Diaphragmatic Rupture Research Articles

Occult diaphramatic injury in penetrating trauma: a diagnostic challenge

Abstract Diaphragmatic injuries in penetrating trauma are occult and may be easily missed. Common signs of diaphragmatic injury on computed tomography scan include discontinuous and/or dangling diaphragm sign, thickened diaphragm, organ herniation, collar sign, associated rib fracture, and contiguous injury on either side of the diaphragm. The detection of these signs varies based on the mechanism of injury, that is, penetrating versus blunt injury. Surgical management of an unstable patient with penetrating trauma and diaphragmatic injury is exploratory laparotomy, while laparoscopy is an alternate option in hemodynamically stable patients. A high level of suspicion is required to avoid missing this occult diagnosis and its associated complications.

Monitoring Respiratory Effort and Lung-distending Pressure Noninvasively during Mechanical Ventilation: Ready for Prime Time.

Monitoring Respiratory Effort and Lung-distending Pressure Noninvasively during Mechanical Ventilation: Ready for Prime Time.

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

BackgroundIn 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 presentationA 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.ConclusionsIn 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.

Diaphragmatic rupture and massive pneumoperitoneum after cardiopulmonary resuscitation

Introduction:Although cardiopulmonary resuscitation is an emergency life‐saving procedure, the intervention itself can cause major and often fatal injuries, with diaphragmatic rupture being very rare. This report describes a patient who experienced bilateral pneumothoraces, left diaphragmatic rupture, and pneumoperitoneum after extended cardiopulmonary resuscitation.Case presentation:A 90‐year‐old woman experienced a cardiac arrest. Spontaneous circulation was restored after 49 min of cardiopulmonary resuscitation performed by a bystander, emergency medical service providers, and emergency department staff. Imaging showed bilateral pneumothoraces, left diaphragmatic rupture, and massive pneumoperitoneum. The patient's guardian refused to permit surgery for the diaphragmatic rupture, and the patient died despite chest and abdominal decompression and post‐cardiac arrest care.Discussion and conclusion:Procedures to restore spontaneous circulation in patients experiencing cardiac arrest may result in fatal cardiopulmonary resuscitation–related injuries. Clinicians providing post‐cardiac arrest care should plan management for these iatrogenic injuries.

Evisceration of intestines with diaphragmatic laceration and gastric perforation secondary to trauma by rhinoceros attack and its management: a case report.

A 36-year-old male presented with an alleged history of attack by two rhinoceros sustaining injuries over the abdomen, chest, shoulder and thigh. There was a lacerated abdomen with evisceration of the stomach, small intestine, transverse colon and omentum and a lacerated wound over the left lateral thigh and left buttock along with the right shoulder. Extended Focused Assessment with Sonography in Trauma ultrasound showed minimal free fluid in the pelvis. Blood profile revealed reduced haemoglobin and deranged prothrombin time/international normalized ratio. Patient underwent exploratory laparotomy twice with repair of diaphragmatic injury, excision of avulsed greater omentum in the first setting and repair of gastric perforation in the second setting with stable haemodynamic status. Abdominal evisceration injury by rhinoceros attack is life threatening though rare. Its management should consist of assessing for and controlling associated haemorrhage, assessing for bowel content leakage, covering the eviscerated abdominal contents and early reduction of viscera if there is no active bleeding.

Evaluation of the accuracy of established patient inspiratory effort estimation methods during mechanical support ventilation

There is a clinical need for monitoring inspiratory effort to prevent lung- and diaphragm injury in patients who receive supportive mechanical ventilation in an Intensive Care Unit. Different pressure-based techniques are available to estimate this inspiratory effort at the bedside, but the accuracy of their effort estimation is uncertain since they are all based on a simplified linear model of the respiratory system, which omits gas compressibility of air, and the viscoelasticity and nonlinearities of the respiratory system. The aim of this in-silico study was to provide an overview of the pressure-based estimation techniques and to evaluate their accuracy using a more sophisticated model of the respiratory system and ventilator.The influence of the following parameters on the accuracy of the pressure-based estimation techniques was evaluated using the in-silico model: 1) the patient's respiratory mechanics 2) PEEP and the inspiratory pressure of the ventilator 3) gas compressibility of air 4) viscoelasticity of the respiratory system 5) the strength of the inspiratory effort.The best-performing technique in terms of accuracy was the whole breath occlusion. The average error and maximum error were the lowest for all patient archetypes. We found that the error was related to the expansion of gas in the breathing set and lungs and respiratory compliance. However, concerns exist that other factors not included in the model, such as a changed muscle-force relation during an occlusion, might influence the true accuracy. The estimation techniques based on the esophageal pressure showed an error related to the viscoelastic element in the model which leads to a higher error than the occlusion. The error of the esophageal pressure-based techniques is therefore highly dependent on the pathology of the patient and the settings of the ventilator and might change over time while a patient recovers or becomes more ill.

Laparoscopic Repair of a Right-Sided Diaphragmatic Hernia

Introduction: Blunt trauma may cause small occult diaphragmatic injuries that increase in size over the course of decades. The gradual increase is secondary to the pressure disparity between the abdominal and thoracic cavities. Over time, visceral contents may traverse the defect and become incarcerated within the thoracic cavity.1 Typically, the defect occurs on the left side with gastric herniation. Rarely, the defect occurs on the RIGHT side since the large right lobe of the liver may preclude herniation through a right-sided diaphragmatic defect.2,3 This video presents a repair of a symptomatic right-sided diaphragmatic hernia that occurred decades after blunt trauma. Materials and Methods: A 58-year-old man was admitted to the emergency department with a 2-day history of acute abdominal pain that was sharp and diffuse. He had vomited several times and denied flatus for 24 hours. He had a history of three prior motor vehicle accidents in the 1980s. He had a history of oropharyngeal cancer that was treated with radiation then a neck dissection 2 years before presentation. He had no history of abdominal or thoracic surgery but had a significant tobacco history for 40 years. His blood work was normal. A CT scan of the abdomen showed a right-sided diaphragmatic hernia defect that contained small intestine and colon. There was no dilated bowel or evidence of a pneumoperitoneum or free fluid. There was air in the rectum. A well-healed old nondisplaced pubic rami fracture was evident also on the scan. Surgical intervention included a laparoscopic possible thoracoscopic diaphragmatic repair. Operatively, he was placed in a semilateral position at 30°. A Veress needle was used to enter the abdomen and three 5 mm ports were placed along the subcostal border. One of the 5 mm ports was upsized to a 10 mm port. Diagnostic laparoscopy delineated the diaphragmatic defect containing bowel. Several adhesions were divided and the colon and small intestine were reduced from the defect. There was no hernia sac and the thoracic cavity was pristine. Once the bowel was reduced, the defect was measured at ~5 cm by 3 cm. The defect was closed with interrupted 0-silk sutures. The suture line was then buttressed with a 15 cm by 10 cm mesh. The mesh was secured with absorbable tacks. A 28F chest tube was placed. Results: The operative time was 90 minutes. The patient was started on a clear liquid diet on postoperative day 1 and advanced to a regular diet on postoperative day 2. Because of social issues, he was discharged on postoperative day 4. A chest CT at ~6 months postoperatively showed no evidence of a recurrent diaphragmatic defect. Conclusions: Minimally invasive techniques are well suited for diaphragmatic defects. If a right-sided symptomatic diaphragmatic hernia is diagnosed, a minimally invasive approach through the abdomen may be performed without a thoracic approach. Adhesions may warrant thoracic access to reduce the abdominal contents, so double lumen intubation is prudent. A durable repair may be obtained by suturing the defect and adding a mesh buttress. Patient consent has been obtained. Authors have received and archived patient consent for video recording/publication of the procedure. There are no conflict of interests associated with this video in terms of commercial or financial interests. Runtime of video: 5 mins 42 secs

VATS VERSUS LAPAROSCOPY TRAUMATIC DIAPHRAGMATIC INJURY REPAIR

Introduction:Diaphragmatic injury is usually missed in case of trauma patient, clinical picture is usually masked by other abdominal or thoracic injuries. CXR (chest X ray), abdominal ultrasound have a high rate of missing. High index of suspicion is required to diagnose diaphragmatic injury. Discussion:Comparison between 20 cases of traumatic diaphragmatic injury. Surgery is the only treatment. Different approaches are used, taking advantage of the wide spread practice of minimal invasive surgeryVATS (Video assisted thoracoscopic surgey) and laparoscopy. Overlooked injuries are usually on the right side and after blunt trauma in these cases open surgery is favoured.Prolene stitch repair (primary repair) was the main modality of repair, mesh repair was used in larger tears with poor quality tissues .Quality of life improves remarkably after repair with most patients discharged from hospital within few days. Conclusion:VATS and Laparoscopy show efficiency in both diagnosis and treatment of diaphragmatic injuries. Conversion to open surgery may be needed in case of severe visceral injuries.Combined approach needs good communication between thoracic and general surgeonsOutcome is usually favourable with competent long term repair. Uunfavourable outcome is associated with multiple visceral organ injury and critical pre operative status.

Prognosis of Traumatic Diaphragmatic Injury in Dhaka Medical College Hospital, Dhaka

Introduction: Diaphragmatic injuries include wounds and diaphragmatic ruptures due to thoracoabdominal blunt or penetrating trauma. Their incidence ranges between 8 and 15%. The diagnosis is often delayed despite several medical imaging techniques. The mortality is mainly related associate Injury. Aims: The aim of our study was to evaluate the prognosis, after surgery of our patient with diaphragmatic injury. Patients and methods: We performed a prospective study over a period of two years, between January 2018 December 2019, at the department of thoracic surgery of Dhaka Medical College Hospital, Dhaka, Bangladesh. All patients diagnosed with diaphragmatic injury were included in this study. Each patient operated because traumatic diaphragmatic injury was evaluated in respect of age, sex, nature of injury, preoperative examination findings, laboratory test results, imaging methods, time of diagnosis, operation findings, concomitant injures to other organs, operations performed, length of stay in hospital and development of postoperative morbidity and mortality. Results: Over the study period, 22 cases of diaphragmatic injuries were included. The female was 4 and 18 was male. The mean age of male patients 29.2±12.1 and female 28±11.6 years. RTA with blunt trauma chest was 12, 6 was fall from height and 5 were stab injuries. The most common injuries concomitant to traumatic diaphragmatic rupture were a haemothorax, rib fracture, stomach, colon, liver and spleen. Three patients developed wound infection and two patients died. Conclusion: In high energy blunt and penetrating thoracoabdominal trauma, diaphragmatic injures should be suspected. An emergency thoracotomy or laparotomy followed by reposition of abdominal organ and repair of the defect of the diaphragm is the gold standard for the management of these cases. J Dhaka Med Coll. 2021; 30(2) : 131-135

Imaging characteristics and treatment strategies of traumatic diaphragmatic hernia with aortic dissection: a report of 3 cases

BackgroundTraumatic aortic dissection with traumatic diaphragmatic hernia is a rare traumatic disease. The purpose of this article is to investigate the imaging characteristics and treatment strategies for traumatic diaphragmatic hernia with aortic dissection.Case presentationThe imaging and clinical data of 3 patients with traumatic diaphragmatic hernia combined with aortic dissection were analyzed retrospectively. Of the three cases, two were males, and one was female; their mean age was 52.7 years (range, 47–62 years). Plain chest CT scans revealed diaphragmatic hernia in 2 patients, but no traumatic aortic dissection was found. Diaphragmatic hernia repair was performed in all patients. Aortic dilatation was found during intraoperative exploration, and aortic dissection was confirmed by postoperative enhanced CT. One patient underwent stent implantation and recovered smoothly (Case 1). The other patient refused stent implantation and died of thoracic hemorrhage (Case 2). The third patient underwent preoperative enhanced CT to identify traumatic diaphragmatic hernia with aortic dissection (Case 3). Aortic covered stent implantation was performed immediately, and diaphragmatic hernia repair was performed at a selected time. The patient’s postoperative recovery was good.ConclusionA preoperative plain chest CT scan indicated diaphragmatic hernia in major blunt thoracic trauma patients with a history of trauma and blurred periaortic spaces accompanied by hematocele and other imaging manifestations. Chest-enhanced CT should be performed to improve the diagnostic accuracy of aortic dissection.

A rare case of delayed presentation of post traumatic diaphragmatic hernia presented with intestinal obstruction

Traumatic diaphragmatic injuries are rare complications resulting from a thoracic-abdominal blunt or penetrating trauma. Diaphragmatic injury is a rare entity and clinically difficult to be diagnosed as symptoms are often masked due to associated injury in poly trauma case. There are no specific signs and symptoms for diagnosing diaphragmatic rupture. High degree of clinical suspicion is needed in all cases of thoroco-abdominal injury to diagnose a case of diaphragmatic rupture. Left sided diaphragmatic injuries are more commonly reported in literature.

Endometriosis-related Nontraumatic Diaphragmatic Rupture with Partial Liver Herniation

Endometriosis-related Nontraumatic Diaphragmatic Rupture with Partial Liver Herniation

Various Anaesthetic Techniques used in the Management of Traumatic Diaphragmatic Hernia: A Series of Three Cases

Traumatic diaphragmatic hernia is relatively uncommon and occurs most commonly after a road traffic accident (5%). Diaphragmatic rupture is mostly associated with vital organ injuries such as the liver, spleen, lungs, bones, pelvis, and brain, which can be severely damaged. The anaesthetic management of a patient presenting with traumatic diaphragmatic hernia depends on any associated vital organ injuries. Hereby, the author present a case series of three patients with traumatic diaphragmatic hernia with different presentations managed accordingly. In the first case, a 37-year-old male presented with diaphragmatic hernia and cervical spine fracture following a road traffic accident. Awake fibreoptic intubation was performed with utmost care to avoid further injury to the cervical spine. After intubation, positive pressure ventilation was given with low tidal volume to avoid barotrauma and to expand the atelectatic lung. The second case involved a 48-year-old male with a history of falling from a height one week prior, who presented with right-sided diaphragmatic rupture and a liver contusion. Intubation was performed using a left-sided double-lumen tube, and one-lung ventilation was applied to facilitate thoracotomy. A thoracic paravertebral block was administered to alleviate postoperative pain, providing good pain relief. In the third case, a 56-year-old male with a known case of Chronic Obstructive Pulmonary Disease (COPD) presented to the hospital following a road traffic accident. The patient had lung contusion and haemopneumothorax with poor pulmonary reserve, and required emergency surgical repair. Combined spinal-epidural anaesthesia was preferred over general anaesthesia, as intubation may cause bronchospasm and life-threatening complications in COPD patients.

Complications and outcome of traumatic diaphragmatic hernia repair without post-operative chest drain: Retrospective study in 90 cats.

Diaphragmatic herniorraphy is the treatment of choice for traumatic diaphragmatic hernia (TDH). Several methods have been described for the removal of residual air and fluid during and after surgery, such as the insertion of chest drains, intercostal thoracentesis, and transdiaphragmatic thoracentesis. However, there are no indications regarding the most useful technique and the impact that choice of technique could have in the immediate postoperative period. To evaluate the development of complications and outcomes associated with the use of intraoperative transdiaphragmatic thoracentesis in cats undergoing diaphragmatic herniorrhaphy for TDH. Medical records of cats treated for acute and chronic TDH between 2010 and 2019 were reviewed. Cats were included if intraoperative pneumothorax was treated with transdiaphragmatic thoracentesis, without the use of intercostal chest drain. Outcome, intra- and post-operative complications were recorded. Intraoperative and postoperative complication rates were 3.3% and 12.4%, respectively. Development of postoperative pneumothorax was associated with the presence of comorbidities (p = 0.046). The overall survival rate was 93.3%. Long-term survival had a significant association with the presence of comorbidities (p = 0.045), if the procedure was performed as an emergency (p = 0.041) or in older cats (p = 0.011). Intraoperative transdiaphragmatic thoracentesis could be considered an effective method for the removal of residual air after surgery for TDH, because it ensures a good outcome for the patient, with low development of complications, especially for uncomplicated cases. The presence of comorbidities, the need to perform a surgical procedure in emergency, and the age of the patient can be considered factors influencing the development of complications. Critical patient selection, based on assessment of potential risk factors for complications is warranted to understand which patient will benefit from thoracostomy tube placement.

Is diagnostic laparoscopy necessary in the management of left thoracoabdominal stab wounds?

The diagnosis of a diaphragmatic rupture and the identification of patients for surgical repair is challenging despite current diagnostic algorithms and imaging technologies. Unless treated on time, acute traumatic diaphragmatic injury due to stab wounds has a high mortality and morbidity rate, with an increasing trend in the presence of organ herniation. In this study, we aimed to investigate the efficacy of diagnostic laparoscopy in patients with an anterior thoracoabdominal stab wound and to compare the follow-up outcomes of cases. We retrospectively reviewed our institutional database of patients who were admitted with stab wounds between Oc-tober 2012 and 2022. Patients who underwent diagnostic laparoscopy were divided into two groups depending on the presence of a diaphragmatic injury. We analyzed demographics, the success of computed tomography (CT) imaging in the diagnosis, the presence of hemomediastinum, pneumomediastinum, tube thoracostomy application, associated organ injury, type of surgery, duration of surgery, complications, and the length of stay between the groups. Of the 39 patients with penetrating left thoracoabdominal injury underwent diagnostic laparoscopy, CT had a diagnostic sensitivity of 63.16% (95% Confidence interval [CI] 38.36-83.71%), and a specificity of 100% (95% CI 82.35-100.00%). We could not find a statistically significant difference between the groups in terms of studied variables, while operation time was significantly higher in the diaphragmatic injury group (P<0.01). Fourteen patients had accompanied visceral injuries. Diagnostic laparoscopy is still the gold standard particularly in the ER setting, particularly in the absence of an experienced radiologist for 24 h and when the close monitoring of the patient by the same team cannot be provided.

Repair of diaphragmatic hernias: Retrospective analysis of 70 cases.

Congenital and traumatic diaphragmatic hernias (DH) can lead to respiratory and gastrointestinal complications that can be the cause of serious morbidity and mortality. In this study, we aimed to share our experience with the surgical repair of complicated or non-complicated DH. Patients who were operated on under emergency or elective conditions with the diagnosis of DH between 2009 and 2023 were analyzed retrospectively. Demographic characteristics, histories, symptoms, etiology of DH, computed tomography find-ings, surgical techniques, and postoperative outcomes of the patients were recorded. The mean age of the cases was 51.5±18.5, and 29 were female and 41 were male. Hernia etiology was found to be con-genital (40%), traumatic (32.8%), spontaneous (14.3%), and iatrogenic (12.8%), respectively. The mean diameter of the defects was 7.3±2.76 cm (range: 3-15 cm), and 84% of the defects were on the left side. Sixty percent of the cases were treated by laparoscopic surgery and 11.4% by laparotomy. The conversion rate from laparoscopic to open was 24.3%. Dual mesh was used in 48% of the pa-tients, and primary suturing was applied in 34%. The postoperative mortality rate was 7.1%. DH is an important cause of morbidity and mortality due to abdominal organ strangulation and pulmonary and cardiac complications. When a DH is diagnosed, laparoscopic or open surgery is the treatment that should be preferred.

Right Diaphragmatic Rupture with Passage of an Intrathoracic Ileal Segment Apropos of a Case and Review of the Literature at the Kankan Regional Hospital

Right Diaphragmatic Rupture with Passage of an Intrathoracic Ileal Segment Apropos of a Case and Review of the Literature at the Kankan Regional Hospital

Role and Limitations of Laparoscopy in Abdominal Trauma

Trauma surgery is traditionally carried out through open procedures; however, the use of laparoscopy in stable patients has been gaining room due to favorable outcomes reported in different studies available in the literature. Nowadays, laparoscopy applied to trauma cases can be divided into screening, diagnosis, and therapeutic applications. Laparoscopic surgery application was initially limited to screening procedure focused on finding peritoneal violations; such a procedure would be followed by exploratory laparotomy. The benefits of using laparoscopy in trauma cases as diagnostic tool to rule out intra-abdominal injuries that may have gone unnoticed in computed tomography, such as diaphragmatic injuries can be easily seen. It can be used to prevent unnecessary laparotomies in patients with penetrating injuries, whose fascial breach cannot be clinically or radiologically ruled out. This paper describes the current indications for the use of laparoscopy in trauma, its potential benefits as well as complications related to the technique. We highlight and describe the importance of systematization for investigation of the peritoneal cavity as well as the expansion of indications for treatment of certain lesions by exclusive laparoscopic approach. This is due to the development of equipment as well as a greater number of surgeons trained in advanced laparoscopic surgery. We also present the main potential complications related to the method as well as the limitations still encountered today.

Surgical Management of Sudden Intrathoracic Hemorrhage in Two Patients with Occult Diaphragmatic Injury and Rib Fracture

Background: A sudden massive hemothorax as the initial manifestation of delayed diagnosis of blunt occult diaphragmatic injuries is extremely rare. We report our experience with two cases of sudden massive thoracic hemorrhage treated surgically for occult blunt diaphragm injury. In the present study, we aimed to present the successful rescue of two cases of sudden massive thoracic hemorrhage due to occult blunt diaphragmatic injury during hospitalization by surgical treatment. Sudden massive hemothorax a few days after hospitalization as an initial manifestation of blunt mysterious diaphragm injury is extremely rare.

Diaphragmatic injury post blunt trauma precipitating a year later as tension fecopneumothorax and left liver lobe herniation: Lesson to learn

Bowel perforation leading to feco-pneumothorax is rare yet serious acute emergency with poor prognosis, requiring urgent surgical intervention and often intensive postoperative care. Worldwide, there are a handful of case reports of missed post traumatic diaphragmatic hernia of which feco-pneumothorax as presentation is even rarer. Here, we report a case of 38 years old male who following RTA one year ago developed left side hemopneumothorax with 4th–6th rib fracture with right shaft of femur fracture, which was managed by left ICD, open reduction with internal fixation of shaft of femur, antibiotics & analgesics. He was then discharged after uneventful hospitalization. Patient was asymptomatic in interim until one day, he presented to emergency and diagnosed with feco-pneumothorax due to perforation of herniated bowel along with herniation of falciform ligament and segment of left liver lobe through an anteromedial diaphragmatic rent.