Atypical course of incarcerated post-traumatic diaphragmatic hernia.

The article focuses on the instrumental imaging methods which greatly enhance the possibilities when arriving at correct and quick diagnosis of acute surgical pathology. Analysis of clinical and anamnestic data of the disease course and the results of instrumental research methods made it possible to arrive at clear clinical diagnosis, determine the indications for surgical treatment in this specific clinical case. The use of modern visualization methods while examining the patients prevents errors in diagnosis and helps to determine the optimal treatment tactics.

[Giant traumatic diaphragmatic hernia as a complication after laparoscopic liver surgery]. / Gigantskaya travmaticheskaya diafragmal'naya gryzha kak oslozhnenie posle laparoskopicheskoi operatsii na pecheni.

Laparoscopic surgery is now one of the main options for patients with surgical diseases of abdominal cavity, pelvis and retroperitoneal space. Postoperative complications are known, and methods for their prevention after such interventions are well developed. However, there are rare complications, and their management deserves a special attention. The authors present a patient with giant traumatic hernia in long-term period after laparoscopic liver surgery. Clinical manifestations of disease are retrospectively analyzed. The authors discuss surgical aspects of treatment, i.e. choice of access, repair of diaphragmatic defect and peculiarities of postoperative period associated with non-anatomic return of abdominal organs through the diaphragmatic defect. This report will be useful for radiologists, thoracic and abdominal surgeons, anesthesiologists and intensive care specialists.

[Traumatic Diaphragmatic Hernia due to Rib Fracture Caused by a Tumble:Report of a Case].

A 63-year-old female was admitted to our hospital on the fifth day after a tumble. Computed tomography showed multiple rib fractures, massive hemothorax and diaphragmatic hernia in the left side of the chest and the emergency operation was performed. About 20 mm sized omental diaphragmatic hernia was found and repaired with direct suture. The hernia was thought to be caused by fractured rib. The postoperative course was uneventful, and the patient was discharged on the 11th day after the operation.

Blunt Traumatic Diaphragmatic Hernia in Children: A Systematic Review.

BACKGROUND: Traumatic diaphragmatic hernia (TDH) is rare in children, most often occurring following blunt thoracoabdominal trauma from high energy mechanisms, such as motor vehicle collisions (MVC). We performed a systematic review to describe injury details and management. METHODS: Following PRISMA guidelines, a systematic literature search was performed to identify publications of blunt TDH in patients < 18 y old. Conflicts were resolved by consensus. Data were collected on demographics, TDH location, mechanism of injury, associated intraabdominal injuries (IAI), management, and outcomes. Denominators vary depending on number of patients with such information reported. RESULTS: Fifty-eight articles were reviewed with 142 patients with TDH. The median age was seven y (range 0.25-16). Most were left-sided (85 of 126, 67.5%). MVC was the most common mechanism (66 of 142, 46.5%). IAI was present in 50.0% (57 of 114), most commonly liver injuries (25 of 57, 43.9%). Delayed diagnoses occurred in 49.6% (57 of 115, range 8 h-10 y), and were more common with right-sided TDH (76.0% versus 48.5%, P = 0.02). Chest radiography was 59.0% sensitive for TDH, while computed tomography sensitivity was 65.8%. Operative repair was performed on all surviving patients, and all underwent primary diaphragm repair. The overall mortality was 11.3% (n = 16), with four attributable to the TDH. There were no reported recurrences over a median follow-up of 12 mo. CONCLUSIONS: Pediatric TDH is a rare diagnosis with a high rate of associated IAI and delayed diagnosis. Primary diaphragm repair was performed in all cases. Surgeons should maintain a high suspicion for diaphragm injury in blunt thoracoabdominal trauma.

Core curriculum illustration: blunt traumatic diaphragmatic hernia.

This is the 43rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Traumatic Diaphragmatic Lesions - Considerations Over a Series of 15 Consecutive Cases.

Introduction: Diaphragmatic injuries are produced by blunt or penetrating thoracoabdominal trauma. They are potentially life-threatening due to the herniation of abdominal organs into the pleural cavities and severe associated lesions. The aim of this retrospective study was to analyse the clinical presentation and management of patients admitted with diaphragmatic rupture in our institution. Material and Method: We performed a 5-year retrospective study of patients admitted with acute blunt or penetrating diaphragmatic rupture in the Department of General Surgery of "Bagdasar- Arseni" Emergency Hospital. We have studied sex, age, mechanism of trauma, side-location, timeto-diagnosis, concomitant injuries, surgical treatment and outcome. Results: Fifteen patients (8 males, 7 females, mean age: 42 years) with diaphragmatic rupture (left-side: 13, right-side: 2) following blunt (8 patients) or penetrating (7) trauma were included. Patients with blunt diaphragmatic injury had larger tears and abdominal viscera herniation was observed in 6of these cases. A direct suture was performed for all 15 patients. Laparotomy was the surgical approach preferred in most of the cases. Mortality rate was 20%, mainly caused by severe associated lesions. Conclusion: Although traumatic diaphragmatic lesions are frequently associated with severe cerebral and thoraco-abdominal trauma that is also the main cause of death, a prompt diagnosis and treatment can lead to good outcome.

[Giant posttraumatic diaphragmatic hernia in 17 years after rupture of the diaphragm]. / Lechenie gigantskoi posttravmaticheskoi diafragmal'noi gryzhi cherez 17 let posle razryva grudobriushnoi pregrady.

Blunt chest trauma followed by diaphragm rupture is a severe injury requiring surgical correction both in acute and long-term periods. Posttraumatic diaphragmatic hernia is dangerous by infringement of dislocated organs. Thanks to adaptive mechanisms of the organism, patients with non-functioning half of the diaphragm have a good quality of life for a long time. Symptoms (respiratory disorders and arrhythmia, predominantly) occur over time in patients with concomitant diseases and impaired function of vital organs. At the same time, simultaneous thoracic and abdominal surgery is possible. Thoracotomy is advisable for injury of the right half of the diaphragm, thoracotomy and laparotomy - for injury of the left half. It is presented case report of diaphragm repair by primary suture without application of strengthening materials in 17 years after complex trauma. In this case, diaphragm function was restored that resulted improved quality of life.

Traumatic Right Diaphragmatic Hernia; A Delayed Presentation.

Diaphragmatic rupture following blunt or penetrating thoraco-abdominal trauma is frequently missed. It presents years later with herniation of abdominal viscera. Surgical treatment should be sought for when diagnosed. A 56 year old female presented to emergency with traumatic right diaphragmatic hernia, road traffic accident 8 years ago when she sustained multiple rib fractures on the right side. Upon diagnosis, successful primary hernia repair was performed. Non-specific clinical and radiological features of diaphragmatic hernia (diminished breath sounds, respiratory distress, orthopnoea, dyspnoea, hydro-pneumothorax, and mediastinal shift and lung collapse) lead to delayed or missed diagnosis. Patients present months to years later with complications. By including it in the differentials while managing a trauma patient along with collaboration of the radiology department, the chances of missing this finding would be lowered substantially.

[Late presentation of traumatic diaphragmatic hernia]. / Presentación tardía de hernia diafragmática traumática.

Four years old male, who was operated four months ago to present chest injuries caused by a firearm projectile, where injuries in the diaphragm were not observed. Now is admitted because of an intestinal obstruction. By medial laparotomy, a defect of 3 cm in diameter was exposed in the left diaphragm, containing a transverse colonic segment of 5 cm and omentum. The treatment performed is described.

Varón de cuatro años de edad que hace cuatro meses fue intervenido por presentar lesiones en el tórax producidas por un proyectil de arma de fuego, sin que se observaran lesiones en el diafragma. Ahora ingresa por un cuadro de obstrucción intestinal. Por laparotomía media, se expuso un defecto de 3 cm de diámetro, en el diafragma izquierdo, que contenía un segmento de 5 cm de colon transverso y omento. Se describe el tratamiento efectuado.

[Bilateral post-traumatic diaphragmatic hernias].

Traumatic diaphragmatic hernias could be clinically apparent and diagnosed after months and years after trauma. Bilateral ruptures of the diaphragm rarely appeared. Patients (46 cases) with diaphragmatic hernias were treated at the period from 1998 to 2010. The rate of diaphragmatic hernias consisted of 41,3%, bilateral post-traumatic hernias was noted in 2.2%. The article presents a follow-up study of bilateral diaphragmatic hernia, which was formed on the left (after 1 year) and on the right after 5 years. Diagnosis was supported by radiographic contrast research and computed tomography data. The stomach and omentum were displaced to the pleural cavity on the left, the transversely colon and omentum had a shift on the right. Thoracotomy and diaphragm plasty were performed in both cases. Hernial orifice was located in the area of esophageal opening and crura of diaphragm. It is necessary to increase clinical suspicion in relation to possibility of diaphragmatic hernia origin after severe closed trauma.

Missed diagnosis of a delayed diaphragmatic hernia as intestinal obstruction: a case report.

Penetrating diaphragmatic injury rarely occurs in isolation. Diagnosis of traumatic diaphragmatic hernia resulting from penetrating diaphragmatic injury may be delayed or missed with attendant high morbidity and mortality. We reported a 28-year-old man who presented with features of subacute intestinal obstruction which became severe over the last four days. He had a stab injury to his left lower chest wall that was sutured 31/2 years prior to the development of symptoms. Emergency laparotomy with incidental findings of missed diaphragmatic hernia with gangrenous jejunal segment was found. The hernia was reduced, gangrenous segment resected with end to end anastomosis, and repair of diaphragmatic rent done. He had an uneventful recovery and follow up. There is the need to maintain high index of suspicion of Traumatic Diaphragmatic Hernia (TDH) in a patient with recent or previous thoraco-abdominal injury that will reduce the rate of missed or delayed diagnosis.

[Laparoscopic reconstruction in traumatic rupture of the diaphragm]. / Traumás rekeszruptura laparoscopos reconstructiója.

The authors report the case of a 63-year-old patient who was polytraumatized in a motor vehicle accident and suffered multiple traumatic injuries. Chest and pelvic fractures as well as left-sided diaphragmatic rupture with associated omentum herniation were diagnosed on CT scan. None of the injuries required urgent surgical intervention. After 10 days supportive therapy, elective laparoscopic reconstruction of the diaphragmatic hernia was performed. The authors discuss the role of laparoscopic diaphragm reconstruction.

Laparoscopic-assisted thoracoscopic repair of latent traumatic diaphragmatic hernia: A case report.

Surgical approaches for traumatic diaphragmatic hernia include transabdominal, transthoracic, and thoracoabdominal. Selection of the optimal approach depends on the timing and organ damage, often minimally invasive approaches with laparoscopy or thoracoscopy are performed. A 47-year-old man with blunt chest trauma was diagnosed with left traumatic diaphragmatic hernia 1 month after the trauma. The prolapsed omentum was detached from the chest wall and around the hernia orifice and returned to the abdominal cavity by coordinated thoracoscopic and laparoscopic manipulations. The 4 × 2 cm herniation in the diaphragm was sutured closed from the thoracic side while preventing re-prolapse of the omentum and abdominal organs from the abdominal side. A combined thoracoscopic and laparoscopic approach can be effective in confirming organ damage, repositioning of prolapsed organs, and safe repair of the diaphragm in latent traumatic diaphragmatic hernia.

Late gastric incarceration 20 years after penetrating chest trauma.

The diagnosis of diaphragmatic injury in trauma patients is a challenge for surgeons. Misdiagnosis is common and can only be corrected when patients present with symptoms of diaphragmatic hernia. We report a rare case of delayed traumatic diaphragmatic hernia masquerading as empyema 20 years after lower chest penetrating trauma. The herniated stomach was found intraoperatively. Delayed traumatic diaphragmatic hernia should always be suspected in patients with trauma that may have occurred many years ago.

Tension viscerothorax after blunt abdominal trauma: a case report and review of the literature.

BACKGROUND: Tension viscerothorax is herniation of abdominal viscera into the thorax. Tension viscerothorax can simulate tension pneumothorax. Immediate decompression with a nasogastric tube is required for hemodynamic stabilization. OBJECTIVE: A case of tension viscerothorax is reported along with a review of the literature to highlight this rare complication of blunt abdominal trauma, and to emphasize the importance of nasogastric tube decompression in tension viscerothorax. CASE REPORT: A 10-year-old boy with a remote history of trauma related to a motor vehicle crash was brought into the Emergency Department with a 3-day history of vomiting, epigastric pain, and dyspnea. By physical examination and chest X-ray study, tension gastrothorax was diagnosed. Nasogastric tube placement was difficult and delayed, and the patient deteriorated into cardiac arrest, but after successful cardiopulmonary resuscitation and nasogastric tube insertion, the patient was stabilized. Laparotomy was performed and primary repair of a ruptured diaphragm was done. The patient made an uneventful recovery. CONCLUSION: Acute tension viscerothorax should be considered in the differential diagnosis of tension pneumothorax, and its initial resuscitation should include nasogastric tube insertion for immediate decompression.

[Traumatic diaphragmatic hernia].

Historical and statistical data on traumatic diaphragmatic hernias are presented. It was shown that frequency of occurrence of the pathology in question was dependent on principal causes of its development, anatomic features of diaphragmatic hernias and mechanisms of damage of the diaphragm. In the article the author notes that the worsening of criminogenic situation, increased number of road and traffic accidents were principal causes of the development of diaphragmatic hernias. Special place in the review is given to strangulated diaphragmatic hernias. The basic diagnostic methods for this pathology are radiological investigation, computed tomography and ultrasonic scanning. In addition, the methods of treatment, prognosis of the development of diaphragmatic hernias, complications included, are presented.

Delayed presentation of a post-traumatic large right diaphragmatic hernia displacing liver and gallbladder - A case report.

Blunt or penetrating trauma resulting in injury or rupture of the diaphragm is rare and constitutes about 1% to 3.9% of all thoraco-abdominal injuries. It is often regarded as a marker of severe trauma. Unfortunately about half of these injuries can be missed during the index admission. Contrast-enhanced computed tomography is the best modality to assess the extent, size of diaphragmatic defect and nature of hernial contents. Surgery is mandatory once the diagnosis is made to prevent future strangulation of hernial contents. Although technically challenging, laparoscopic reduction and mesh repair is feasible in expert hands. We report our experience with laparoscopic repair and mesh re-enforcement in a patient who had a large right diaphragmatic hernia with part of liver, gallbladder, small bowel and omentum within the right hemithorax secondary to a penetrating trauma he had incurred 29 years earlier.

Successful thoracoscopic repair of traumatic diaphragmatic hernia in a child.

Traumatic diaphragmatic hernia is very rare in children, and the diagnosis is often missed or delayed. Herein, we reported a 2-year-old boy who had suffered with traumatic diaphragmatic hernia due to a car crash. The child was manifested as tachypnoea without any other severe symptoms. The computed tomography scanning showed his right diaphragm was rupture. Soon, this patient was received a thoracoscopic repair surgery, and he was discharged 2 weeks later without any complication.

Never to be missed again - an analysis of 55 consecutive cases of traumatic diaphragmatic hernia.

BACKGROUND: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care. METHODS: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality. RESULTS: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides. CONCLUSION: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach.

Life threatening rupture of the diaphragm after Covid 19 pneumonia: a case report.

BACKGROUND: The incidence of diaphragmatic rupture is low; however, it may be life threatening. Normally caused by blunt trauma, some cases are reported after pulmonary infections with extensive coughing. Covid 19 causes pulmonary infections and pneumonia and has been associated with weakening of the diaphragm after prolonged ventilation. We present a patient who suffered from diaphragmatic rupture 2 months after recovering from a severe Covid 19 pneumonia. CASE: A 71 years old male patient presented with massive thoraco-abdominal pain and severe dyspnea. At the time of admission, the patient was diagnosed with rupture of the diaphragm and developed cardiogenic shock. Intraoperatively there was a 4 cm diameter large rupture of the diaphragm with enterothorax (transverse colon, stomach, spleen, parts of the jejunum). Avulsion of the mesenteric arteries made a segmental resection of the jejunum together with the spleen necessary. A jejuno-jejunostomy was performed and organs were replaced into the abdomen. The rupture of the diaphragm underwent primary closure with non-resorbable suture material. The patient has shown an uneventful post-operative course, fully recovered and was discharged on day 11 after surgery. CONCLUSION: Covid 19 is a disease that is known to have various effects on different organs. The diaphragm is only paid heed in case of dysfunction. Also in the setting of Covid 19 it is not known as prominent effector organ. Nevertheless its affection by coughing caused by Covid 19 can lead to life threatening complications.