Traumatic Diaphragmatic Ruputure: 4-Year Clinical Experience

PURPOSE: A traumatic diaphragmatic rupture (TDR) is a diagnostic challenge and the associated injuries determine the outcome in those diagnosed early. A TDR has long been considered to be a marker of the severity of injury with an average reported Injury Severity Score (ISS) between 31 and 50. This report reviewed the TDR cases in order to emphasize the method and timing of the diagnosis, associated injuries and the outcome. METHODS: A retrospective analysis was performed on 30 patient treated for TDR between August 1998 and september 2002. RESULTS: The mean age of the patients was 33.4 years and the injury predomiantly affected males (male: female=2: 1). Blunt trauma by TA was the most common cause of the TDR (25 patients). The ruptured sites were on the left in 22 cases and on the right in 8 cases. The most common symptom was chest pain (23 cases) followed dyspnea (21 cases). Liver injuries and a pneumo-hemothorax were the most common associated injuries. The mean CRAMS scale was 6.47 and Injury Severity Score (ISS) was 18.93. Eighteen TDR cases were suspected based on the abnormal chest X-ray findings. Nineteen cases underwent surgery within 6 hours after the trauma (early diagnosis). Although many complications occurred in 11 cases, there were no lethal complications. The mean size of the diaphragmatic rupture was 9.77 cm and an intraabdominal organ herniation had not occurred in ruptures smaller than 6 cm. Surgical repair of the diaphragm was performed via a laparotomy in 20 cases and thoracotomy in 7 cases. A left side TDR was preferred to a laparotomy whereas a right sided TDR was preferred to a thoracotomy. Pulmonary complications (atelectasis, pneumonia, pleural effusion) occurred in 14 cases postoperatively. CONCLUSION: The patient's complaints and physical findings were not a reliable indicator of the diagnosis, but usually a manifestation of the associated injuries. A suspicion and routine chest X-ray was the most reliable diagnostic tool, even though the chest X-ray was normal in 12 cases. A high rate of early diagnosis can be achieved using an aggresive investigation protocol, suspicion and a combined radiologic evaluation in multiple trauma patients. Although pulmonary complications occurred in the early diagnosed cases, lethal complications and long term sequela were directly related to the time of diagnosis. The higher ISS had many complications (11 cases) but there were no lethal complications, long term sequela.

Strangulated Obturator Hernia: Mesh-Plug Technique

Although obturator herniae are rare, they are associated with a high mortality, as diagnosis is often delayed and the condition tends to occur in the elderly. The preoperative diagnosis is difficult because of nonspecific symptoms and sign. They often produce a small bowel obstruction. The treatment is always surgical. Several repair techniques have been described: a sac ligation alone, a direct suture repair, and the use of autologous tissue or prosthetic repair. Recently, the placement of permanent mesh prostheses, in a clean contaminated operative field, has been performed due to the minimal wound-related morbidity and patient mortality. Thus, utilization of a permanent mesh in an obturator hernia is a new, simple and effective method for repair. Two cases of a strangulated obturator hernia were experienced in elderly women. The peritoneal cavity was not overly contaminated, with only necrotic foci on the herniated small bowel wall noted. A segmental resection of the small bowel was performed. Consequently, the hernia defect was closed with mesh- plug between the peritoneum and periosteum of the obturator foramen. Here, two cases of obturator herniae treated by use of a mesh-plug are reported, with a brief review of the literature.

Trauma-related Acute Spigelian Hernia in Right Upper Abdomen

Trauma-related spigelian hernia is a rare event that has been reported only sporadically. Because of its rare nature and nonspecific physical findings, its diagnosis is difficult. This hernia most commonly presents at the level of the semicircular line known as the arcuate line. A 70-year-old man was admitted after overturn of his cultivator. A scratch wound surrounding a cutaneous sign of the cultivator handlebar impact was evident on his right upper abdominal wall. Trauma-related spigelian hernia occurred in the site of the handlebar impact. We report this cases of trauma-related spigelian hernia that was treated by primary repair with a brief review of the literature.

A Comparision of the Mesh Technique in Inguinal Hernia Repair with the Non-mesh Method

PURPOSE: The mesh technique of inguinal hernia repair has revealed encouraging results in groin hernia repair. However, there are few reports in Korea analyzing the clinical results of the mesh technique compared with the non-mesh method of inguinal hernia repair. METHODS: Information was assimilated from randomized trials comparing the mesh and non-mesh methods in order to assess both benefits and safety. The clinical results of the mesh technique (n=38) and the non-mesh method (n=33) were compared. The clinical features analyzed were age, sex, location, type of hernia, surgical time, use of postoperative analgesics, length of hospital stay, complication and recurrence. RESULTS: There was no significant difference between the mesh technique and the non-mesh method on sex, age, location, type of hernia. The average operation time was significantly longer in the mesh group than the non-mesh group (P<0.01, 60.9 min vs 46.8 min). The average number of analgesics used was significantly smaller in the mesh group than the non-mesh group (P<0.01, 4.6 vs 8.2). The average duration of hospital stay was statistically shorter in the mesh group than the non-mesh group (P<0.01, 4.5 days vs 6.3 days). Postoperative complications were observed in only one case (hematoma) in the non-mesh group. Recurrence rate in the non-mesh group was 9% (3 cases), although there was no recurrence in a mesh group. CONCLUSION: The mesh technique of inguinal hernia repairis a useful technique because it is less painful and causes a shorter hospital stay than the non-mesh method. In this study, we observed not a shortened surgical time and lower recurrence rate in the mesh group than in non-mesh.