Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma

Abstract

Background: Traumatic diaphragmatic injuries (TDIs) are relatively uncommon and require surgical repair to prevent or address herniation. Three quarters of TDIs are due to blunt thoraco-abdominal trauma. In blunt TDIs, variable clinical presentations and frequent concurrent life-threatening injuries may hinder early recognition and treatment, leading to diagnostic delays, which may result in technically more challenging repairs. Right-sided blunt TDIs are much less common than left-sided ones, are difficult to visualize on imaging studies, are more frequently associated with other potentially lethal injuries, and tend to present more subtly, so that diagnostic delays are more likely. Case presentation: We report the diagnosis and elective repair of a large right-sided traumatic diaphragmatic hernia resulting from a distant blunt abdominal injury, describing the techniques used to address the challenges presented by the chronic intrathoracic displacement of the entire liver with the gallbladder, as well as the right side of the colon and part of the duodenum. Conclusions: Early diagnosis of right-sided TDIs can be especially elusive. The management of delayed diaphragmatic hernias can be challenging, but with meticulous planning and a flexible surgical approach, a repair can be achieved resulting in good recovery and low risk of recurrence.

Post-traumatic giant thrombosis of inferior vena cava induced right-sided blunt traumatic diaphragmatic injury: a case report

“…In contrast, open thoracotomy or thoracoscopic surgery is also an option for patients without abdominal organ injuries. In the acute phase of injury, direct suture using non-absorbable threads is considered, but if the diaphragmatic defect is significant or has been days since the injury, patch closure using an artificial material is also an option [22]. The diagnosis and treatment of diaphragmatic injuries with stable vital signs and no evidence of peritonitis can be challenging.…”

Delayed hepatothorax: An unusual presentation case report

“…Additionally, chest radiographs have a low sensitivity for detecting delayed diaphragmatic hernias. Current literature suggests that the slightest suspicion should be confirmed with thoracoabdominal CT-scan, which is considered more reliable for diagnosis [4] . Magnetic resonance imaging (MRI) is also significant in determining the type of diaphragmatic rupture because diaphragmatic abnormalities can be detected from various images in axial, coronal, and sagittal planes [7] .…”

“…In cases of delayed presentation, the diagnosis becomes increasingly difficult over time due to a reduced index of suspicion [3] . The estimated prevalence of traumatic diaphragmatic hernia is 3–7% of all abdominal and thoracic trauma; meanwhile, the incidence is approximately 0.8–8% of trauma presentations [4] , with the left-sided hernias being more common than right-sided [5] . This discrepancy in incidence is attributed to the cushioning effect of the liver, increased strength of the right hemidiaphragm, underdiagnosis of right-sided ruptures, and congenital weakness of the left hemidiaphragm [6] .…”

“…There are several reports about misdiagnosed hepatothorax, primarily since the chest radiography or computed tomography (CT) scan does not reveal a specific sign [7] . Furthermore, they present later with symptoms due to herniation of abdominal organs into the thoracic cavity [4] . Usually, the clinical presentation of an hepatothorax is dyspnea and chest pain, but may also include upper abdominal pain, cyanosis, cardiac arrhythmias, and hypotension [4] , [6] , [8] , [9] .…”

“…Furthermore, they present later with symptoms due to herniation of abdominal organs into the thoracic cavity [4] . Usually, the clinical presentation of an hepatothorax is dyspnea and chest pain, but may also include upper abdominal pain, cyanosis, cardiac arrhythmias, and hypotension [4] , [6] , [8] , [9] . Once hepatothorax has been diagnosed, current literature establishes that the standard of care is surgical repair.…”