Diaphragmatic Rupture Research Articles

Traumatic Diaphragmatic Rupture Leading to Tension Gastrothorax: A Critical Case Report and Surgical Insight

Traumatic diaphragmatic rupture (TDR) is a serious but relatively uncommon injury, often resulting from blunt trauma, particularly motor vehicle accidents. Among these, blunt TDR presents with more severe outcomes than penetrating injuries, including higher mortality rates. A life-threatening complication of TDR is gastrothorax, which occurs when the stomach herniates into the thoracic cavity, leading to elevated intrathoracic pressure and potentially fatal consequences such as respiratory failure or cardiac arrest. This case reported a 23-year-old male who sustained a motor vehicle collision, presenting with progressive shortness of breath, nausea, and vomiting 15 hours post-injury. Imaging confirmed a diaphragmatic rupture with associated tension gastrothorax. Immediate intervention with nasogastric tube placement provided symptom relief, followed by exploratory laparotomy to repair the diaphragmatic defect. The patient's recovery was uneventful, demonstrating the critical importance of early diagnosis and timely surgical management in cases of TDR with gastrothorax. Traumatic diaphragmatic rupture occurs in approximately 0.8–1.6% of trauma cases, with motor vehicle accidents being the leading cause. Due to its potential for delayed diagnosis, the rupture is often missed initially, leading to higher rates of morbidity and mortality. Early detection is critical, as it can prevent serious complications such as bowel herniation into the thoracic cavity, respiratory distress, or even death.

General theory of diaphragm rupture in a shock tunnel

As the flow field starting device is in a shock tunnel, the rupture performance of the diaphragm directly influences the successful formation of the shock wave. The general theory of diaphragm rupture in shock tunnels is proposed first in this paper. The reasons for diaphragm rupture are explained fundamentally. The existing ideologies on diaphragm rupture are unified, and two hypotheses with corresponding methods are introduced. In the ideal diaphragm, diaphragm rupture pressure or rupture time can be predicted by considering the diaphragm opening as a throat through a diaphragm opening aperture. In the non-ideal diaphragm, the control of diaphragm rupture pressure can be realized by considering nominal rupture stress and grooved thickness. The correctness of the general theory of diaphragm rupture is proved through argumentation and based on experimental results of the literature. The general theory of diaphragm rupture can be used to predict the diaphragm rupture behavior of any shock tunnel worldwide and avoid the risk of shearing of petals on the diaphragm caused by the impact load. A new system of diaphragm rupture theory is constituted, and it is of significant importance for the efficient operation of shock tunnel equipment.

Transvenous phrenic nerve stimulation reduces diaphragm injury during controlled mechanical ventilation in a preclinical model of ARDS.

Patients with acute respiratory distress syndrome (ARDS) require periods of deep sedation and mechanical ventilation, leading to diaphragm dysfunction. Our study seeks to determine whether the combination of temporary transvenous diaphragm neurostimulation (TTDN) and mechanical ventilation changes the degree of diaphragm injury and cytokines concentration in a preclinical ARDS model. Moderate ARDS was induced in pigs using oleic acid, followed by ventilation for 12 h post-injury with volume-control at 8 mL/kg, positive end-expiratory pressure (PEEP) 5 cmH2O, respiratory rate and [Formula: see text] set to achieve normal arterial blood gases. Two groups received TTDN: every second breath (MV + TTDN50%, n = 6) or every breath (MV + TTDN100%, n = 6). One group received ventilation only (MV, n = 6). Full-thickness diaphragm and quadricep muscle biopsies were taken at study end. Samples were fixed and stained with hematoxylin and eosin and a point-counting technique was applied to calculate abnormal muscle area fraction. Cytokine concentrations were measured in homogenized tissue using porcine-specific enzyme-linked immunosorbent assay (ELISA) and compared with serum samples. Percentage of abnormal diaphragm tissue was different between MV [8.1% (6.0-8.8)] versus MV + TTDN50% [3.4% (2.1-4.8)], P = 0.010 and MV versus MV + TTDN100% [3.1% (2.5-4.0)], P = 0.005. Percentage of abnormal quadriceps tissue was not different between groups. Cytokine concentration patterns in diaphragm samples were different between all groups (P < 0.001) and the interaction between TTDN application and resultant cytokine concentration pattern was significant (P = 0.025). TTDN, delivered in synchrony with mechanical ventilation, mitigated diaphragm injury, as evidenced by less abnormal tissue in the diaphragm samples, in pigs with oleic acid-induced ARDS and is an exciting tool for lung and diaphragm-protective ventilation.NEW & NOTEWORTHY This study adds to our understanding of applying transvenous diaphragm neurostimulation synchronously with mechanical ventilation by examining its effects on diaphragm muscle injury and cytokine concentration patterns in pigs with acute respiratory distress syndrome (ARDS). We observed that using this therapy for 12 h post lung injury mitigated ventilator-induced diaphragm injury and changed the pattern of cytokine concentration measured in diaphragm tissue. These findings suggest that transvenous diaphragm neurostimulation is an exciting tool for lung and diaphragm protective ventilation.

030. Delayed Presentation of Blunt Traumatic Diaphragmatic Hernia 15 Years After Injury: A Case Report

Background: Traumatic diaphragmatic rupture is rare with incidence between 0.8-8% and often resulting from blunt or penetrating trauma. We present a case of delayed diaphragmatic hernia in a 41-year-old male, 15 years after blunt abdominal trauma. Case: A 41-year-old male presented with dyspnea and severe abdominal pain. He reported being struck in the abdomen with wood during a gang attack 15 years prior. A year after the accident, he complained of uncomfortable breathing that worsened in the past 6 years. Physical examination revealed decreased breath sounds on the left side and a distended abdomen. Imaging confirmed bowel herniation into the left hemithorax, partial lung collapse, and a mediastinal shift. Emergency laparotomy revealed a 5 cm diaphragmatic defect, massive gastric necrosis, and herniation of abdominal organs into the thoracic cavity. The defect was closed with primary repair, and necrotic gastric tissue was excised and repaired using primary closure with omental patch. The patient recovered well and was discharged on day 11. Conclusion: Diaphragmatic ruptures require prompt surgical repair to prevent complications. Physicians must carefully evaluate trauma history and conduct thorough examinations to improve outcomes in emergency settings.

028. Traumatic Diaphragmatic Rupture with Unstable Hemodynamic: A Case Report of a Rare Surgical Trauma Emergency

Background: Traumatic diaphragmatic rupture (TDR) with unstable hemodynamics is a life-threatening condition often masked by other injuries, necessitating timely diagnosis and treatment. This case report illustrates the significance of rapid response and resuscitation in managing a 17-year-old female patient with TDR following a severe traffic accident. Case: A 17-year-old female patient was admitted after a motorcycle accident, arriving at the hospital 4 hours and 10 minutes post-incident. She displayed respiratory distress (SpO2: 80% on FM) and severe hemodynamic instability (BP: 70/40 mmHg, HR: 121 bpm). Grade IV traumatic diaphragmatic rupture (AAST) was confirmed alongside multiple injuries. Resuscitation began with intubation, 1 L of crystalloid fluid, and a 1-unit PRC transfusion. Initial management improved her BP to 80/60 mmHg; however, it later dropped to 60/40 mmHg. A FAST Ultrasonography (USG) revealed free echogenic fluid in the hepatorenal space, prompting emergency exploratory laparotomy. Intraoperatively, a diaphragmatic rupture was identified, with herniation of the liver, stomach, and colon. Surgical interventions included diaphragmatic repair and chest tube insertion. Postoperatively, the patient required vasopressors (dobutamine and epinephrine) to stabilize her hemodynamics (BP: 100/60 mmHg, HR: 83 bpm). Conclusion: Early diagnosis and aggressive resuscitation are vital in managing TDR with unstable hemodynamics, underscoring the necessity for rapid assessment and intervention.

Traumatic Diaphragmatic Hernia in Cats and Factors Affecting Survival (A Clinical Study with 24 Cats)

Diaphragm hernia is still a serious problem in cats exposed to trauma. In this study, it was aimed to contribute to clinical practice and colleagues by notifying clinical observations on traumatic diaphragm rupture in cats and factors effective on survival. In this study, 24 cats with traumatic diaphragm hernia were presented. Contrast radiography has provided great convenience in suspicious cases in terms of diagnosis. 20 out of 24 cats (83%) remained alive, but 4 of them died. The localization of the diaphragm of these cats in 3 cats was in the left half, which was quite high (50%) in the left tears. In the defects on the right, the herniated organ was the liver, small intestine and omentum, while the stomach, small intestine and spleen in the defects on the left. As a result, survival in 83% is important and this is a good prognosis for aperture hernia. Despite many negative stress factors, a good operation management and postoperative maintenance can be increased with the survival rate.

Post-traumatic diaphragmatic rupture: two observations at the National Hospital of Niamey

Introduction: Trauma to the diaphragm is rare, accounting for 3.6% of injuries sustained in road accidents. They are the result of violent trauma and most often occur in the left dome. Observations: The two patients were young adults (18, 55), male, and all victims of road traffic accidents resulting in firm trauma to the thorax. All patients had left basithoracic lesions. Both patients were diagnosed intraoperatively based strong clinical and radiological suspicion. The diaphragm ruptures presented by our patients were found on the left, with intra-abdominal viscera ascending into the thorax. Therapeutically, an emergency exploratory laparotomy was performed. The approach was abdominal for two patients, and the surgical procedure involved lowering the herniated organs and suturing the diaphragm for both patients. Postoperative management was straightforward. Conclusion: Post-traumatic diaphragmatic hernia is a particular injury in traumatology. It most often occurs in the setting of polytrauma. Its seriousness derives from its complications and associated lesions, which can be life-threatening.

Uncovering Diaphragm Cramp in SIDS and Other Sudden Unexpected Deaths.

The diaphragm is the primary muscle of respiration. Here, we disclose a fascinating patient's perspective that led, by clinical reasoning alone, to a novel mechanism of spontaneous respiratory arrests termed diaphragm cramp-contracture (DCC). Although the 7-year-old boy survived its paroxysmal nocturnal "bearhug pain apnea" episodes, essentially by breathing out to breathe in, DCC could cause sudden unexpected deaths in children, especially infants. Diaphragm fatigue is central to the DCC hypothesis in SIDS. Most, if not all, SIDS risk factors contribute to it, such as male sex, young infancy, rebreathing, nicotine, overheating and viral infections. A workload surge by a roll to prone position or REM-sleep inactivation of airway dilator or respiratory accessory muscles can trigger pathological diaphragm excitation (e.g., spasms, flutter, cramp). Electromyography studies in preterm infants already show that diaphragm fatigue and sudden temporary failure by transient spasms induce apneas, hypopneas and forced expirations, all leading to hypoxemic episodes. By extension, prolonged spasm as a diaphragm cramp would induce sustained apnea with severe hypoxemia and cardiac arrest if not quickly aborted. This would cause a sudden, rapid, silent death consistent with SIDS. Moreover, a unique airway obstruction could develop where the hypercontracted diaphragm resists terminal inspiratory efforts by the accessory muscles. It would disappear postmortem. SIDS autopsy evidence consistent with DCC includes disrupted myofibers and contraction band necrosis as well as signs of agonal breathing from obstruction. Screening for diaphragm injury from hypoxemia, hyperthermia, viral myositis and excitation include serum CK-MM and skeletal troponin-I. Active excitation could be visualized on ultrasound or fluoroscopy and monitored by respiratory inductive plethysmography or electromyography.

Features of diagnosis and treatment of a polytrauma victim with predominant closed chest trauma with lung and diaphragm rupture. Clinical case

The article describes a clinical case and presents clinical signs of traumatic rupture of the diaphragm and lung on the background of a wave‑like course of the postoperative period. Open diaphragmatic injuries are more common than closed ones. In this case, the closed chest and abdominal trauma was sustained as a result of a road traffic accident. The injury was combined and severe, with signs of traumatic shock. The location of the diaphragmatic injury was on the right side, which is less common. The severe condition of the patient with respiratory failure (respiratory rate over 30 per minute) was an indication for artificial lung ventilation, which made it impossible to take complaints and anamnesis. The individual spatial topography of the diaphragm depends on the size and location of the abdominal organs, body structure, and depends on the line of examination. The movement of internal organs into the pleural cavity indicates a diaphragmatic rupture, but in this case, the extrahepatic location of the diaphragmatic defect was covered by the liver, the lower lobe of the right lung, and adhesions, which led to the cover­up of the diaphragmatic defect. Increased abdominal size due to polytrauma and mechanical ventilation in case of closed chest and abdominal trauma; increased air discharge through pleural drainage during video laparoscopy or increased abdominal size during video thoracoscopy; clamping of the pleural drainage with a spiral computed tomography of the chest and abdominal organs allows detecting pneumoperitoneum and pneumothorax, which indicates the presence of a defect in the diaphragm and lung. The use of video thoracoscopy, video laparoscopy, and spiral computed tomography does not always provide complete information about the existing damage to the diaphragm, so dynamic observation with control radiological examinations is preferred.

Traumatic Diaphragmatic Hernia: A Retrospective Analysis of 10 Consecutive patients

Traumatic diaphragmatic hernia (TDH) is a rare but potentially life-threatening condition.This retrospective study reviews the clinical presentation, diagnostic challenges, and surgical outcomes of 10 consecutive patients with TDH.

Diagnostic confusion caused by tension gastrothorax – Case series

Abstract The presence of the stomach in the thorax is called gastrothorax. If excessive dilatation occurs due to a valve mechanism in the stomach which then is herniated into the thorax, it is called tension gastrothorax and the situation can be life-threatening. In late presentation, congenital diaphragmatic hernias or traumatic diaphragmatic hernias, if the stomach located in the thorax is severely distended, it can be confused with tension pneumothorax or pleural effusion/empyema. We presented tension gastrothorax in two patients with distended stomach in the thorax, in which tension pneumothorax and pleural effusion/empyema-like images were created, based on plain X-rays taken at the first admission in the emergency department, which may cause diagnostic confusion. The tension gastrothorax can cause mediastinal shift, which can lead to respiratory distress and eventually cardiac arrest secondary to obstructive shock. In case of mediastinal shift, it should reduce the tension of the stomach located in the thorax by inserting a nasogastric catheter, and if this fails, by aspiration with a needle.

A case of traumatic diaphragmatic rupture in a child

Traumatic diaphragmatic rupture (TDR) is a rare injury in children. It occurs in a context of polytrauma. It can go unnoticed with a difficult diagnosis that can be late. Imaging is a key element of diagnosis. We report the case of a 10-year-old child with post-traumatic left diaphragmatic rupture suspected by chest X-ray and confirmed by thoraco-abdominal computed tomography. Keywords: Traumatic, diaphragmatic rupture, Child.

Bilothorax as an endoscopic retrograde cholangiopancreatography complication and a review of the literature.

Bilothorax, the accumulation of bile in the pleural space, is an uncommon but serious condition often linked to biliary tract or diaphragmatic injury. This case report describes a 70-year-old female with decompensated liver cirrhosis due to primary sclerosing cholangitis, who developed a moderate sized pleural effusion following ERCP and biliary stenting. The patient's pleural effusion persisted for 2 months without respiratory symptoms, indicating a self-limited low-volume leak. She eventually underwent thoracentesis for a non-resolving unilateral effusion, which drained 435 mL of bilious fluid with an elevated pleural fluid bilirubin level, confirming the diagnosis of bilothorax. This case highlights the importance of considering bilothorax as a cause of pleural effusion in patients with biliary tract disease and who undergo high risk procedures including ERCP.

Association of diaphragmatic dysfunction with duration of mechanical ventilation in patients in the pediatric intensive care unit: a prospective cohort study

BackgroundMechanical ventilation (MV) can cause diaphragmatic injury and ventilator induced diaphragmatic dysfunction (VIDD). Diaphragm ultrasonography (DU) is increasingly used to assess diaphragmatic anatomy, function and pathology of patients receiving MV in the pediatric intensive care unit (PICU). We report the poor contractile ability of diaphragm during ventilation of critically ill patients in our PICU and the association to prolonged length of MV and PICU stay.MethodsPatients who received MV within 24 h of admission to the PICU, expected to undergo continuous MV for more than 48 h and succeeded to extubate were included in the study. DU monitoring was performed daily after the initiation of MV until extubation. Diaphragm thickening fraction (DTF) measured by DU was used as an indicator of diaphragmatic contractile activity. Patients with bilateral DTF = 0% during DU assessment were allocated into the severe VIDD group (n = 26) and the rest were into non-severe VIDD group (n = 29). The association of severe VIDD with individual length of MV, hospitalization and PICU stay were analyzed.ResultsWith daily DU assessment, severe VIDD occurred on 2.9 ± 1.2 days after the initiation of MV, and lasted for 1.9 ± 1.7 days. Values of DTF of all patients recovered to > 10% before extubation. The severe VIDD group had a significantly longer duration (days) of MV [12.0 (8.0-19.3) vs. 5.0 (3.5–7.5), p < 0.001] and PICU stay (days) [30.5 (14.9–44.5) vs. 13.0 (7.0-24.5), p < 0.001]. The occurrence of severe VIDD, first day of severe VIDD and length of severe VIDD were significantly positively associated with the duration of MV and PICU stay. The occurrence of severe VIDD on the second and third days after initiation of MV significantly associated to longer PICU stay (days) [43.0 (9.0–70.0) vs. 13.0 (3.0–40.0), p = 0.009; 36.0 (17.0-208.0) vs. 13.0 (3.0–40.0), p = 0.005, respectively], and the length of MV (days) was significantly longer in those with severe VIDD on the third day after initiation of MV [16.5 (7.0–29.0) vs. 5.0 (2.0–22.0), p = 0.003].ConclusionsDaily monitoring of diaphragmatic function with bedside ultrasonography after initiation of MV is necessary in critically ill patients in PICU and the influences and risk factors of severe VIDD need to be further studied. (355 words)

Emergency Operable Traumatic Pulmonary Injury at a Level 1 Trauma Center: A Retrospective Descriptive Study

ABSTRACT Introduction Despite the use of body armor, emergency operable pulmonary trauma (EOPT) remains a major cause of battlefield morbidity and mortality. While EOPT during military conflicts has some features that distinguish it from EOPT in civilian settings, the 2 occurrences demonstrate overall parallel findings related to presentation, management, and outcome. The goals of the present study were to provide a descriptive analysis of the nature of EOPT and its management at a level 1 trauma center and to determine the associations between EOPT patient demographics and/or patient management and outcome in order to better understand battlefield EOPT. Materials and Methods This is a retrospective, descriptive analysis of EOPT at a level 1 trauma center during a recent 9-year period (2012–2020). The Oregon Health &amp; Science University Trauma Registry was searched, and 106 patients met inclusion criteria for the study. Patients with primary cardiac trauma were excluded. Individual electronic medical records were reviewed to obtain descriptive data, and associations were evaluated for statistical significance. Results In-hospital mortality in this cohort was 17.0%. The most common pulmonary injury associated with EOPT was unilateral diaphragmatic laceration (62.3%), and the most common single operation performed for EOPT was a laparotomy (71.7%) often involving diaphragmatic repair. In the remaining instances of EOPT, a thoracotomy (11.3%), a thoracotomy and a laparotomy (10.4%), or another surgery (6.6%) occurred. The primary indication for EOPT surgery was uncontrolled hemorrhage, and one-third of patients received massive transfusion. One-lung ventilation (OLV) was infrequently employed (8.5%). When OLV was used, it was equally likely to involve a single-lumen endotracheal tube (SLETT) with mainstem bronchus insertion, a SLETT with a bronchial blocker, or a double-lumen endotracheal tube. Time from EOPT to operating room arrival was inversely related to in-hospital mortality. Also, both initial in-hospital endotracheal intubation and low injury severity score were strongly associated with survival in the population studied. Conclusions The most common indication for EOPT surgery was uncontrolled hemorrhage. The most frequent operation performed for this EOPT cohort was a laparotomy for diaphragmatic repair. A total of 91.5% of EOPT surgery was performed without OLV, an unexpected finding. When OLV occurred, it was equally likely to involve an SLETT with mainstem bronchus insertion, an SLETT with bronchial blocker, or a double-lumen endotracheal tube. The most common indication for OLV was surgical exposure. More extensive injury (expressed as an injury severity score), preadmission endotracheal intubation, and a shorter time from EOPT to operating room arrival were associated with increased odds ratios for mortality. A better understanding of the nature of EOPT at a civilian level 1 trauma center can serve to identify conditions that are associated with more favorable outcomes for EOPT under battlefield conditions and thereby assist in both management decisions and to help prognosticate and triage severely injured patients in that setting.

Diaphragmatic Injuries in Patients with Penetrating Thoracoabdominal Injuries without Shock or Acute Abdomen at Admission

Diaphragmatic Injuries in Patients with Penetrating Thoracoabdominal Injuries without Shock or Acute Abdomen at Admission

SP6.14 - The Burden of Penetrating Junctional Injuries in a UK Major Trauma Centre: a Retrospective Cohort Study

Abstract Background Junctional injuries occur at the join of ‘anatomically distinct zones’. The emergence of junctional injuries in trauma care has been a consequence of recent battlefield casualties; accounting for 21% of potentially survivable deaths from haemorrhage. Although well described in military literature, there are no civilian studies into junctional injuries. This study aims to examine the epidemiology and resource burden of junctional penetrating injuries. Methods Retrospective study of adult and paediatric patients with penetrating injuries to a junctional zone presenting to an urban MTC in one year. Electronic patient records were searched and data on anatomical distribution of injury, imaging and theatre utilisation, inpatient stay, and discharge codes extracted. Discharge codes were referenced with the National Schedule of NHS costs to produce a cost. Results In 132 patients 92.4% (n=122) were male with median age 27.5 and in hospital mortality 1.6% (n=2). Saturday and Sunday were most frequent 37.9% (n=50) and 81.8% (n=108) attended after 1700 and before 0800. 37.9% (n=50) of injuries were buttock; 22% (n=29) neck; 18.9% (n=25) multiply-injured; 8.3% (n=11) axilla; 6.8% (n=9) diaphragm; and 6.1% (n=8) groin. Median Injury Severity Score (ISS) 8. 46.2% (n=61) underwent surgery; 50.8% (n=67) were admitted, 7.6% (n=10) to ITU. Median length of ward stay was 3 days. 15.9% (n=21) received blood products. The overall cost was £914,076. Conclusion Junctional injuries are a significant resource burden. Buttock wounds were the most common but had the lowest median ISS and cost. Diaphragmatic injuries appear distinct from junctional wounds in terms of ISS and cost, and may be separate to other junctional zones.

Hérnia diafragmática traumática em cão

The term diaphragmatic hernia refers to rupture of the diaphragm, the muscle that separates the thoracic and abdominal cavities. The diaphragm plays an important role in ventilation, serving as an inspiratory muscle, in addition to helping transport lymphatic fluid. Most diaphragmatic hernias in dogs and cats are caused by trauma, particularly being run over by a car. They are frequently diagnosed in small animal clinics and there is no age or species predisposition for traumatic diaphragmatic hernias. Symptoms vary but include difficulty breathing, tachypnea, pale or cyanotic mucous membranes, tachycardia and oliguria. The definitive diagnosis is confirmed by the combination of a well performed anamnesis and imaging tests such as radiography and ultrasound. The recommended treatment is surgery, with diaphragm surgery, combines with follow-up and post-operative care to ensure a good recovery. This work reports the case of a female puppy, ran over by a vehicle. After imaging tests, she was diagnosed with a diaphragmatic hernia and subsequently underwent diaphragmatic herniorrhaphy, a diaphragm correction procedure. The surgical procedure and the patient's recovery went well, without complications.

Single-incision Retroperitoneal Laparoscopic Resection of Adrenal Tumors in Children

BackgroundWe describe our experience with single-incision retroperitoneal laparoscopic (SIRL) for resection of adrenal tumors in pediatric patients and discuss the technique's clinical value. MethodsWe retrospectively analyzed clinical data of 27 pediatric patients who underwent SIRL between January 2020 and September 2023. Patients with tumors >5 cm in size and those requiring vascular skeletonization surgery or extensive lymph node dissection were excluded. Demographic, perioperative, and prognostic data were collected, and computed tomography (CT) and magnetic resonance imaging were used for preoperative tumor assessment. ResultsOf 27 patients, 16 were male and 11 were female; mean age 54 ± 45 months and mean body mass index 17.2 ± 3.6 kg/m2. Mean tumor length, width, and height were 4.1 ± 1.8 cm, 3.3 ± 2.1 cm, and 2.9 ± 1.7 cm, respectively. One patient experienced a diaphragmatic tear, three patients incurred peritoneal damage, and one patient developed postoperative renal artery injury, leading to thrombosis and renal atrophy. No surgery was converted to open surgery, and no intraoperative or postoperative blood transfusions were required. Operative time, blood loss, and postoperative dietary recovery time were satisfactory. No local recurrence or distant metastases were detected during the 6–48 months of follow-up involving outpatient and telephone assessments. ConclusionsApplication of SIRL in pediatric patients with adrenal tumors achieved favorable clinical outcomes with an effective, minimally invasive surgical option for treating children with adrenal tumors. This technique demands a high level of surgical expertise, specialized instruments and experienced surgeons. Our findings indicate that SIRL is safe and provides significant postoperative benefits in pediatric patients. Level of EvidenceLevel IV.

Delayed presentation of traumatic diaphragmatic injury and a spleno-pulmonary fistula with haemoptysis as only sign: A case report

Delayed presentation of traumatic diaphragmatic injury and a spleno-pulmonary fistula with haemoptysis as only sign: A case report