Diagnosis Of Traumatic Diaphragmatic Hernia Research Articles

Traumatic Diaphragmatic Hernia: An Uncommon Entity

Traumatic Diaphragmatic hernia is secondary to penetrating injuries and blunt abdominal and thoracic trauma. It is an uncommon entity. Early diagnosis is necessary to decrease morbidity and mortality. Here we report a case of 22-year-old male with diagnosis of traumatic diaphragmatic hernia. On examination abdomen was distended, guarding present, tender present and bowel sound not appreciated with decreased air entry over left side. CT Scan showed left sided diaphragmatic defect with intrathoracic herniation of abdominal viscera. Laparotomy and exploration revealed a diaphragmatic tear of size 7.5cm X 5cm, with herniation of stomach, spleen, splenic flexure of colon, distal pancreas through diaphragmatic tear.

Traumatic Diaphragmatic Hernia: Safety and Efficacy of a Minimally Invasive Approach: Case Report

Missed diagnosis of traumatic diaphragmatic hernia is a known complication of blunt trauma as the diagnosis can be difficult to ascertain acutely. Pre-operative diagnosis is challenging, and to date, there is no consensus on the standard management for this condition. Until recently, open primary repair was the standard of care with few centers attempting laparoscopic repair for select patients. The objective of this study was to evaluate the safety, technical feasibility, and clinical outcomes for minimally invasive repair utilizing the DaVinci Robotic platform for traumatic diaphragmatic hernia repair. Robotic repair was performed on a patient who presented with a large diaphragmatic hernia 9 years after blunt trauma. The procedure was recorded, technique detailed, and clinical outcomes assessed. There were no significant adverse events noted. After 1 year, the patient is doing well with no complaints, no evidence of recurrence and no other complications. Robotic repair of traumatic diaphragmatic hernia effectively achieved reduction of herniated contents, primary defect closure, and broad mesh overlap with good results at 1 year. This approach may provide an innovative minimally invasive option for surgeons and patients.

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

BackgroundTraumatic 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 presentationA 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.ConclusionsA 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.

Thoracotomy for Traumatic Diaphragmatic Hernia.

The aim of this retrospective study is to review our experience in the diagnosis and role of thoracotomy for traumatic diaphragmatic hernia (TDH). Between January 2008 and June 2014, 23 patients from Yangzhou Medical College (Yangzhou China) and Lishui Center Hospital (Lishui China), who underwent thoracotomy for TDH, were analyzed. The clinical features, imaging findings, operative findings, and outcome of treatment in these patients are presented. There were 23 patients (18 males and 5 females) who underwent surgical procedures due to TDH. The median age of the patients was 43.2years (range, 15-68years). The cause of rupture was penetrating trauma in 1 (4.3%) patient and blunt trauma in 22 (95.7%) patients. The TDH was left sided in 21 patients and right sided in two patients. The diagnosis was made by chest X-ray (n = 2) and chest or abdominal CT (n = 13) and at thoracotomy based on a high index of suspicion (n = 8). Associated injuries were seen in 21 patients (91.3%). Twenty-two patients underwent thoracotomy, and one underwent thoracotomy with laparotomy. The mean operating time was 112min (range, 60-185min) and the mean blood loss was 116mL (range, 20-400mL). The most common herniated organs were the omentum (n = 15), stomach (n = 14), spleen (n = 11), colon (n = 10), small bowel (n = 2), and liver (n = 1). All diaphragmatic defects were repaired using interrupted prolene sutures. The overall mortality rate was 4.3% (n = 1). The diagnosis of TDH is easily missed or delayed. Chest X-ray and computer tomography (CT), especially chest and abdominal CT, are useful in the diagnosis of diaphragmatic ruptures, and thoracotomy is an effective and successful treatment for TDH.

Delayed Presentation of Traumatic Diaphragmatic Hernia: The Evaluation of Surgical Treatment Results

Introduction: Diaphragmatic hernia could be caused by congenital disorders, blunt trauma or penetrating injuries. The diagnosis of traumatic diaphragmatic hernia is normally neglected during the first presentation leading to late complications and considerably increased mortality and morbidity among the patients. Materials and Methods: In this retrospective, descriptive study, we reviewed the medical records of patients presented with traumatic diaphragmatic hernia who had undergone surgical operations between 1982-2015 in Ghaem Hospital and Omid Hospital affiliated to Mashhad University of Medical Sciences, Iran. The studied variables included age, gender, clinical symptoms, location of hernia, involved organs, type of imaging modalities, surgical techniques, length of hospital stay, mortality rate and surgical complications. Results: In this study, 38 patients were diagnosed with traumatic diaphragmatic hernia consisting of 28 men and 10 women. In total, 79% and 21% of the patients suffered from penetrating trauma and blunt trauma, respectively. In addition, left-sided, right-sided and bilateral hernias were present in 33%, 4% and 1% of the patients, respectively. The most frequently herniated organ was the stomach, and the most common clinical symptoms were abdominal pain (84%) and dyspnea (53%). Initially, chest radiographs were performed on all the patients, and thoracotomy was performed to repair diaphragmatic tears in all the cases (100%). In this study, 3 patients had previously undergone Hartmann’s operation for gangrenous herniated colon, and devolvulation of gastric volvulus had also been performed on 3 patients. The main post-operative complications were reported to be pneumonia and respiratory insufficiency (2 cases), and the mean length of hospital stay was 6 days (5-8 days) which was longer (1-2 months) in patients with gangrenous bowel (3 patients). Furthermore, no mortality was reported during the course of hospitalization in these patients. Conclusion: According to the results of this study, patients presented with blunt or penetrating traumas to the upper abdomen or lower chest require urgent attention as to immediately rule out diaphragmatic hernia in order to prevent later complications and mortality and morbidity among these patients.

Traumatic diaphragmatic hernia in children

Traumatic diaphragmatic hernia (TDH) is very rare in the pediatric age group. Because of its rarity and its coexistence with more serious injuries, the diagnosis is often missed or delayed. All children with the diagnosis of TDH were retrospectively reviewed for age at diagnosis, sex, mechanism of injury, site of diaphragmatic rupture, associated injuries, injury severity score, investigations, treatment and outcome. Over a period of 15 years (1992-2007), we treated seven children with TDH. All were males except one. Their mean age was 7.4 years (3.75-14 years). The site of TDH was on the left in three, on the right in three and one had bilateral TDH. The mechanism of injury was blunt trauma in six and penetrating injury from a stab in one. Three had right TDH and in all three, the diagnosis of TDH was delayed. All sustained severe injuries as reflected by the ISS score (mean 38.6). The time from presentation to diagnosis was variable ranging from 3 to 240 h (mean 65.7 h). The three patients with left TDH were repaired trans-abdominally while the three with right TDH were repaired via a right thoracotomy. The patient with bilateral TDH required laparotomy and thoracotomy. All our patients survived and the hospital stay was variable ranging from 7 to 24 days (mean 17 days). TDH is very rare in children and often associated with severe more serious injuries. These two factors contribute to the delay in diagnosis. This is specially so for right TDH. To obviate delay in diagnosis, it is important to have a high index of suspicion as well as careful interpretation of the initial and follow-up radiological investigations including CT-scan of the chest and abdomen. This is important to detect a slowly increasing TDH that may not be apparent initially.

Computed Tomography in the Evaluation of Diaphragmatic Hernia following Blunt Trauma

Diagnosis of traumatic diaphragmatic hernia due to blunt abdominal trauma requires a high index of suspicion. This study was conducted to assess the accuracy of multidetector computed tomogram (MDCT) in the diagnosis of traumatic diaphragmatic hernia. All patients with thoracoabdominal blunt trauma with diaphragmatic hernia diagnosed on radiologic evaluation during a 3-year period (i.e., from June 2004 to June 2007) were analyzed. Nineteen patients with diaphragmatic injuries in 117 patients with blunt thoracoabdominal injury (16.23%) were studied. Age range was 8-60years (mean 34years). Male-female ratio was 18:1. Various features seen on CT scan were diaphragmatic discontinuity in 13 (68.42%), thickened diaphragm in 10 (52.63%), "collar sign" in 8 (42.10%), visceral herniation in 12 (63.15%), dependent viscera sign in 8 (42.10%), and segmental nonrecognition of the diaphragm in 1 patient (5.88%). Two patients presented with delayed rupture. In the rest mean duration between time of injury and performance of CT scan was 44.35h (range 3-288h). Fourteen patients underwent operative management. Sensitivity, specificity, and accuracy of MDCT scan were 100, 93, and 95%, respectively. Three patients (15.78%) expired. MDCT is a highly accurate modality for detecting traumatic diaphragmatic hernia.

A case of acquired diaphragmatic hernia presenting with pneumothorax

Diaphragmatic hernia can be congenital or acquired. Both are rare (1 in 2000 births). We report a case of acquired diaphragmatic hernia in a 23-year old male who presented with complications due to delayed diagnosis of traumatic diaphragmatic hernia. DOI: http://dx.doi.org/10.4038/sljs.v27i1.1898 The Sri Lanka Journal of Surgery 2009: 27 : 17-18

Congenital double diaphragm initially diagnosed as traumatic ruptured diaphragmatic hernia

An 11-year old boy, a victim of penetrating stab wound to his chest, presented with severe respiratory distress and dyspnoea. The knife had entered the chest at the rightmid-axillary line, at the level of 7th–8th ribs. He was initially diagnosed of having a right sided pneumothorax and therefore primary resuscitation was performed and a right sided chest tube was inserted. However patient’s severe shortness of breath did not improve. His respiratory rate was 40/min, blood pressure 90/60 mm Hg, and pulse rate was 140/min. Physical examination demonstrated a small (1 cm) laceration on the right chest at the level of 7th intercostal space just below the tip of the scapula. Patient’s chest X-ray revealed intestinal gas above the diaphragmwith chest tubes in the right and left lungs (Fig. 1). The patient was hypoxic (PO2 78.8 mmHg, PCO2 31.5 mm Hg, pH 7.46, HCO3 21.8 mmol/L and O2 saturation of 96.2%), in spite of 10 L of O2. Base on his chest X-ray findings and his unstable clinical features, he was emergently taken to the operating room (OR) with possible diagnosis of traumatic diaphragmatic hernia. During the operation, a double diaphragmwith a large central defect was diagnosed. Hernia repair surgery was done and he was taken to the intensive care unit. His clinical condition progressively improved. Hewas discharged from the hospital 10 days post-surgery.

Delayed diagnosis of traumatic diaphragmatic hernia may cause colonic perforation: a case report

Early diagnosis of diaphragmatic rupture after traumas may be difficult, and delayed diagnosis may result in increased morbidity and mortality. This paper describes the case of a 32-year-old man who experienced a traffic accident and had diagnosis of traumatic diaphragmatic hernia nearly four months later. The patient was referred to our emergency room suffering from ileus symptoms. Physical examination demonstrated an apparent abdominal distention, tenderness at the upper abdominal quadrants, rebound, and defense. Thoraco-abdominal X-rays and computerized tomography imaging demonstrated intestinal segments with air-fluid levels in thorax. Laparotomy was performed after a preoperative diagnosis of a strangulated-diaphragmatic hernia. At abdominal exploration, it was found that transverse colon and omentum entered into thorax through diaphragmatic defect located at the left diaphragm. Herniating colon segment was complicated with ischemic necrosis and perforation. In conclusion, colon necrosis and perforation may develop when early diagnosis of diaphragmatic ruptures are missed.

Isolated rupture of the right hemidiaphragm with eventration of the liver demonstrated by liver scan.

A case of isolated rupture of the right hemidiaphragm secondary to blunt abdominal trauma with hepatic herniation into the right thorax is described. Early diagnosis was established by a liver scan obtained in the acute stage of injury. Primary repair was followed by uneventful recovery. This case indicates that liver imaging is a very helpful method in the early diagnosis of traumatic diaphragmatic hernia as well as in hepatic injury.

A CASE OF TRAUMATIC INTRAPERICARDIAL DIAPHRAGMATIC HERNIA OPERATED ON 5 YEARS AFTER A SERIOUS TRAFFIC ACCIDENT

Traumatic intrapericardial diaphragmatic hernia with rupture of the diaphragm localized at the pericardial side is very uncommon. A 51-year-old man was referred to the hospital because of an abnormal sound of the left anterior chest after meals. He had been involved in a serious traffic accident 5 years before and drained left hemothorax for several days. After admission chest CT showed the gastrointestinal tract existed above the diaphragm. Thoracoscopy was tried with a diagnosis of traumatic diaphragmatic hernia, but no diaphragmatic hernia in the left thoracic cavity was seen. It was traumatic intrapericardial diaphragmatic hernia, in which ruptured portion in the diaphragm was localized at the pericardial side. Since the repair of hte hernia was impossible by thoracotomy, he underwent a small left side thoracotomy and the pericardial space was opened. The stomach, omentum and a part of colon were found there and reduced gently. The laceration of the diaphragm was closed directly using interrupted sutures. CT scan is helpful to confirm the diagnosis of traumatic intrapericardial diaphragmatic hernia, but the correct preoperative diagnosis is very difficult unless pneumopericardium exists in the pericardial space.

CASE OF TRAUMATIC DIAPHRAGMATIC HERNIA INVOLVING THE LIVER OCCURRED AFTER RECEIVING A STABBED WOUND IN THE CHEST WALL

We experienced an extremely rare case of left-sided traumatic diaphragmatic herina involving the left hepatic lobe as a part of hernia content which occurred about 4 years after receiving a stabbed wound. The case involved a 49-year-old woman. There was a previous history of receiving a stabbed wound in the anterior thoracic region for suicide purpose which was conservatively treated in December 1990. In September 1994 the patient was seen at the hospital because of an upper abdominal pain and vomiting. A simple chest X-ray film revealed pleural effusion. Upper gastrointestinal series and chest CT visualized a protrusion of the upper portion of the gastric body in the left thoracic cavity. Based on her previous history and results of examinations, she was operated on transabdominally under a diagnosis of traumatic diaphragmatic hernia. At laparotomy, the hernia opening was 4×4 cm in size; the hernia was located in the left anterior lateral portion of the central tendon of the diaphragm; and the middle portion of gastric body and a part of the left hepatic lobe were incarcerated. The protruded gastric body appeared good in color, but the liver necrosed and so the portion was excised. The hernia opening was closed in one layer suture. Postoperative course was uneventful.

Traumatic diaphragmatic hernia: an unusual presentation

INTRODUCTION THE diagnosis of traumatic diaphragmatic hernia is often difficult, relying on a high index of suspicion and is frequently delayed, overlooked or missed (Noon et al., 1966). Delayed operative repair is associated with an increased morbidity and mortality (Hegarty et al., 1978). The majority of traumatic diaphragmatic hernias occur on the left (Noon et al., 1966; Ball et al., 1982). When a traumatic diaphragmatic hernia occurs on the right, it is usually the liver which herniates. Traumatic herniation of bowel on the right without liver herniation is unusual and, to our knowledge, has not been described in the literature. In this report we describe a case of right diaphragmatic bowel herniation in which the diagnosis was made only after a barium contrast study had been carried out. Awareness of this condition is important in order to avoid the potentially fatal complications.

労災による横隔膜ヘルニアの１治験例

A 37-year-old man was admitted with multiple fractures and on the 5th day after his admission, complained of increasing dyspnea.Upon auscultation, decreasing breath sound and bowel sound were recognised in the greater part of the left chest.A chest X-P film revealed that the left lung had collapsed and that there were intestinal gases.A left side thoracotomy was performed under the diagnosis of traumatic diaphragmatic hernia. The colon, small intestine and spleen were seen in the left thoracic cavity. The left diaphragm was lacerated about 20cm from the central tendon to the antero-lateral end and a 10cm rupture of the pericardium was seen. These two lacerations were not continuous. The spleen also had a small laceration, but the bleeding had stopped.The rupture of the pericardium was repaired with continuous over and over suture and the diaphragm was repaired with continuous horizontal mattress suture. The postoperative course was uneventful.

RUPTURE OF THE DIAPHRAGM CAUSED BY BLUNT TRAUMA

Our experience with 27 patients who sustained traumatic laceration of the diaphragm caused by blunt forces is described. Automobile accident were the most frequent cause of rupture and young adult males the most vulnerable. The left hemidiaphragm is most frequently injured, but with sufficient force significant tears in the right hemidiaphragm will occur. Most of these patients sustained injury to multiple organ systems. The preoperative diagnosis of traumatic diaphragmatic hernia is based on a high index of suspicion, close and continued observation of the patient, and correct interpretation of roentgenograms of the chest. The mortality rate is high, owing to the magnitude of the injuries.