Diaphragmatic Rupture Research Articles

Post-traumatic Synchronous Twin Inter-muscular Abdominal and Diaphragmatic Hernias: A Rare Presentation

Simultaneous occurrence of traumatic abdominal wall hernia (TAWH) and traumatic diaphragmatic hernia (TDH) is uncommon. Our report documents the rare delayed presentation of simultaneous occurrence of TAWH and TDH in a patient who sustained a bicycle handlebar injury as a consequence of the bicycle he was riding colliding with a motorbike in a road-traffic accident. Excellent outcome could be achieved in this patient with surgical repair without requiring the use of a mesh.

VATS-assisted surgical stabilization of rib fractures in flail chest: 1-year follow-up of 105 cases.

Early surgical stabilization of flail chest has been shown to improve chest wall stability and diminish respiratory complications. The addition of video‑assisted thoracoscopic surgery (VATS) can diagnose and manage intrathoracic injuries and evacuate hemothorax. This study analyzed the outcome of our 7-year experience with VATS-assisted surgical stabilization of rib fractures (SSRF) for flail chest. From January 2013 to December 2019, all trauma patients undergoing VATS-assisted SSRF for flail chest were included. Patient characteristics and complications during 1-year follow-up were reported. VATS‑assisted SSRF for flail chest was performed in 105 patients. Median age was 65years (range 21-92). Median injury severity score was 16 (range 9-49). Hemothorax was evacuated with VATS in 80 patients (median volume 200ml, range 25-2500). In 3 patients entrapped lung was freed from the fracture site and in 2 patients a diaphragm rupture was repaired. Median postoperative ICU admission was 2days (range 1-41). Thirty-two patients (30%) had a post‑operative complication during admission and six patients (6%) a complication within 1year. In-hospital mortality rate was 1%. Six patients (6%) died after discharge, due to causes unrelated to the original injury. Addition of VATS to SSRF for flail chest seems helpful to diagnose and manage intrathoracic injuries and adequately evacuate hemothorax. The majority of complications are low grade and occur during admission. Further prospective research needs to be conducted to identify potential risk factors for complications and better selection for addition of VATS to improve care in the future.

Never to be missed again - an analysis of 55 consecutive cases of traumatic diaphragmatic hernia

BACKGROUND: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care. METHODS: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality. RESULTS: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides CONCLUSION: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach.

Blunt thoracic trauma: role of chest radiography and comparison with CT - findings and literature review.

In the setting of acute trauma where identification of critical injuries is time-sensitive, a portable chest radiograph is broadly accepted as an initial diagnostic test for identifying benign and life-threatening pathologies and guiding further imaging and interventions. This article describes chest radiographic findings associated with various injuries resulting from blunt chest trauma and compares the efficacy of the chest radiograph in these settings with computed tomography (CT). Common chest radiographic findings in blunt thoracic injuries will be reviewed to improve radiologic identification, expedite management, and improve trauma morbidity and mortality. This article discusses demographic information, mechanism of specific injuries, common imaging findings, imaging pearls, and pitfalls and exhibits several classic imaging findings in blunt chest trauma. Thoracic structures commonly injured in blunt trauma that will be discussed in this article include vasculature structures (aortic trauma), the heart (cardiac contusion, pericardial effusion), the esophagus (esophageal perforation), pleural space and airways (pneumothorax, hemothorax, bronchial injury), lungs (pulmonary contusion), the diaphragm (diaphragmatic rupture), and the chest wall (flail chest). Chest radiography plays an important role in the initial evaluation of blunt chest trauma. While CT imaging has a higher sensitivity than chest radiography, it remains a valuable tool due to its ability to provide rapid diagnostic information in time-sensitive trauma situations and is ubiquitously available in the trauma bay. Familiarity with the gamut of injuries that may occur as well as identification of the associated chest radiograph findings can aid in timely diagnoses and prompt management in the setting of acute blunt chest trauma.

Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients With Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset.

We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients. Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed. Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001). Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.

Delayed tension gastrothorax caused necrosis of stomach and re-expansion pulmonary edema: a case report

BackgroundTraumatic tension gastrothorax is a rare and potentially fatal condition occurring in patients with congenital or acquired diaphragmatic defects. Traumatic tension gastrothorax leads to acute and severe respiratory distress. Delayed tension gastrothorax that develops late during injury can be more severe.Case presentationAn 84-year-old woman was brought to our facility with cardiac arrest and returned to spontaneous circulation after 2 min of cardiopulmonary resuscitation. Computed tomography showed diaphragmatic injury and tension gastrothorax due to trauma because of a fall episode few days earlier. Emergency thoracotomy and laparotomy was performed, because nasogastric tube insertion failed. There was a partially necrotic stomach in the chest cavity. The stomach was retracted from the thoracic cavity into the abdominal cavity and placed in its proper position. There was a 5 cm tear of the diaphragm. The tear was sutured and closed and then the necrotic area of the stomach was resected. Although the surgery relieved the intrathoracic compression, it resulted in re-expansion pulmonary edema immediately after surgery and hypoxemia. The patient was unable to overcome the hypoxemic state and eventually died.ConclusionsDelayed tension gastrothorax can lead not only to obstructive shock due to intrathoracic compression but also to more severe organ ischemia and re-expansion pulmonary edema due to insufflation.

Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë

We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

A Hydatic Cyst into a Large Diaphragmatic Hernia

A 44-year-old woman, presented to the emergency department with dyspnea since 1 month, associated with vomiting and right upper quadrant pain. She has a surgical history of hydatid cyst of the right liver for which a resection of the protruding dome was performed 18 years ago. On physical examination, she was tachypneic and pulmonary auscultation revealed bowel sounds in the right hemithorax with reduction of vesicular murmur. Chest X-ray showed bowel gas with air-fluid levelsinside the right chest cavity. A chest-abdominal computed tomography revealed a 9cm right diaphragmatic hernia which allowed passage of the right colon and gastric antrum into the chest cavity. The right lung was collapsed and the mediastinal shift towards the left. CT scan also revealed a 94*50mm multivesicular hydatid cyst strongly adherent to the liver and which is also included in the hernial content (figure). The patient was operated on. A resection of the hydatid cyst was performed, with reduction of the herniated organs into peritoneal cavity and diaphragmatic suture. The post-operative course was uneventful. Iatrogenic right diaphragmatic hernia is a rare complication after hepatic surgery. It can sometimes be difficult to identify at an early stage and can result in diagnostic delays with life-threatening outcomes. In our case , diaphragmatic injury and liberation of the liver during the first operation could explain hepatic location in the left abdomen and the occurrence of diaphragmatic hernia.

Hepatic foreign body removal with intravascular occlusion balloon in retrohepatic IVC in a pediatric patient

Penetrating hepatic injuries in pediatric patients represent a clinical challenge that carries significant morbidity and mortality. We report a case of a 13-year-old male with a penetrating injury to his right flank that resulted in a diaphragmatic injury, liver laceration, and a retained hepatic foreign body nearly abutting a major vessel. We review the literature on managing penetrating hepatic injuries in pediatric patients and describe our novel hybrid endovascular approach for hepatic vascular isolation during open intrahepatic foreign body removal.

An isolated left diaphragmatic injury due to blunt trauma abdomen: a rare case entity

Isolated diaphragmatic injury in blunt trauma occurs acutely and can be associated with other life-threatening organ injuries. A sudden increase in abdominal pressure causes injury in the membranous or muscular part of the diaphragm. Isolated left diaphragmatic injury after blunt trauma is rarely seen, its diagnosis can be overlooked frequently. Early diagnosis is the most important step in the treatment thereby reducing morbidity and mortality. The most critical point during the diagnosis is the suspicion for clinical diaphragm injury like respiratory distress. Single or serial plain chest radiographs with a high index of suspicion are diagnostic in most cases. Computed tomography of the abdomen and thorax can be a guide for identifying the size of diaphragmatic injury and the contents. In this case report, we presented an isolated left side diaphragmatic rupture after blunt abdominal trauma and treated with an urgent surgical operation.

Traumatic abdominal intercostal transdiaphragmatic hernia: a case report and literature review

Abdominal intercostal herniations are a rare entity where abdominal contents herniate through the intercostal space with or without diaphragmatic rupture. Because they are rare, there is little literature to support how they should be treated, conservatively or surgically, and if surgically, what techniques provide the best outcome. This case illustrated the potential for good recovery post-surgical repair of a traumatic intercostal hernia and suggests a guideline used to determine surgical technique.

Delayed asymptomatic blunt traumatic diaphragmatic hernia: an unusual case report

IntroductionTraumatic diaphragmatic hernia (TDH) is uncommon, being encountered in around 0.8%-8% of patients with blunt abdominal trauma. Severe comorbidities such as fractures and thoraco-abdominal or head injuries that accompany TDH, are responsible for poor prognosis and often mask diaphragmatic injury itself. Objective of this case report was to highlight rare blunt TDH case to avoid missed diagnosis leading to complications. Case descriptionSixty seven-year old man presenting with right chest pain without difficulty of breathing after falling from stairs 1 hour before hospital admission. On clinical examination, vitals were stable, but with decreased breath sounds on right lower side of chest. Patient had history of trauma from being crushed by elevator 40 years ago without any proven diaphragmatic injury. Initial erect chest X-ray findings were inhomogeneous opacity shadow on lower right hemithorax suspected to be diaphragmatic hernia and 7th right rib fracture with pleural effusion. Thorax CT scan showed herniated right lobe of liver, gall bladder, and mesenteric fat on right hemithorax causing displacement of mediastinal structures. Patient was diagnosed with delayed TDH and hemothorax caused by newly fractured rib. Patient was referred to a better-equipped facility due to the limited surgical facilities in referring hospital. ConclusionDelayed TDHs are not common, but can lead to serious consequences. Blunt TDH occurs more often on left than on right side, in ratio of approximately 3:1. Traumatic diaphragmatic hernia is sometimes diagnosed many years after traumatic event due to latent phase of disease possibly ranging from days to years.

Development of Diaphragmatic Hernia in Patients with Penetrating Left Thoracoabdominal Stab Wounds.

This study aimed to investigate the consequences of repairing versus not repairing diaphragmatic injury caused by penetrating left thoracoabdominal stab wounds. Diagnostic laparoscopy was performed to evaluate the left diaphragm in patients with penetrating left thoracoabdominal stab wounds who did not have an indication for emergency laparotomy. Patients who did not consent to laparoscopy were discharged without undergoing surgery. Post-discharge radiological images of patients who underwent diaphragmatic repair and radiological images of patients who could not undergo laparoscopy, both during hospitalization and after discharge, were evaluated and compared. Diagnostic laparoscopy was performed on 109 patients. Diaphragmatic injuries were detected and repaired in 32 (29.36%) of these patients. Seventeen patients were lost to follow-up. After a mean follow-up of 57.67months, none of the remaining 15 patients developed a diaphragmatic hernia. On the other hand, 43 patients refused to undergo diagnostic laparoscopy. Twenty of them were lost from follow-up. The diaphragmatic injury was detected in seven of the remaining 23 patients (30.44%) during initial computed tomography (CT) examinations. In this group, the mean follow-up time was 42.57months, and delayed diaphragmatic hernia developed in one patient (14.30%). Patients who underwent diaphragmatic repair were compared to patients who did not undergo diagnostic laparoscopy but had diaphragmatic injuries detected on their CT. No statistical differences were detected. Diaphragmatic injuries caused by penetrating stab wounds can sometimes heal spontaneously. However, diagnostic laparoscopy is still relevant for revealing and repairing possible diaphragmatic injuries.

Diaphragmatic Injury in Multisystem Closed Abdominal Trauma: Features of Diagnosis and Treatment

INTRODUCTION In connection with the increase in the number of cases of combined and multiple injuries among the population, a proportional increase in the number of cases of diaphragm injury is also observed. In this case, shock is observed, damage to the organs of the chest and abdomen prevails in the absence of strictly specifi c clinical symptoms of diaphragm rupture, which leads to a large percentage of medical and diagnostic errors and complications. The described diffi culties in diagnosing cases of diaphragm injury dictate the need to develop a standardized approach to the management of this category of patients.AIM OF STUDY Refi nement of the treatment and diagnostic approach to the management of patients with concomitant blunt trauma and diaphragm injury from the view of modern diagnostic and surgical technologies.MATERIAL AND METHODS The literature review presents materials of domestic and foreign publications for the period from January 2015 to December 2020, obtained from electronic databases of medical literature PubMed, Cochrane Library, Scopus, eLibrary using the primary search strategy for the following search queries: diaphragm damage, diaphragm rupture, multisystem injury of the chest and abdomen, tactics of multi-stage surgical treatment, closed abdominal trauma, treatment and diagnostic algorithm, thoracoscopy, thoracotomy, laparoscopy, laparotomy (total 308 publications), with subsequent exclusion of experimental studies, non-full-text articles, publications not in Russian or English, manuscripts on open trauma and post-traumatic diaphragmatic hernia older than 30 days old from the moment of injury. The data extraction method was performed by two researchers independently of each other. The analysis was made of multicenter studies, systematic reviews, large case series, original articles (14 retrospective selective studies from 1994 to 2018; a total of 928 patients with closed diaphragmatic injury) and one meta-analysis (2023 patients).RESULTS The treatment and diagnostic algorithm for multisystem closed diaphragmatic injury has been standardized based on the hemodynamic status of the patient, the indications for minimally invasive and open interventions in this category of patients have been clarifi ed, and a description of the staged surgical treatment has been given.CONCLUSION Timely diagnosis, minimally invasive interventions in the treatment of diaphragmatic injuries, as well as their stage-by-stage organization in conditions of severe polytrauma contribute to a decrease in mortality.

Expression of Concern: Giant Traumatic Diaphragmatic Hernia: A Report of Delayed Presentation.

Expression of Concern: Giant Traumatic Diaphragmatic Hernia: A Report of Delayed Presentation.

Delayed hepatothorax: An unusual presentation case report.

Introduction and importanceWe are reporting a case of a delayed hepatothorax due to a right-sided diaphragmatic rupture 13 years after a blunt trauma due to a motor vehicle accident, who presented as isolated gastritis without any type of respiratory symptomatology.Case presentationPatient refers that his symptoms remained refractory to medical treatment and had gotten worse over time. Chest wall inspection showed asymmetric thoracic expansion and a decreased movement of right hemithorax when compared to the left. Cardiorespiratory auscultation was significant for growling sounds on the right second intercostal space and reduction of breath sounds on the right lower lobe region of the lung when compared to the left side.Clinical discussionThoracotomy was indicated since patient presented late. Meanwhile, laparotomy would have been appropriate if the patient had presented immediately after trauma. After the procedure, the patient presented in great condition and all the gastrointestinal symptoms associated with the traumatic diaphragmatic hernia had resolved. We propose that the absence of respiratory symptoms in our patient could be due to the progressive adaptation of small, cumulative changes in decreasing breathing capacity through time.ConclusionA case like ours has not been reported in the literature and clinicians should take this case report into consideration when suspecting a possible diagnosis of a delayed traumatic diaphragmatic hernia that may be complicated by a hepatothorax. We recommend maintaining a high index of clinical suspicion for hepatothorax due to delayed traumatic diaphragmatic hernia for all patients with a history of trauma.

Lung and diaphragm protective ventilation: a synthesis of recent data

ABSTRACT Introduction : To adhere to the Hippocratic Oath, to ‘first, do no harm’, we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients’ spontaneous breaths, while at the same time adhering to lung-protective targets. Areas covered This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. Expert opinion Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient–ventilator interaction.

Management of Traumatic Diaphragmatic Injury-A Peep into Bowel Repair via Thoracotomy.

Background:Traumatic diaphragmatic injury (TDI) is a relatively rare condition, and there is a high tendency for it to be missed if thorough clinical assessment and imaging review are not carried out. The surgical approach for TDI can be challenging, especially with bowel perforation.Materials and Methods:This is a retrospective case series of all consecutive patients with TDI from two tertiary hospitals in the southern part of Nigeria between January 2013 and December 2019. The demographic data of the patients, type, cause, and clinical diagnosis, intraoperative findings, Injury Severity Score, and outcome were noted. The descriptive statistics were presented in percentages and fractions.Results:Fourteen (4.3%) of the 326 chest trauma patients had TDI with 57.1% from penetrating causes and 42.9% from blunt causes. The causes of the TDI were gunshot injuries (42.9%), road traffic crashes (35.7%), stab injury (14.3%), and domestic accidents (7.1%). The preoperative method of diagnosis was mainly by massive haemothorax necessitating open thoracotomy (42.9%) and mixed clinical evaluation, chest radiograph, and upper gastrointestinal contrast studies (35.7%), and the drainage of intestinal content following the insertion of a chest tube to initially drain haemothorax (21.4%) and other modality of diagnoses (7.1%). The operative finding was mainly intestine content in the chest (50%) and only diaphragmatic injury (35.7%). The major complication after surgery was empyema thoracis (14.3%) and the mortality rate (14.3%).Conclusion:Penetrating injury of the chest was the major factor responsible for the TDI, and even with bowel perforation and acute TDI, thoracotomy offered an effective surgical approach for all the patients.

Delayed presentation of traumatic right diaphragmatic hernia in a child

Traumatic diaphragmatic hernia is a rare entity in children which could be secondary to blunt or penetrating injury to the abdomen. Due to the presence of other distracting injuries and delayed presentation, diaphragmatic injury could be missed in the initial evaluation. Here we present a case study of a child with a delayed presentation of a right traumatic diaphragmatic hernia following an elephant attack. A 2 year and 7 months old girl was admitted following a tragic elephant attack, with evidence of bilateral lung contusion and right femur fracture. In addition she developed hemoglobinuria complicated with acute renal injury which improved with fluid resuscitation and diuresis. She was ventilated due to respiratory distress and the initial imaging showed normal diaphragmatic margin. On further review there was a lucency in the right hemithorax in the chest x-ray, which appeared to be an eventration in the contrast CT chest. However on laparoscopic examination it was found to be a right traumatic diaphragmatic hernia which was repaired primarily. She was extubated 10 days after the procedure and had an uneventful recovery. Delayed presentation of traumatic diaphragmatic hernia is a known occurrence which could be detected timely by active surveillance of such injury in a child with multiple injuries. Laparoscopy is an important adjunct in the diagnosis of traumatic diaphragmatic hernia in doubtful instances where imaging findings are equivocal.

Our surgical experience in traumatic and congenital diaphragmatic hernia: Single-center study.

Diaphragmatic hernias can develop congenitally or secondary to trauma. Congenital diaphragmatic hernias occur with Bochdalek hernia and Morgagni hernia (MH). In this study, we aimed to present laparoscopic and open surgical treatment for traumatic and congenital diaphragmatic hernias, and complications and length of hospital stay in the light of the literature. Twenty-two patients who were diagnosed with diaphragmatic hernia between January 2013 and January 2020 in our clinic were examined retrospectively in terms of demographic features, clinical and radiological findings, and length of hospital stay. The complaints of the patients diagnosed with diaphragmatic hernia were often abdominal pain, shortness of breath, early satiety, nausea, vomiting, and abdominal distention. The mean age of the patients was 54 (19-88) years. Sixteen patients were females and six were males. Two patients were operated due to stab injury, six patients were operated due to ileus, and the remaining fourteen patients were operated due to congenital diaphragmatic hernia. Eight patients were operated under emergency conditions. The remaining patients were operated under elective conditions. The average hospital stay was 6(3-15) days. The length of hospital stay of those who underwent laparoscopic surgery was 4 (3-5) days. No patient had an exitus. All patients were discharged with healing. This rare pathology should be remembered especially in patients presenting with acute abdominal complaints accompanied by respiratory complaints. We think that cases with MH detected incidentally should be operated laparoscopically before becoming complicated.