Traumatic diaphragmatic hernia: delayed presentation with tension viscerothorax – lessons to learn

Abstract

Diaphragmatic rupture is a serious complication of thoracoabdominal trauma. The condition may be missed initially. We describe the clinical course of a patient who sustained blunt abdominal trauma in a car accident. His diaphragmatic injury passed unnoticed, to present two years later with left tension viscerothorax, a rarely reported and hardly recognised entity. Nasogastric tube insertion aborted the emergency situation and the hernia was repaired successfully in a semielective setting.

Diaphragmatic hernia following a liver resection: A rare cause of bowel obstruction

“…The rate of a late presentation of an iatrogenic diaphragmatic hernia is disparate ranging from 5% to 62% of the cases [3], with delayed presentation occurring as late as many months or years after the supposedly harmful event [2,3,[11][12][13].…”

Posttraumatic Diaphragmatic Hernia (Diagnostics and Treatment)

“…Наруше-ние тактики обследования и лечения пациентов с травматическими повреждениями грудной клетки и живота, приводит к несвоевременному выявлению и лечению этого заболевания [2,4,5,7,8,10,11,17,19].…”

“…Диагностика посттравматической диафраг-мальной грыжи нередко бывает затруднительной, особенно если факт повреждения диафрагмы не был установлен в остром периоде травмы [1,2,5,11,15,18]. Особую сложность представляет диагностика и лечение пациентов с осложнённой посттравматиче-ской диафрагмальной грыжей [2,9,17].…”

Anesthesia for Traumatic Diaphragmatic Hernia Associated with Corneal Laceration

“…Although different anesthetic methods have been proposed for management of these patients [ 13 ], the usual recommended methods of anesthesia are awake intubation, crash induction, NG tube insertion [ 14 ], avoidance of mask ventilation, administration of nitrous oxide for maintaining spontaneous ventilation after induction of anesthesia [ 15 ], and one lung ventilation [ 10 , 12 ].…”

“…This is supported by some clinical observations, i.e., the less suggestive or diagnostic chest x-rays (CXRs) of diaphragmatic hernia in intubated patients [ 18 ] or progressive herniation of abdominal viscera after termination of ventilatory support [ 19 ]. Some authors [ 6 ] have considered a prophylactic effect for higher intrathoracic pressure against visceral herniation when they say: “In the setting of abbreviated thoracotomy or laparotomy diaphragm repair can be delayed, but if there is a question about abdominal compartment syndrome, it is better to leave the abdomen ‘open’ to avoid cardiopulmonary compromise by herniated viscera, which cannot be overcome by increasing PEEP.” Al Skaini et al believe that viscera can be sucked into the thorax by negative intrathoracic pressure causing tension viscerothorax or gastrothorax and enlarging the diaphragmatic hole [ 13 ]. The case reported by Yoshidome et al, in which the patient’s lung was herniated into the abdominal cavity, could also indicate that the pressure gradient could prevent abdominal viscera from entering the thoracic cavity during mechanical ventilation [ 19 ].…”