The Current Status of Traumatic Diaphragmatic Injury: Lessons Learned From 105 Patients Over 13 Years

Right side traumatic diaphragmatic hernia presented after 20 years with shortness of breath; a rare case presentation, and literature review

INTRODUCTION

A right side diaphragmatic injury was linked to serious trauma to the abdomen, pelvis, and chest. The most significant type of injury was blunt abdominal trauma sustained in a car collision. The left side was more likely than the right to experience herniation. The stomach and colon were the most often herniated abdominal viscera. In the same location as the diaphragm rupture, there were rib fractures, hemothorax, and liver damage. Delayed diaphragmatic rupture with diaphragmatic hernia is rare and has a mysterious nature.

CASE PRESENTATION

A 68 years old female patient who has repeated history of shortness of breath, for which she treated as lung infection presented with sudden exacerbation of shortness of breath, she witnessed history of blunt trauma 20 years back and up on investigation bowel herniation to the chest cavity diagnosed. Posteriolateral thoracotomy done, the herniated bowel reduced and the diaphragmatic defect repaired. The patient significantly improved and discharged from the hospital smoothly on 4th postoperative day.

DISCUSSION

Careful recording of past history and physical examination are the best approaches in diagnosing delayed presentation of traumatic diaphragmatic rupture. CT scan with reconstruction of the diaphragm is helpful in both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment.

CONCLUSION

Delayed right side diaphragmatic hernia is a rare entity resulting in grave consequences, In a patient with history of trauma there should be a high index of suspension and patients should undergo imaging and surgical management is the best treatment.

Management of Traumatic Diaphragmatic Injuries

Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.

Twenty-year perspective on blunt traumatic diaphragmatic injury in level 1 trauma centre: Early versus delayed diagnosis injury patterns and outcomes

OBJECTIVE

Blunt traumatic diaphragmatic injury (TDI) is typically associated with severe trauma and concomitant injuries. It is a diagnostic challenge in the setting of blunt trauma and can be easily overlooked especially in the acute phase often dominated by concurrent injuries.

METHODS

A retrospective review was conducted of patients with blunt-TDI identified from a level 1 trauma registry. Variables associated with early versus delayed diagnosis as well as non-survivor and survivor groups were collected to examine factors associated with delayed diagnosis.

RESULTS

A total of 155 patients were included (mean age 46 ± 20, 60.6% male). Diagnosis was made <24 h in 126 (81.3%), and >24 h in 29 (18.7%). Of the delayed diagnosis group, 14 (48%) were diagnosed >7 days. Overall, 27 (21.4%) patients had a diagnostic initial CXR and 64 (50.8%) had a diagnostic initial CT. Fifty-eight (37.4%) patients were diagnosed intraoperatively. Of the delayed diagnosis group, 22 (75.9%) had no initial signs on CXR or CT, 15 (52%) of this group had persistent pleural-effusions/elevated-hemidiaphragm leading to further investigation and diagnosis. No significant difference in survival was observed between early and delayed diagnoses, no clinically significant injury patterns to predict delayed diagnoses were noted.

CONCLUSION

The diagnosis of TDI is challenging. Without frank signs of herniation of abdominal contents on CXR or CT, the diagnosis is often not made on initial imaging. In patients with the evidence of blunt traumatic injury in the lower-chest/upper-abdomen, a high degree of clinical suspicion should be held and follow-up CXRs/CTs arranged.

The edemiological state of blunt diaphragmatic injury: An analysis of a nationwide trauma registry in Japan

BACKGROUND

Little is known about blunt traumatic diaphragmatic injury (BTDI). This study aimed to investigate the epidemiological state of BTDI, using a nationwide trauma registry in Japan.

METHODS

Data of patients aged ≥18 years who experienced blunt injury between January 2004 and May 2019 were extracted from the Japan Trauma Data Bank. Demographics, cause of trauma, mechanism of injury, physiological parameters, organ injuries, and bone fractures were compared between patients with and those without BTDI. Multivariable logistic regression analysis was performed to identify factors associated with BTDI.

RESULTS

A total of 305,141 patients from 244 hospitals were analyzed. The median patient age (interquartile range) was 65 (44-79) years, and 185,750 (60.9%) were men. BTDI was diagnosed in 868 patients (0.3%). The prevalence of BTDI was stable, between 0.2 and 0.6%, over the study period. Among the 868 patients with BTDI, 408 (47.0%) fatalities were recorded. Mortality rates in each year were 42.5-68.2%, with no significant trend toward an improved outcome (P = 0.925). Our multivariable logistic regression analysis found that mechanism of injury, Glasgow Coma Scale score (9-12 or 3-8) on hospital arrival, hypotension (systolic blood pressure <90 mmHg) on hospital arrival, organ injuries (lung, heart, spleen, bladder, kidney, pancreas, stomach, and liver), and bone fractures (rib, pelvis, lumbar spine, and upper extremities) were independently associated with BTDI.

CONCLUSION

Using a nationwide trauma registry, this study revealed the epidemiological state of BTDI in Japan. BTDI was found to be a very rare but devastating injury, with high in-hospital mortality. Some clinical factors, such as mechanism of injury, Glasgow Coma Scale score, organ injuries, and bone fractures, were independently associated with BTDI.

Connected simultaneous rupture of the diaphragm and pericardium via congenitally fused site due to blunt trauma

Background

In severe blunt trauma, multiple organ injuries are often observed. Patients with a ruptured diaphragm and pericardium are referred to as having pericardio-diaphragmatic rupture. However, few studies have reported a narrowly defined case of connected rupture of the diaphragm and pericardium via their congenitally fused site along with an abdominal visceral herniation and cardiac luxation into the thoracic cavity.

Case presentation

A 78-year-old man presented to our hospital with left chest pain caused by a traffic accident. Contrast-enhanced computed tomography revealed a left diaphragmatic rupture and an intestinal herniation into the thoracic cavity. Surgical repair of the diaphragm was performed, and pericardial rupture was noted during surgery. It was considered that the laceration had spread via the congenitally fused site of the diaphragm and pericardium. The diaphragm was sutured, but the pericardium was left open because the laceration was large and the risk of cardiac incarceration was thought to be low. One year after the operation, no recurrence of diaphragmatic hernia was observed and any circulatory symptoms were not occurred.

Conclusions

In cases of diaphragmatic laceration extending to the fused site of the pericardium, connected pericardial rupture should also be considered. It would be challenging to detect without intraoperative findings, and it is desirable to observe both the thoracic and abdominal cavities.

[Giant traumatic diaphragmatic hernia as a complication after laparoscopic liver surgery]

Laparoscopic surgery is now one of the main options for patients with surgical diseases of abdominal cavity, pelvis and retroperitoneal space. Postoperative complications are known, and methods for their prevention after such interventions are well developed. However, there are rare complications, and their management deserves a special attention. The authors present a patient with giant traumatic hernia in long-term period after laparoscopic liver surgery. Clinical manifestations of disease are retrospectively analyzed. The authors discuss surgical aspects of treatment, i.e. choice of access, repair of diaphragmatic defect and peculiarities of postoperative period associated with non-anatomic return of abdominal organs through the diaphragmatic defect. This report will be useful for radiologists, thoracic and abdominal surgeons, anesthesiologists and intensive care specialists.

Laparoscopic repair and total gastrectomy for delayed traumatic diaphragmatic hernia complicated by intrathoracic gastric perforation with tension empyema: a case report

Background

Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury. If missed, it could lead to critical presentations, such as incarceration or strangulation of the herniated intra-abdominal organs, and thus, early surgical repair is required. Methods of the operative approach against delayed TDH remain unclear. Even with the spread of the minimally invasive approach, laparotomy has been predominantly selected for cases with hemodynamic or gastrointestinal complaints. Literature on the use of laparoscopy for repair of such cases is limited, and no study has been conducted for those with intrathoracic gastric perforation.

Case presentation

A 55-year-old male patient with a history of multiple traumas presented with shock, followed by left hypochondrium pain and vomiting. The patient was admitted to the emergency department of our institution and diagnosed with delayed TDH complicated by intrathoracic gastric perforation, and tension empyema. Emergency surgery using laparoscopic approach was performed, despite unstable hemodynamics, considering orientation, exposure, and operativity compared with laparotomy. Repair of the diaphragm plus total gastrectomy was successfully performed by minimally invasive management. The patient made an uneventful recovery without recurrence after 8 months.

Conclusion

Unstable hemodynamic conditions and intrathoracic gastric perforation could not be contraindications to laparoscopic repair in treating delayed TDH.

Traumatic Diaphragmatic Injuries at Medicolegal Autopsy: A 1-Year Prospective Study

INTRODUCTION

Traumatic diaphragmatic injuries (TDIs) are relatively rare. The forensic literature pertaining to TDIs consists mainly of case studies, suggesting little attention to these injuries during autopsies and research.

MATERIALS AND METHODS

This prospective study was conducted at the Ga-Rankuwa Forensic Pathology Services mortuary over a 1-year period. We included all cases who had a full medicolegal autopsy, as prescribed by the relevant South African legislation (Inquest Act 58 of 1959). All diaphragms were examined by a forensic medical practitioner performing the autopsy.

RESULTS

Nine hundred ninety-nine cases were analyzed; of these, 71 cases with TDIs were identified. The incidence of TDI was, therefore, determined to be 7.11%. A total of 60.56% involved the right hemidiaphragm, 19.72% the left hemidiaphragm, and 19.72% were present bilaterally. A total of 85.92% were present in men and 14.08% in women. Blunt force trauma comprised 33.80%, and penetrative trauma 61.97%. Most were associated with severe injuries. A total of 12.68% had organ herniation through the defects present.

CONCLUSIONS

Our study revealed that TDIs were more common than initially reported. The right side was more often involved in our study than in other studies. Diaphragmatic injuries were observed in 21.46% of all penetrative trauma cases received in a year.

Natural evolution of perforating wounds of 30% extension of the left diaphragm and the anatomopathological characteristics of its healing. Experimental Study

INTRODUCTION

diaphragmatic injury is a challenge for surgeons. It is an injury that can be isolated. It is frequent in penetrating thoracoabdominal trauma. It represents a diagnostic challenge and the ideal approach is not yet well established. The occurrence of spontaneous healing of these injuries is still much discussed and even more, if it does, what is the healing mechanism?

OBJECTIVE

to macroscopically and histologically evaluate the natural evolution of perforation and cutting wounds equivalent to 30% of the left diaphragm.

METHOD

50 specimens of rats underwent a surgical procedure and, after 30 days, were euthanized and those that presented scar tissue in the diaphragm, the samples were submitted to histopathological study, using the hematoxylin and eosin stains, Massons trichrome and Picrosirius to assess the presence of collagen or muscle fibers (hyperplasia) in the scar.

RESULTS

it was found that healing occurred in diaphragmatic injuries in 90% of rats. We also observed the presence of fibrosis in all analyzed samples.

CONCLUSION

Spontaneous healing occurred in most diaphragmatic injuries and the inflammatory reaction represented by the presence of fibrosis and collagen deposition was observed in all our samples. Muscle fiber hyperplasia did not occur.

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

BACKGROUND

The 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.

METHODS

Single 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.

RESULTS

230 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%).

CONCLUSIONS

Radiologic diagnosis of DI is unreliable. CT scan is much more sensitive than CXR. Laparoscopic evaluation should be considered liberally, irrespective of radiological findings.

Evolução natural das feridas perfurocortantes de 30% de extensão do diafragma esquerdo e das características anatomopatológicas de sua cicatrização. Estudo Experimental

RESUMO Introdução: o ferimento diafragmático é um desafio para os cirurgiões. É uma lesão que pode ser isolada. É frequente nos traumas penetrantes toracoabdominais. Representa um desafio diagnóstico e a conduta ideal ainda não está bem estabelecida. A ocorrência da cicatrização espontânea dessas lesões é ainda muito discutida e mais ainda, se ocorre, qual o mecanismo de cicatrização? Objetivo: avaliar macroscopicamente e histologicamente a evolução natural das feridas perfuro cortantes equivalentes a 30% do diafragma esquerdo. Método: 50 espécimes de ratos, foram submetidos a procedimento cirúrgico e, após 30 dias, foram submetidos à eutanásia e aqueles que apresentaram tecido cicatricial no diafragma, as amostras foram submetidas a estudo histopatológico, usando as colorações de hematoxilina e eosina, tricrômico de Masson e Picrossirius para avaliar a presença de colágeno ou de fibras musculares (hiperplasia) na cicatriz. Resultados: verificou-se que ocorreu nas lesões diafragmáticas, a cicatrização em 90% dos ratos. Observamos também, a presença de fibrose em todas as amostras analisadas. Conclusão: ocorreu cicatrização espontânea na maioria das lesões diafragmáticas e a reação inflamatória representada pela presença de fibrose e deposição de colágeno foi observada em todas as nossas amostras. Não ocorreu hiperplasia de fibras musculares.

Unexpected Diaphragmatic Hernia Among Patients Undergoing Video-Assisted Thoracic Surgery for Internal Fixation of Rib Fractures

Traumatic blunt diaphragm injuries are a diagnostic challenge in trauma. They may be missed due to the increasing trend of non-operative management of patients. The purpose of this study was to review the rate of occult blunt diaphragm injuries in patients who underwent video assisted thoracic surgery (VATS) for rib fixation. This retrospective study included patients that received VATS as part of our institutional protocol for rib fracture management. This includes utilizing incentive spirometry, multimodal analgesia, and early consideration for VATS. Data was abstracted from the electronic medical record and included demographics, operative findings, and outcomes. Thirty patients received VATS per our rib fracture protocol. No patients had any identified diaphragm injury on pre-operative imaging. A concomitant diaphragm injury was identified in 20% (6/30) of the study population. All patients were alive at 30 days. For all patients, total hospital length of stay was 14.5 days, ICU length of stay was 8.9 days, and average ventilator days was 4.2 days. When comparing patients with and without concomitant diaphragm injuries, hospital length of stay was 16.8 days vs. 14.5 (P = 0.59), ICU length of stay was 11.8 days vs. 8.2 (P = 0.54), and ventilator days was 4.5 days vs. 4.2 (P = 0.93). This study revealed that 20% of patients undergoing VATS for rib fracture fixation had a concomitant diaphragm injury. This higher-than-expected prevalence suggests that groups of patients sustaining blunt trauma may have occult diaphragmatic injuries that are otherwise unidentified. This raises the need for improved diagnostic modalities to identify these injuries.

Need for a Change - Extended-FAST to Extended Diaphragmatic-FAST

Post-traumatic hypoxia can be due to different causes, namely airway problems, pneumothorax, hemothorax, lung contusion, flail chest, traumatic diaphragmatic injuries (TDI), aspiration due to low sensorium, a respiratory paradox in cervical spine injury, severe hypotension, etc., It is a great challenge to identify the cause of hypoxia in a trauma setting because the contributing factors can be multiple or can be a remote cause, which is often missed out. Here, we describe a 50-year-old female who presented to our emergency department with Post-traumatic hypoxia whose sensorium, blood pressure, chest X-ray, E-FAST computed tomography of brain, and other baseline investigation were completely normal, diagnosed later as TDI with the help of diaphragmatic ultrasound and computed tomography of thorax.

A safe and simple procedure for laparoscopic hepatectomy with combined diaphragmatic resection

Diaphragmatic resection may be required beneath the diaphragm in some patients with liver tumors. Laparoscopic diaphragmatic resection is technically difficult to secure in the surgical field and in suturing. We report a case of successful laparoscopic hepatectomy with diaphragmatic resection. A 48-year-old man who underwent laparoscopic partial hepatectomy for liver metastasis of rectal cancer 20 months ago underwent surgery because of a new hepatic lesion that invaded the diaphragm. The patient was placed in the left hemilateral decubitus position. The liver and diaphragm attachment areas were encircled using hanging tape. Liver resection preceded diaphragmatic resection with the hanging tape in place. Two snake retractors were used to secure the surgical field for the inflow of CO₂ into the pleural space after diaphragmatic resection. The defective part of the diaphragm was repaired using continuous or interrupted sutures. Both ends of the suture were tied with an absorbable suture clip without ligation. In laparoscopic liver resection with diaphragmatic resection, the range of diaphragmatic resection can be minimized by performing liver resection using the hanging method before diaphragmatic resection. The surgical field can be secured using snake retractors. Suturing with an absorbable suture clip is conveniently feasible.

Open versus laparoscopic repair of traumatic diaphragmatic injury: A nationwide propensity-matched analysis

INTRODUCTION

Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair.

METHODS

Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality.

RESULTS

A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m². 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P<0.001), shorter hospital LOS (6 [3-9] versus 9 [5-13] days; P<0.001) and ICU LOS (3 [2-7] versus 5 [2-10] days; P<0.001). No difference was found in rates of in-hospital mortality (0.6 versuss 2.0%; P = 0.129) between the 2 groups.

CONCLUSION

Laparoscopic repair of traumatic diaphragmatic injury was associated with decreased morbidity and a shorter hospital course, with a low conversion rate to open repair. Future studies remain necessary to further explore the long-term outcomes of patients with such injury.

LEVEL OF EVIDENCE

Level III STUDY TYPE: Therapeutic.

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.

Unusual Complication of Intercostal Tube Drainage of Penetrating Chest Injury: A Case Report

Penetrating chest injuries can lead to diaphragmatic injuries, which are often missed easily on initial assessments, especially in patients with polytrauma. We are usually more focused and biased towards other evident, immediately life-threatening injuries. The fact that clinical and radiological findings are subtle, especially on chest X-rays, which is sometimes the only investigation performed, highlights the importance of using higher imaging modalities in stable patients and that a clinician should be suspicious of this entity with the corresponding history. Intervening in such patients with the placement of intercostal drain can contribute to morbidity and mortality, as in our case, by causing inadvertent injury to the herniating structures. The case report briefs the same and emphasizes that thoracic injuries, especially penetrating ones, should ring a bell and should be carefully investigated further before the intervention.

Postoperative chest liver herniation after cardiophrenic lymph node resection by a transdiaphragmatic approach following primary cytoreductive surgery for advanced endometrioid ovarian cancer: A case report

Resection of enlarged cardiophrenic lymph nodes (CPLN) is a procedure required to obtain complete cytoreduction in selected patients affected by advanced ovarian cancer. Their resection by transdiaphragmatic approach has been demonstrated to be feasible with low rates of morbidity. The main complications associated with this procedure are pleural effusion, pneumothorax, and rarely, chylothorax. This case describes a postoperative chylothorax and chest liver herniation in a patient who underwent a cytoreductive surgery for advanced endometrioid ovarian cancer, which included a right transdiaphragmatic CPLN resection. Surgical management by thoracotomy was required to repair the right diaphragmatic defect combined with conservative management of the chylothorax. The diaphragmatic closure was achieved employing interrupted stitches with a non-absorbable suture. No prosthetic material was required.

A case of diaphragmatic hernia incarceration after a heart transplant operation

We report a case of a diaphragmatic hernia after a heart transplant operation. A 43-year-old woman, who underwent orthotropic heart transplantation for hypertrophic cadiomyopathy two year earlier, presented with vomiting and epigastric pain. A computed tomography scan showed that the stomach and transverse colon were dislocated in the left thoracic cavity. We diagnosed left diaphragmatic hernia incarceration and performed laparoscopic repair of the diaphragmatic hernia. A 12 × 8 cm diaphragmatic defect was found intraoperatively on the ventrolateral aspect of the left diaphragm, and the stomach with volvulus had herniated into the thorax through the defect. The hernia was considered to be iatrogenic. The diaphragmatic defect was large, and the diaphragm was thinning. We closed the defect by mesh repair. Laparoscopic mesh repair of the diaphragmatic hernia could be performed safely and with minimal invasiveness.

Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes?

Background

Flail chest and severely displaced rib fractures due to blunt trauma can be associated with intrathoracic injuries. At our institution, two thoracic surgeons perform all surgical stabilization of rib fractures (SSRF): one performs routine uniportal thoracoscopy (R-VATS) at the time of SSRF and the other for only select cases (S-VATS). In this pilot study, we hypothesized that R-VATS at the time of SSRF identifies and addresses intrathoracic injuries not seen on imaging and may impact patient outcomes.

Methods

A retrospective review of all patients who underwent SSRF from 2013–2019 at our institution was performed for severely displaced rib fractures or flail chest. Data collected included demographics, imaging results, treatment strategy, and operative findings.

Results

Ninety-nine patients underwent SSRF. Uniportal thoracoscopy was performed on 69% of these patients. When thoracoscopy was performed, 31 additional injuries were identified. R-VATS identified 23 additional intrathoracic findings at time of thoracoscopy not seen on CT scan compared to 8 findings in the S-VATS group (P=0.367). At 3 months follow-up, one empyema and one diaphragmatic hernia required reoperation—neither of which underwent thoracoscopy at time of SSRF. There were no differences in LOS, operative times, and overall mortality between the SSRF/thoracoscopy and SSRF only groups.

Conclusions

R-VATS at the time of SSRF did not identify a statistically significant greater number of occult intrathoracic injuries compared to S-VATS. R-VATS was not associated with increased operative time, LOS, and mortality. Further study is needed to determine if there is benefit to R-VATS in patients meeting requirements for rib fracture repair.

Traumatic diaphragmatic rupture: delayed presentation following a SCUBA dive

Traumatic diaphragmatic rupture (TDR) is a rare yet life-threatening occurrence that remains a diagnostic challenge for clinicians. Delayed presentation with associated strangulation of the contents, although uncommon, requires emergent management. A 42-year-old woman presented with constant, severe left-sided shoulder and chest pain, as well as associated upper abdominal pain following a self-contained underwater breathing apparatus (SCUBA) dive. A chest radiograph (CXR) and CT showed a left-sided diaphragmatic hernia containing stomach. She subsequently underwent a laparoscopic repair of the diaphragmatic defect and recovered well postoperatively.

Faecopneumothorax Caused by Perforated Diaphragmatic Hernia

Incarcerated diaphragmatic hernias with intrathoracic perforation of the colon is a very rare but serious surgical emergency. A 78-year-old male patient presented to our emergency department with severe abdominal pain. A computer tomography (CT) scan revealed herniation of the left transverse colon and spleen into the thorax with colon perforation and fecal contents in the thoracic cavity. An emergent laparotomy confirmed the radiological diagnosis and showed a 6 cm dehiscence of the left diaphragm with strangulation of the left transverse colon as well as the spleen. A left-sided hemicolectomy with terminal transversostomy and splenectomy were performed. The diaphragm was closed with interrupted nonabsorbable sutures. We abstained from reinforcement of the suture line with a mesh because of the feculent contamination of the abdominal cavity. After extensive thoracoscopic lavage and insertion of two chest tubes, the patient was transferred to the intensive care unit. Diaphragmatic hernia even after a mild chest trauma can cause fatal complications. Diagnosis and treatment can be challenging and an interdisciplinary approach is recommended. Due to the associated comorbidity and long-lasting sequelae, we believe the awareness of this rare pathology as a differential diagnosis is important; both as an abdominal and thoracic emergency.

Unravelling the Mysteries of Traumatic Diaphragmatic Injury: An Up-to-Date Review

Traumatic diaphragmatic injury (TDI) is an underdiagnosed condition that has recently increased in prevalence due to its association with automobile collisions. The initial injury is often obscured by concurrent thoracic and abdominal injuries. Traumatic diaphragmatic injury itself is rarely lethal at initial presentation, however associated injuries and complications of untreated TDI such as herniation and strangulation of abdominal viscera have serious clinical consequences. There are 2 primary mechanisms of TDIs: penetrating TDI which tend to be smaller, more difficult to detect, and result in fewer complications; and blunt TDIs which are larger and have higher overall mortality due to associated injuries or delayed complications. The anatomy of thoracic and abdominal cavities distinguishes the epidemiology, pathophysiology, symptoms, treatment, and prognosis of right versus left TDI. Although there is no definitive radiologic sign for diagnosing TDI, many signs have been introduced in the literature and the concurrent presence of multiple signs increases the sensitivity of TDI detection. Conservative versus surgical management depends on mechanism of TDI, side, and most importantly the associated injuries.

Acute and chronic traumatic diaphragmatic hernia: 10 years' experience

Controversy persists regarding many aspects of traumatic diaphragmatic hernia (TDH). We aimed to understand why some traumatic diaphragmatic injuries present with chronic hernia and to evaluate diagnosis and treatment options. Fifty acute and 19 chronic TDH patients were diagnosed and treated at our institution over a 10-year period. Clinical data from these two groups were analyzed statistically and compared. Chronic TDH patients had a significantly lower Injury Severity Score than acute TDH patients (10.26 ± 2.68 vs. 26.92 ± 4.79, P < 0.001). The most common surgical approach for acute and chronic TDH was thoracotomy and laparotomy, respectively. The length of the diaphragmatic rupture was significantly shorter in chronic TDH patients than acute TDH patients (6.00 ± 1.94 cm vs. 10.71 ± 3.30 cm, P < 0.001). The mean length of hospital stay was significantly longer for acute TDH patients than chronic TDH patients (41.18 ± 31.02 days vs. 16.65 ± 9.61 days, P = 0.002). In conclusion, milder trauma and a smaller diaphragmatic rupture were associated with delayed diagnosis. A thoraco-abdominal computed tomography scan is needed for patients with periphrenic injuries to avoid delayed diagnosis of TDH. Improved awareness and understanding of diaphragmatic injuries will increase the rate of early diagnosis and improve prognosis.

Chronic cough causing unexpected diaphragmatic hernia and chest wall rupture

Cough is a defense mechanism for airway protection and is associated with multiple systemic complications such as ribs fracture. Diaphragmatic rupture is commonly caused by blunt or penetrating trauma. We presented a case of a 72-year-old female with a 1-year history of chronic cough, not responding to medical management. Imaging showing abdominal herniation into the thoracic cavity and rib fracture due to diaphragmatic and chest wall rupture. Abdominal herniation and diaphragmatic rupture were repaired through surgery allowing resolution of symptoms. This is a life-threatening condition with a high-mortality rate in which early diagnosis and repair are desirable. Therefore, awareness of this uncommon complication of cough should be acknowledged.

Avulsion Injuries of Right Hemidiaphragm: Report of Two Case Scenarios with Different Outcomes

Avulsion injuries of domes of the diaphragm are rare injuries and may occur following lateral thoracoabdominal trauma. We share our experience of two cases of avulsion injuries of the right dome of the diaphragm. Our first case presented within a week following blunt trauma to the abdomen, and on thoracotomy, an effective repair was performed by restoring attachment of the diaphragm to the parietes. Our second case presented with severe respiratory distress, 1½ months after sustaining blunt injury chest and abdomen in a road traffic accident and on thoracotomy was found to have a completely necrosed right hemidiaphragm, and hence, no repair could be performed. However, the patient could not be weaned off ventilator and died after 3 months of primary injury. These cases highlight the importance of early diagnosis and repair of diaphragmatic injuries for a favorable outcome.

Innovative and Contemporary Interventions of Diaphragmatic Disorders

The diaphragm is an inconspicuous fibromuscular septum, and disorders may result in respiratory impairment and morbidity and mortality when untreated. Radiologists need to accurately diagnose diaphragmatic disorders, understand the surgical approaches to diaphragmatic incisions/repairs, and recognize postoperative changes and complications. Diaphragmatic defects violate the boundary between the chest and abdomen, with the risk of herniation and strangulation of abdominal contents. In our surgical practice, patients with diaphragmatic hernias present acutely with incarceration and/or strangulation. Bochdalek hernias are commonly diagnosed in asymptomatic older adults on computed tomography; however, when viscera or a large amount of fat herniates into the chest, surgical intervention is strongly advocated. Morgagni hernias are rare in adults and typically manifest acutely with bowel obstruction. Patients with traumatic diaphragm injury may have an acute, latent, or delayed presentation, and radiologists should be vigilant in inspecting the diaphragm on the initial and all subsequent thoracoabdominal imaging studies. Almost all traumatic diaphragm injury are surgically repaired. Finally, with porous diaphragm syndrome, fluid, air, and tissue from the abdomen may communicate with the pleural space through diaphragmatic fenestrations and result in a catamenial pneumothorax or large pleural effusion. When the underlying disorder cannot be effectively treated, the goal of surgical intervention is to establish the diagnosis, incite pleural adhesions, and close diaphragmatic defects. Diaphragmatic plication may be helpful in patients with eventration or acquired injuries of the phrenic nerve, as it can stabilize the affected diaphragm. Phrenic nerve pacing may improve respiratory function in select patients with high cervical cord injury or central hypoventilation syndrome.

Diaphragm and transdiaphragmatic injuries

The incidence of traumatic diaphragmatic rupture (TDR) is around 0.5% of all trauma patients, located more frequently on the left side (80%), with penetrating trauma being more predominantly the cause (63%) than blunt injuries (37%). TDR typically develops during thoracoabdominal injuries and outcome depends on the severity of the associated organ lesion. Diagnosis is sometimes very difficult: chest X-ray can verify TDR in only 25-70% of cases, although the specificity of a multidetector computed tomography (MDCT) is 100% and 83% for left and right-sided ruptures, respectively. When TDR is a part of a polytrauma, the management of the patient must follow the ATLS (Advanced Trauma Life Support) protocol and surgery is rarely based on the primary survey. The usual scenario involves cases detected during the secondary survey. In acute cases approach is determined by the site of the life-threatening injuries. In the daily surgical routine, in cases of acute TDR, laparotomy provides the best approach to manage the associated abdominal injuries and diaphragmatic rupture. Alternatively a transthoracic approach offer access to reconstruction in cases of delayed. A transdiaphragmatic procedure is offered when during an exploration (laparotomy or thoracotomy), any sign of an injury (bleeding, perforation) is verified through the rupture of the diaphragm in the other cavity (abdomen or chest and vice versa): the injury via a transdiaphragmatic way can be managed. Usually, a simple and small rupture up to 5-6 cm can be reconstructed with No. 0 or 1 monofilament non-absorbable or absorbable interrupted sutures, while for larger defects, interrupted figure-of-eight or horizontal mattress sutures are required. Mesh prosthesis is rarely needed.

A Diaphragmatic Hernia and Pericardial Rupture Caused by Blunt Injury of the Chest: A Case Review

Blunt traumatic diaphragmatic hernias are most commonly seen in combination with other injuries. Right diaphragmatic ruptures with serious pericardium ruptures are relatively rare. The diagnosis of diaphragmatic hernias is not difficult; however, prior to surgery, it is difficult to judge whether pericardium damage has occurred, particularly on the right side. This injury may occur in a critical pathological state in which cardiac tissue is outside the pericardium due to the pericardial defect. Severe hemodynamic disorders or even death may occur if the patient's condition is not diagnosed and treated in a timely manner. The transportation of patients with severe trauma must be performed with extreme caution. It is necessary to weigh a wide range of differential diagnoses in a serious and thorough initial investigation.

Relevance of early CT scan diagnosis of blunt diaphragmatic injury: A retrospective analysis from the Northern French Alps Emergency Network

INTRODUCTION

Diaphragmatic rupture following blunt trauma occurs rarely. Classically described after high-velocity accidents, ruptures are often associated with multiple organ injuries. The diagnosis is sometimes difficult. The goal of this study was to analyze and to discuss the modalities of early radiologic diagnosis and management of these injuries.

PATIENTS AND METHODS

This multicenter retrospective study included patients seen between 2009 and 2017 within the Northern Alpine Emergency Network [REseau Nord Alpin des Urgences (RENAU)]. Clinical, radiologic and surgical data from all patients sustaining blunt diaphragmatic rupture were studied.

RESULTS

Thirty-one patients (18 men and 13 women), median age 44, were included. The principle mechanism of injury was road or traffic accidents for 22 patients. Diaphragmatic rupture occurred on the left side in 23 patients. Diagnosis was delayed in two patients, at 11 days and three months after the initial accident. Chest X-rays were diagnostic in 18 of 29 patients. CT scan was the reference investigation since it was performed in all patients and confirmed the diagnosis in 26 instances. Repair was surgical via a midline laparotomy in 27 patients, via laparoscopy in three, and via thoracoscopy in one. Three patients died.

CONCLUSION

At urgent surgical exploration in the unstable blunt trauma patient, the surgeon should keep in mind the relatively poor diagnostic performance of chest X-rays. Accurate diagnosis relies on routine inspection of the diaphragmatic cupolas. In the stable trauma victim, contrast-enhanced abdomino-thoracic CT with reconstruction can lead to early diagnosis, which allows for repair under optimal conditions, whether by laparotomy, laparoscopy or thoracoscopy, according to local conditions and expertise.

A case of tension faecopneumothorax after delayed diagnosis of traumatic diaphragmatic hernia

Background

Traumatic diaphragmatic injuries from blunt or penetrating trauma are difficult to detect in the acute setting and, if missed, can result in significant morbidity and mortality in the future. We present a case demonstrating the natural progression of this resulting in faecopneumothorax, which is a rare but serious presentation.

Case presentation

A 22-year-old young man presented with left upper quadrant and chest pain, nausea, vomiting, and intermittent obstipation with a background of previous lower chest wall stabbings. Computed tomography demonstrated a diaphragmatic hernia containing the splenic flexure of the colon, but he declined treatment and self-discharged. He presented three more times with similar symptoms and self-discharged within a 2-week period and finally presented dyspnoeic and septic. Computed tomography demonstrated tension faecopneumothorax from the perforated colon. He was taken to theatres and found to have a 3-mm perforation at his splenic flexure and underwent a segmental resection of the affected colon, intrathoracic washout, and biological mesh repair of his diaphragmatic hernia. He remained alive and postoperative recovery was uneventful.

Conclusions

A review of the literature demonstrates the rarity of traumatic diaphragmatic injuries resulting in faecopneumothorax with only a few case reports in the last 50 years. We present a case demonstrating a natural progression of the condition and highlight the importance of having a high index of suspicion of diaphragmatic injuries in the trauma setting.

Laparoscopic approach to the management of penetrating traumatic diaphragmatic injury

Background

Traditionally, laparotomy/thoracotomy is the standard approach for thoracoabdominal injuries. However, it has a non-therapeutic rate of 12–40% and 40% morbidity. Laparoscopy, as a diagnostic and therapeutic modality, has evolved to be integral to general and subspecialty surgeons in the management of patients. However, its use in the field of trauma surgery has been limited. We present a case of traumatic diaphragmatic injury from a low velocity penetrating wound successfully repaired through laparoscopic approach.

Case presentation

A 20 year old male, presented with a traumatic diaphragmatic injury secondary to a low velocity penetrating injury. A computed tomographic scan revealed a tear on the left diaphragm with the superior pole of the spleen and omentum eviscerating through. He subsequently underwent diagnostic laparoscopy and primary repair of the diaphragmatic injury. His recovery was uneventful and he was discharged on the third postoperative day.

Conclusion

A review of current literature and our case suggest that the use of laparoscopy for the management of penetrating thoracoabdominal injuries is continually evolving and has shown to be a promising approach compared to traditional laparotomy in carefully selected patients. Laparoscopic repair of penetrating traumatic diaphragmatic injuries is a safe and expedient option for hemodynamically stable patients.

Bilateral Hip Dislocation: An Indicator for Emergent Full-Body Computed Tomography Scan in Polytraumatized Patients? A Case Report and Review of the Literature

We present a rare case of traumatic bilateral asymmetric hip dislocation with pelvic fractures and a traumatic diaphragmatic hernia. A 53-year-old machinist was transferred to our emergency department with the suspicion of a bilateral hip dislocation after he was trapped between an elevator and the roof. Immediate closed reduction of the hips was not performed because of the expected risk of increasing hemodynamic instability with muscular relaxation. An emergent full-body computed tomography (CT) scan was made to assess injuries with need for further operative treatment. Thus, closed reduction of both hips was finally performed in the OR directly before the laparotomy for the diaphragmatic repair and the osteosynthesis of the anterior pelvic ring. A 12-month follow-up showed good general health condition with asymptomatic situation of the hip joints and the abdomen. The diagnostic work-up of patients with severe trauma is still debated, a randomized controlled trial showed no reduction of the in-hospital mortality with immediate full-body CT scan compared to a conventional radiological work-up. Traumatic hip dislocations (THDs) are always due to high-energy trauma and additional injuries are frequent. To attempt a closed reduction of THD, under general anesthesia can be life-threatening with unrecognized associated injuries. Therefore, THD can serve as selection criteria for immediate full-body CT scan to facilitate diagnosis and treatment of associated injuries sustained by the patient.

Huge post-traumatic diaphragmatic hernia remained asymptomatic for 14 years. A case report

A 27-year-old male had an abdominal violation in a prison 14 years before the display of his symptoms and was misdiagnosed as massive haemothorax. The patient remained asymptomatic for 14 years and his symptoms were only a mild dyspnoea and mild dysphagia. This patient had a huge chronic postdiaphragmatic hernia with most of the abdominal organs in the left hemithorax. A left thoracotomy was performed and a mesh was used to close the huge posttraumatic diaphragmatic hernia (diameter of 15 cm), after repositioning the abdominal organs. The left lung was completely consolidated and required dissection of multiple adhesions and high pressure manual ventilation to reexpand normally. Blunt post-traumatic diaphragmatic ruptures may be misdiagnosed and become chronic asymptomatic hernias for several years. Once they become symptomatic, they have to be treated as soon as possible as major organ injuries may be hidden.

Transthoracic Littre's hernia presenting with faecopneumothorax following perforation of the Meckel's diverticulum: a late complication of oesophagectomy

A Littre's hernia is an unusual phenomenon where a Meckel's diverticulum protrudes through a potential abdominal opening. We wish to present a unique case of a 79-year-old man with respiratory distress following a fall from standing, initially managed as a haemothorax. After a chest drain was placed, bowel contents were drained from the pleural cavity and he was taken to theatre. He had a history of minimally invasive oesophagectomy for cancer and had subsequently developed a diaphragmatic hernia. A blind ending diverticulum with a perforation at its tip was found in the left oblique lung fissure that was subsequently confirmed histologically as a perforated Meckel's diverticulum. The patient had a prolonged stay on the intensive care unit with a left-sided empyema that was managed radiologically prior to discharge. Unfortunately 4 months postoperatively, he passed away from hospital-acquired pneumonia on a rehabilitation ward.

Tension enterothorax and hepatothorax due to a diaphragmatic hernia: successful emergency repair of a life-threatening condition

A 70-year-old female patient presented with acute severe respiratory distress at a district general hospital. Medical history included type 2 diabetes, recurrent pulmonary embolisms and pre-existing diaphragmatic hernia containing part of the liver. Despite initial treatment with steroid inhalers, her clinical picture rapidly deteriorated requiring emergency intubation and positive pressure ventilation. Imaging investigations revealed tension enterothorax and hepatothorax with tracheal deviation. The patient was transferred and underwent an emergency laparotomy at the Regional Oesophagogastric Unit. A large diaphragmatic hernia (central tendon defect) which contained the duodenum, porta hepatis, right lobe of liver, gallbladder and right colon was reduced and successfully repaired. Her postoperative course was uneventful with no signs of recurrence at 2 months follow-up.This case describes an extremely rare and life-threatening condition of tension enterothorax and hepatothorax, which should be considered in the differential diagnosis of acute respiratory distress with tracheal deviation.

The clinical implications of severe low rib fracture in the management of diaphragm injury: A Case Control Study

BACKGROUND

The objective of this study was to analyze the differences in clinical presentation and characteristics with regard to diaphragmatic injury between blunt trauma patients with severe low rib fractures and those without severe low rib fractures.

METHODS

The medical records of all patients with diaphragmatic injuries who were surgically treated at this level I trauma center, between January 2004 and December 2016 were reviewed. Patient notes, radiologic findings, and operative reports were evaluated. All of the diaphragmatic injuries were confirmed based on the operative findings. Rib fracture with displacement between the ends of the fracture of more than half the width of the fractured rib on computed tomography was classified as 'severe rib fracture'. Patients were categorized into 2 groups and analyzed: those who had more than one severe rib fracture in low ribs on the ipsilateral side of the diaphragm injury (Severe group), and those with no severe rib fracture (Non-severe group).

RESULTS

Delayed diagnosis of diaphragmatic injury was more frequent in the Severe group than in the Non-severe group (81.8% vs 36.8%, p-value = 0.026). With regard to initial indications for operation, intrathoracic visceral herniation was more frequent in the Non-severe group (78.9% vs 18.2%, p-value = 0.002), while hemothorax was more frequent in the Severe group (63.6% vs 5.3%, p-value = 0.001). Central type diaphragmatic laceration was more frequent in the Non-severe group than in the Severe group (78.9% vs 18.2%, p-value = 0.002). The diameter of diaphragmatic injury was larger in the Non-severe group than in the Severe group (9.70 ± 4.10 cm vs 4.80 ± 3.60 cm, p-value = 0.004).

CONCLUSION

The results of this study imply that a low threshold for thoracotomy or laparotomy should be considered in blunt trauma patients with severe low rib fractures for the purpose of hidden diaphragmatic injury detection and management.

Traumatic rupture of the diaphragm resulting in the sub-acute presentation of an incarcerated intra-thoracic transverse colon

The traumatic rupture of the diaphragm after blunt or penetrating injuries is a well described but uncommon entity. Its presentation in the form of herniated abdominal contents into the thoracic cavity is generally obscure and the recognition of this condition is often challenging. Although many cases remain asymptomatic, significant morbidity and mortality ensues with patients who present with incarceration, strangulation and eventual visceral compromise. Definitive guidelines in the management of traumatic diaphragmatic injuries are still lacking. This report outlines a case of sub-acute presentation of a traumatic diaphragmatic rupture in an elderly female following a motor vehicle accident that required urgent surgical intervention. We reviewed the pertinent literature, with an emphasis on the operative approach and the type of repair of the traumatic diaphragmatic defect.

Prevalence, management and outcome of traumatic diaphragm injuries managed by the Pietermaritzburg Metropolitan Trauma Service

INTRODUCTION This audit of traumatic diaphram injury (TDI) from a busy South African trauma service reviews the spectrum of disease and highlights current approaches to these injuries. METHODS The Pietermaritzburg Metropolitan Trauma Service (PMTS) has maintained an Electronic Surgical Registry (ESR) and a Hybrid Electronic Medical Record (HEMR) system since January 1st 2012. RESULTS A total of 105 TDIs were identified and repaired during the study period. The mean patient age was 30 years (range 15-68 years - SD 9.7). The majority (92.4%) of patients were male (97/105). Penetrating trauma was the leading mechanism of injury (94%). 75 patients sustained a TDI from a stab wound, and the remaining 24 injuries resulted from gunshot wounds. Multiple associated injuries and high morbidity was seen with right diaphragm injury, blunt trauma, gunshot wounds and chronic diaphragmatic hernias. CONCLUSIONS TDI is a fairly uncommon injury with a local incidence of 1.6%. It presents in a spectrum from the obvious to the occult. Multiple associated injuries and high morbidity occur following blunt trauma or gunshot wounds, right diaphragm injury and chronic diaphragmatic hernias. Diagnostic laparoscopy offers a diagnostic and therapeutic tool to prevent progression of occult TDI to chronic diaphragmatic hernias.