Laparoscopically assisted repair of an acute traumatic diaphragmatic hernia

Abstract

SUMMARYA 60-year-old man with chronic obstructive pulmonary disease and a heavy smoker and drinker presented to the emergency department with left-sided thoracoabdominal pain after falling down the stairs. Initial clinical findings were left-sided chest tenderness with no clinical evidence of subcutaneous emphysema. Twenty-four hours later the patient's respiratory distress increased-repeat chest X-ray showed a left gastrothorax indicative of a ruptured left hemi diaphragm. Diagnostic laparoscopy in the supine position via an umbilical port confirmed the presence of the stomach, spleen and splenic flexure of the colon in the left chest. Laparoscopic reduction of the stomach and colon was performed, but a small upper midline incision was required to reduce the spleen without injury. The diaphragmatic tear was repaired by direct open suture. The patient required a brief period of postoperative ventilation via a tracheostomy. The patient remained well at a 3-month follow-up visit. BACKGROUND

Laparoscopic Repair of an Acute Traumatic Diaphragmatic Hernia: Clinical Case

“…Most of the traumatic diaphragmatic injuries (80-90%) occur in the left diaphragm because the left diaphragm is congenitally weaker than the right diaphragm which is protected by the liver [6]. The clinical presentation is varied as patients may be asymptomatic, may have an acute presentation as shortness of breath, shoulder pain, epigastric pain or vomiting, or may manifest at a later stage, after adhesions are formed, as intestinal obstruction, strangulation or perforation [2,7].…”

“…Diaphragmatic rupture is an infrequent and life-threatening complication of trauma. As the signs and symptoms of acute diaphragmatic trauma are often masked by severe concomitant injuries to other organs, a high índex of suspicion is warranted for clinical diagnosis, especially in the absence of pathognomonic radiographic findings [1,2]. Diagnosis is usually delayed and patients may be asymptomatic for years after trauma, until complications occur [3].…”

“…Once diagnosed, left-sided diaphragmatic injuries should be repaired to reduce the risk of subsequent complications [4]. Laparotomy or thoracotomy are the traditional treatment approaches, the choice being largely dependent on the skill set of the surgeon involved [2,3,4]. The advent of laparoscopy has provided a new approach to this clinical situation.…”

Thoracotomy for Traumatic Diaphragmatic Hernia

“…The defective diaphragm was easily repaired via thoracotomy. With the development of minimally invasive surgical technology, more and more surgical interventions are performed by minimally invasive approach due to less pain and less blood loss [9][10][11]. Latic F [12] reported a case of a 56-year-old man who sustained blunt abdominal trauma in a high-speed motor vehicle accident.…”

Patient Characteristics and Outcomes Following Operative Repair of Acute versus Chronic Traumatic Diaphragmatic Hernia

“…The diagnostic challenge has been attributed to asymptomatic presentations, more distinct and urgent concomitant injuries, positive pressure in the chest due to intubation, and visceral "plugging" over the diaphragmatic defect [2,5,8]. The literature suggests that a high index of suspicion is most important to allow for early diagnosis of traumatic diaphragmatic hernia (TDH) [9,10]. It is estimated that missed diaphragmatic hernias in conservatively managed patients occur 12% to 66% of the time [11].…”