Delayed Presentation of Traumatic Diaphragmatic Hernia

Abstract

Twenty-five patients with traumatic diaphragmatic hernia discovered at least five months after injury are described, of whom 18 were male and seven female. All but one hernia occurred on the left side. Stab wounds were the etiological factor in 22 patients and blunt trauma in three. The diagnosis was most often made by a chest or abdominal radiograph, but barium ingestion confirmed the diagnosis in ten patients. Intercostal drainage of gastric contents provided the diagnosis in two patients. In all nine patients initially approached by a thoracotomy or a thoracoabdominal incision, the hernia was easily reduced and the defect repaired. Although reduction and repair were easily accomplished by the abdominal route in seven patients, this approach was unsatisfactory or inadequate in six others. The colon and stomach were usually in the chest, and strangulation occurred in five patients. The mortality was 20% but rose to 80% when gangrene was present.

Delayed presentation of posttraumatic diaphragmatic hernia

“…[9] The literature about the management of delayed diaphragmatic hernia consists mainly of sporadic cases and very few well-documented but limited case series. [7,10,11] Since these case series are more than a decade old, the use of sophisticated diagnostic modalities such as multislice computerized tomography (CT) and magnetic resonance imaging (MRI) in delayed presentation has not been evaluated. Moreover, with the progress in postoperative patient care, morbidity and mortality have been improved.…”

“…The delayed presentation is the last period when patients present with chronic abdominal or respiratory symp- toms and/or obstructive signs. [11] The obstruction can be associated with strangulation and/or perforation of the herniated contents. However, the natural history of the diaphragmatic injury is unknown in most cases.…”

“…[17] Although chest X-ray findings in delayed presentation were more diagnostic than in acute admission in this study and in others, [10] since most patients without acute symptoms had long-term complaints, additional diagnostic tests other than chest X-ray were routinely used. While older case series used upper gastrointestinal (GI) contrast studies, [11] recent reports commonly used CT or MRI. [18,19] With additional imaging, the rate of preoperative diagnosis in our patients with delayed diaphragmatic hernia without obstructive symptoms reaches 100%.…”

“…[7,10,11] Table 2 compares the main characteristics of earlier reports and the present study. The reason for discrepancies could be due to the defect size and the duration, since both may cause the loss of elasticity of the diaphragm.…”

“…Eylül -September 2011 [11] Feliciano et al [7] Reber et al [10] Present study * Included only penetrating injuries. down was successful with both options.…”