem injuries. These diaphragmatic injuries (DI) frequently go undetected specially when occur on the right side. DI associated with hemothorax need insertion of intercostal tube drainage (ICTD). ICTD has never been reported to precipitate diaphragmatic rupture and hernia. We are reporting such a rare case for the first time in medical literature.

Laparoscopic Repair of a Chronic Iatrogenic Diaphragmatic Hernia

We report the diagnosis and repair of a chronic, iatrogenic diaphragmatic hernia using minimally-invasive techniques. A 69-year-old man presented with intermittent abdominal and shoulder pain. He had previously undergone laparoscopic Nissen fundoplication in which a grasper-induced puncture injury to the left hemidiaphragm was noted but not repaired. Radiographs and CT imaging diagnosed a left diaphragmatic hernia, with stomach herniated into the left thoracic cavity. This was repaired successfully via an intra-abdominal laparoscopic approach. This case represents the potential importance of repairing post-traumatic diaphragmatic hernia at the time that they occur, as well as a minimally invasive means for their repair.

Large diaphragmatic hernia subject to successful reconstruction – case report

The study presented a case of a large left-sided diaphragmatic hernia treated by means of successful phrenic reconstruction. The above-mentioned are very challenging considering general surgery, although reluctantly supplied in General Surgery Departments.

Diaphragmatic hernia repair more than four years after severe trauma: Four case reports

INTRODUCTION

Diaphragmatic rupture is an infrequent complication of trauma, occurring in about 5% of those who suffer a severe closed thoracoabdominal injury and about half of the cases are diagnosed early. High morbidity and mortality from bowel strangulation and other sequelae make prompt surgical intervention mandatory.

CASE PRESENTATION

Four Brazilian men with a delayed diagnosis of a rare occurrence of traumatic diaphragmatic hernia. Patient one had diaphragmatic rupture on the right side of thorax and the others three patients on the left thoracic side, all they had to approach by a laparotomy and some approach in the chest, either thoracotomy or VATS. This injuries required surgical repositioning of extensively herniated abdominal viscera and intensive postoperative medical management with a careful control of intra-abdominal pressure.

DISCUSSION

The negative pressure of the thoracic cavity causes a gradually migration of abdominal contents into the chest; this sequestration reduces the abdomen's ability to maintain the viscera in their normal anatomical position. When the hernia is diagnosed early, the repair is less complicated and requires less invasive surgery. Years after the initial trauma, the diaphragmatic rupture produces dense adhesions between the chest and the abdominal contents.

CONCLUSIONS

All cases demonstrated that surgical difficulty increases when diaphragmatic rupture is not diagnosed early. It should be noted that when trauma to the thoraco-abdominal transition area is blunt or penetrating, a thorough evaluation is required to rule out diaphragmatic rupture and a regular follow-up to monitor late development of this comorbidity.

Conventional mesh repair of a giant iatrogenic bilateral diaphragmatic hernia with an enterothorax

Purpose

Diaphragmatic hernias (DHs) are divided into congenital and acquired hernias, most of which are congenital. Among acquired DHs, up to 80% are left-sided, only a few iatrogenic DHs have been reported, and bilateral hernias are extremely rare. For diagnostic reasons, many DHs are overlooked by ultrasonography or X-ray and are only recognized at a later stage when complications occur.

Methods

In 2009, we performed three partial diaphragm replacements in our clinic for repairing DHs using a PERMACOL™ implant.

Results

As all patients had uneventful postoperative courses and the clinical outcomes were very good, we present one special case of a 65-year-old male with a giant iatrogenic bilateral DH with an enterothorax.

Conclusion

We see a good indication for diaphragm replacements by using a PERMACOL™ implant for fixing especially DHs with huge hernial gaps and in cases with fragile tissue.

Delayed right-sided diaphragmatic rupture and laparoscopic repair with mesh fixation

Diaphragmatic rupture is usually an immediate, left-sided complication of high-velocity thoraco-abdominal trauma. Here we present a rare case of delayed, right-sided diaphragmatic rupture and its laparoscopic mesh repair.

Delayed recognition of diaphragmatic injury caused by penetrating thoraco-abdominal trauma

INTRODUCTION

Penetrating trauma to the thoraco-abdomen may cause diaphragmatic injury (DI). We present a case which highlights the difficulties of recognizing DI and the limited role of multimodal diagnostic imaging.

PRESENTATION OF CASE

A 19 year old male presented with stab wounds to his left lateral chest wall. CT was suspicious for diaphragmatic injury but this could not be confirmed despite ultrasound and serial plain radiographs. He was discharged but re-presented with respiratory compromise and diaphragmatic herniation.

DISCUSSION

We review the clinical features of diaphragmatic injury after penetrating thoraco-abdominal trauma and the various imaging modalities available to clinicians.

CONCLUSION

A high index of suspicion must be employed for DI in the context of penetrating thoraco-abdominal trauma. Inpatient observation and laparoscopy/thoracoscopy should be considered when radiological findings are ambiguous. Front line physicians should also consider diaphragmatic herniation in stab victims who re-present with respiratory, circulatory, or gastrointestinal symptomology.

Diaphragmatic hernia masquerading as pleural effusion

Rupture of the diaphragm is almost always due to major trauma. We present here an unusual and rare case of late presentation of diaphragmatic hernia after an innocuous injury. The patient was initially misdiagnosed as a left pleural effusion on the basis of chest X-ray and ultrasound findings. Finally, the diagnosis was confirmed on computerized scanning.

Surviving a delayed trans-diaphragmatic hepatic rupture complicated by an acute superior vena cava and thoracic compartment syndromes

We describe the first reported survivor of a delayed trans-diaphragmatic hepatic rupture complicated by acute superior vena cava (SVCS) and thoracic compartment syndromes (TCS). A thirty one year old male was involved in a boating accident. The patient was diagnosed with a grade IV liver laceration, which was initially managed with both angio-embolization and open surgical repair. Exactly one month from admission, the patient presented with an abrupt cardiac arrest, which was further complicated by a SVCS and TCS. The SVCS was managed with bilateral thoracostomies which revealed a delayed trans-diaphragmatic hepatic rupture into the right chest cavity. The TCS was managed with a decompressive thoraco-abdominal incision. The patient survived and is now leading a normal life. Our success was largely due to an integrated trauma system of physicians, nurses and technicians that prompted the early recognition of two potentially life threatening complications of a delayed trans-diaphragmatic hepatic rupture.

A review on delayed presentation of diaphragmatic rupture

Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture.

Blunt diaphragmatic rupture: four year's experience

BACKGROUND

Blunt diaphragmatic rupture (DR) is a rare condition usually masked by multiple associated injuries, which are the main cause of morbidity and mortality. The overall incidence of diaphragmatic injury is 0.8-5.8% in blunt trauma--2.5-5% in blunt abdominal trauma and 1.5% in blunt thoracic trauma. A correct diagnosis remains difficult and is usually made late.

METHODS

Over four years 12 patients with blunt DR were treated in our hospital. Their charts and X-rays were analyzed. All the surgeons involved were interviewed. Diagnostic and treatment modalities were analyzed and discussed.

RESULTS

Acute diaphragmatic rupture (ADR) was diagnosed in nine patients within seven days. Three patients presented with bowel obstruction and post-traumatic diaphragmatic hernia was diagnosed intraoperatively. Nine patients had rupture of the left hemidiaphragm, two had rupture of the right hemidiaphragm, and one had bilateral DR. Diagnosis of DR was made in all patients in the ADR group before surgery. The correct diagnosis was made within 12 h by junior medical officers in 66.6% of cases. Two patients were diagnosed on a second chest X-ray in response to progressive respiratory distress. The diaphragmatic defect was repaired in all patients via laparotomy; only one patient required additional thoracotomy. Mortality was 25%.

CONCLUSIONS

Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases of DR. Respiratory distress should be treated with intubation as intercostal drainage (ICD) may not improve the situation and is associated with a high risk of iatrogenic injuries. Surgical repair is mandatory and laparotomy should be the preferred approach in unstable patients. To avoid missed injury thorough inspection of both hemidiaphragms should be done routinely on every trauma patient undergoing laparotomy. It is widely recommended to use non-absorbable suturing for diaphragm repair but slowly absorbable material seems reliable also.

Posttraumatic Hernias: Historical Overview and Review of the Literature

Diaphragmatic, lumbar, and extra-thoracic hernias are well-described complications of blunt trauma. However, in the absence of an immediate indication for surgery in the injured patient, early recognition of these hernias can be a diagnostic challenge and delayed presentation is common. Upon diagnosis, surgical repair is necessary secondary to the high morbidity and mortality associated with herniation and strangulation of abdominal organs. Surgical treatment of these hernias is evolving and a variety of options are available to the surgeon. This article will provide a historical overview of post-traumatic diaphragmatic and multi-cavity hernias, and a review of the literature addressing key issues of diagnosis and management.