Fecopneumothorax secondary to a late traumatic diaphragmatic injury

Traumatic diaphragmatic hernias were first described by Ambroise Paré in 1579, who reported the case of an artillery captain, that presented an intestinal perforation that had caused a diaphragmatic hernia (Bhatti and Dawani, 2015). The timely diagnosis of a traumatic diaphragmatic hernia can be a challenge, which requires extensive knowledge of the kinematics of trauma, as well as clinical and radiological evidence (Petrone et al., 2017). We present the case of a 60-year-old male who presented blunt abdominal trauma due to a traffic accident, causing an undetected diaphragmatic hernia in his initial evaluation; months after de incident goes to the emergency room (ER) with hemodynamic instability and septic shock. A diagnosis of complicated diaphragmatic hernia and fecopneumothorax is made, for which he undergoes surgery.

Traumatic rupture of diaphragm with splenic herniation. An unusual cause of hemothorax.

The traumatic diaphragmatic hernia is considered a rare clinic condition and represents a diagnostic challenge. Its presentation is mainly a surgical emergency, leading to scarce time for complementary image studies. We present a case of a 21-year-old male who suffered a penetrating wound in the left hemitorax from whom is suspected to have a traumatic visceral herniation into the thoracic cavity by chest X-ray, confirming a splenic herniation with intrathoracic hemorrhage, as well as the proposal of a management algorithm for this defiant cases.

La hernia diafragmática traumática es poco frecuente en la clínica y representa un reto diagnóstico, ya que su aparición es principalmente de emergencia y esto propicia poco tiempo para la realización de estudios de imagen complementarios. Presentamos el caso de un varón de 21 años que sufrió una herida penetrante en el hemitórax izquierdo con sospecha de herniación traumática diafragmática de vísceras abdominales al tórax por radiografía, y en el quirófano se confirmó una herniación esplénica con hemorragia intratorácica. Se propone un algoritmo de manejo en estos casos tan desafiantes.

Clinical, surgical, and radiographic aspects in a white-eared opossum (Didelphis albiventris) with traumatic diaphragmatic hernia / Aspectos clínicos, cirúrgicos e radiográficos em um Gambá-de-orelha-branca (Didelphis albiventris) com hérnia diafragmática traumática

This is the case of a specimen of Didelphis albiventris with signs of respiratory difficulty after a dog attack. Thoracic radiographic examination revealed pneumothorax, pulmonary contusion, and rib fracture, but no alteration compatible with diaphragmatic hernia was observed. Pneumothorax was reduced and the other alterations were treated. However, clinical manifestations persisted, and thus a contrast-gastrointestinal radiographic study was performed, showing abdominal organs in the thoracic cavity and loss of diaphragmatic line. The surgical approach was instituted, with access to the diaphragm through median laparotomy. Through the diaphragmatic rupture, present in the left antimere, there were herniated liver and gastric portions, intestinal segments, and omentum. After inspection and repositioning of the abdominal organs, the diaphragm raffia was performed with single sutures interrupted with 3-0 Nylon thread. The patients complete recovery occurred 14 days after the surgical procedure, with remission of clinical manifestations and normality of thoracic images in radiographic studies.(AU)

Esse é o caso de um espécime de Didelphis albiventris com sinais de dificuldade respiratória após ataque por cão. O exame radiográfico torácico revelou pneumotórax, contusão pulmonar e fratura de costelas, porém nenhuma alteração com-patível com hérnia diafragmática foi observada. O pneumotórax foi reduzido e as demais alterações tratadas. Contudo; houve a persistência das manifestações clínicas, e dessa forma um estudo radiográfico gastrointestinal contrastado foi realizado, sendo evidenciados órgãos abdominais na cavidade torácica e perda da linha diafragmática. A abordagem cirúrgica foi instituída, com acesso ao diafragma por meio de laparotomia mediana. Através da ruptura diafragmática, presente no antímero esquerdo, estavam herniadas porções hepáticas e gástricas, segmentos intestinais e omento. Após inspeção e reposicionamento dos órgãos abdominais, a rafia do diafragma foi realizada com suturas simples interrompidas com fio Nylon 3-0. A recuperação completa do paciente ocorreu 14 dias após o procedimento cirúrgico, com remissão das manifestações clínicas e normalidade das ima-gens torácicas nos estudos radiográficos.(AU)

Clinical, surgical, and radiographic aspects in a white-eared opossum (Didelphis albiventris) with traumatic diaphragmatic hernia / Aspectos clínicos, cirúrgicos e radiográficos em um Gambá-de-orelha-branca (Didelphis albiventris) com hérnia diafragmática traumática

This is the case of a specimen of Didelphis albiventris with signs of respiratory difficulty after a dog attack. Thoracic radiographic examination revealed pneumothorax, pulmonary contusion, and rib fracture, but no alteration compatible with diaphragmatic hernia was observed. Pneumothorax was reduced and the other alterations were treated. However, clinical manifestations persisted, and thus a contrast-gastrointestinal radiographic study was performed, showing abdominal organs in the thoracic cavity and loss of diaphragmatic line. The surgical approach was instituted, with access to the diaphragm through median laparotomy. Through the diaphragmatic rupture, present in the left antimere, there were herniated liver and gastric portions, intestinal segments, and omentum. After inspection and repositioning of the abdominal organs, the diaphragm raffia was performed with single sutures interrupted with 3-0 Nylon thread. The patient’s complete recovery occurred 14 days after the surgical procedure, with remission of clinical manifestations and normality of thoracic images in radiographic studies.

Esse é o caso de um espécime de Didelphis albiventris com sinais de dificuldade respiratória após ataque por cão. O exame radiográfico torácico revelou pneumotórax, contusão pulmonar e fratura de costelas, porém nenhuma alteração com-patível com hérnia diafragmática foi observada. O pneumotórax foi reduzido e as demais alterações tratadas. Contudo; houve a persistência das manifestações clínicas, e dessa forma um estudo radiográfico gastrointestinal contrastado foi realizado, sendo evidenciados órgãos abdominais na cavidade torácica e perda da linha diafragmática. A abordagem cirúrgica foi instituída, com acesso ao diafragma por meio de laparotomia mediana. Através da ruptura diafragmática, presente no antímero esquerdo, estavam herniadas porções hepáticas e gástricas, segmentos intestinais e omento. Após inspeção e reposicionamento dos órgãos abdominais, a rafia do diafragma foi realizada com suturas simples interrompidas com fio Nylon 3-0. A recuperação completa do paciente ocorreu 14 dias após o procedimento cirúrgico, com remissão das manifestações clínicas e normalidade das ima-gens torácicas nos estudos radiográficos.

Abdomen agudo obstructivo por hernia diafragmática crónica postraumática / Obstructive acute abdomen due to postraumatic chronic diaphragmatic hernia

Se describe el caso clínico de un paciente de 37 años de edad, que acudió al Servicio de Emergencia del Hospital General Docente de Riobamba, en Ecuador, con manifestaciones clínicas e imagenológicas que permitieron diagnosticarle un abdomen agudo obstructivo por hernia diafragmática crónica postraumática, por lo que el tratamiento fue quirúrgico. Teniendo en cuenta la evolución satisfactoria del paciente se le dio el alta hospitalaria 10 días después de la operación. Se mantuvo con seguimiento durante 3 meses sin presentar complicaciones.

The case report of a 37 years patient that went to the Emergency Service of the Teaching General Hospital of Riobamba, in Ecuador, is described. He presented clinical and imaging signs that led to the diagnosis of an obstructive acute abdomen due to postraumatic chronic diaphragmatic hernia, reason why the treatment was surgical. Taking into account the patient's favorable clinical course he was discharged from the hospital 10 days after the surgery and received follow-up care during 3 months without presenting complications.

Ruptura diafragmática y esplénica de origen traumático en un adolescente / Diaphragmatic and splenic rupture of traumatic origin in a teenager

Introducción: La ruptura diafragmática es un reto diagnóstico y terapéutico para los médicos que se enfrentan al manejo de pacientes politraumatizados; debe sospecharse siempre en lesiones traumáticas de localización torácica o abdominal. Objetivo: Informar los elementos diagnósticos y terapéuticos seguidos ante ruptura diafragmática y esplénica de origen traumático. Presentación del caso: Se presenta el caso de un adolescente de 14 años que ingresa por presentar herida punzante por arma blanca de localización abdominal y manifestaciones clínicas que permiten hacer el diagnóstico de la afección tratada. Durante el acto quirúrgico se comprobó la ruptura del diafragma, hernia diafragmática y ruptura esplénica con salida de sangre hacia la cavidad abdominal. Se realizó reducción de la hernia, sutura del diafragma y extirpación del bazo por el estado del órgano en el momento de la cirugía. Conclusiones: La ruptura diafragmática postraumática es una entidad que cada vez se observa con mayor frecuencia en pacientes pediátricos. El examen clínico auxiliado por estudios imagenológicos resulta vital para su diagnóstico, tratamiento precoz y evitar complicaciones. Es importante mantener un alto índice de sospecha ante esta entidad poco frecuente, pero no rara en la edad pediátrica. El paciente tuvo una evolución favorable y fue egresado del servicio de cirugía luego de 10 días de hospitalización(AU)

Introduction: The diaphragmatic rupture is a diagnostic and a therapeutic challenge for physicians who have to face the management of polytraumatized patients; there must always be suspicion on traumatic injuries of thoracic or abdominal location. Objective: To inform the diagnostic and therapeutic elements followed in case of diaphragmatic and splenic rupture of traumatic origin. Presentation of the case: 14-year-old male teenager that was admitted for presenting stabbing wound by sharp weapon, with abdominal location and clinical manifestations that allow making the diagnosis of the condition being treated. During surgery, it was found the rupture of the diaphragm, a diaphragmatic hernia and splenic rupture with output of blood into the abdominal cavity. It was conducted the reduction of the hernia, the suture of the diaphragm and the removal of the spleen due to the state of the organ during the surgery. Conclusions: Post-traumatic diaphragmatic rupture is an entity that it is most often seen in pediatric patients. The clinical examination aided by imaging studies is vital for its diagnosis, early treatment and to avoid complications. It is important to maintain a high index of suspicion to face this rare entity, but not so rare in the pediatric age group. The patient had a favourable evolution and he was discharged of the surgery service after 10 days of hospitalization(AU)

Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case / Hepatotórax crônico devido à ruptura do diafragma direito: um desafio anestésico em um caso raro

Abstract Background: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. Case report: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. Conclusions: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success.

Resumo Justificativa: A ruptura diafragmática é uma condição incomum e ocorre em 90% no lado esquerdo. No entanto, a incidência de ruptura à direita tem vindo a aumentar junto com o aumento dos acidentes automobilísticos. A herniação do fígado pode tornar-se progressiva, causar atelectasia grave do pulmão direito, resultar num débil estado respiratório e alterações hemodinâmicas. Relato de caso: Mulher de 40 anos, estado físico ASA 3, marcada para reparação de hepatotórax que evoluiu de hérnia diafragmática direita, adquirida aos 8 anos, após um acidente automobilístico. Clinicamente apresentava síndrome respiratória restritiva grave, causada pelo hepatotórax. A avaliação anestésica era normal, com exceção da radiografia do tórax, que evidenciava elevação da hemicúpula diafragmática direita, sem desvio traqueal. Diagnóstico foi confirmado por tomografia computadorizada. Depois da recolocação do fígado na cavidade abdominal foram observados um aumento transitório da pressão venosa central, do Stroke Volume Index e Flow Time Corrected (35%) e uma diminuição da resistência vascular sistêmica. Uma vez alcançada a estabilização hemodinâmica geral e hepatoesplênica, bem como da ventilação, a paciente foi transferida entubada, sob ventilação controlada e monitorada para a Unidade de Transplantação Hepática. Conclusões: O hepatotórax é uma condição rara e a sua correção pode representar um desafio anestésico. Após a recolocação abdominal do fígado, durante uma cirurgia corretiva, sob anestesia geral, podem ocorrer complicações, principalmente as associadas à reexpansão pulmonar. Um trabalho em equipe eficaz e o planejamento cuidadoso da cirurgia, entre as equipes cirúrgica e anestésica, são a chave para o sucesso.

Alternativas quirúrgicas en hernias y eventraciones diafragmáticas crónicas / Surgical alternatives for chronic diaphragmatic hernias and eventrations

Introducción: las eventraciones y las hernias diafragmáticas crónicas son dos afecciones que en ocasiones se confunden; tienen una frecuencia relativamente baja y su estrategia quirúrgica varía. Objetivo: mostrar la experiencia del Hospital Universitario Clínico Quirúrgico Comandante Manuel Fajardo en la atención de enfermos con hernias y eventraciones diafragmáticas. Métodos: se presentan 11 pacientes atendidos desde 1998 hasta 2015 por afecciones del diafragma como eventraciones y hernias diafragmáticas crónicas. Del total, 7 fueron operadas con anillos de hasta 10 cm y dos con más de 10 cm. Resultados: se operaron 9 pacientes con hernias diafragmáticas y 2 con eventraciones. Ocho hernias fueron del lado izquierdo y una derecha. En 8 de las hernias el contenido era multivisceral. La hernia derecha tenía un anillo de más de 10 cm y con el hígado en su contenido. Cinco fueron reparadas mediante superposición de colgajos y en cuatro se necesitó una malla protésica. Las eventraciones se presentaron en dos mujeres, ambas parciales, una derecha y otra izquierda, tratadas con plicatura del hemidiafragma en dos planos. Conclusiones: las hernias y las eventraciones diafragmáticas son entidades parecidas con particularidades y terapéutica diferentes. En las eventraciones, la plicatura del diafragma es la técnica de elección, por vía abierta o de preferencia por toracoscopia. En las hernias diafragmáticas, la reparación depende del tamaño del anillo, hasta 10 cm se prefiere la reparación con superposición de colgajos y en defectos mayores el uso de mallas protésicas, preferentemente por una toracotomía(AU)

Introduction: Chronic diaphragmatic hernias and eventrations are two conditions sometimes mistaken for each other. They have a relatively low frequency and their surgical strategy varies. Objective: To show the experience at Comandante Manuel Fajardo Clinical Surgical University Hospital in the caring for patients with diaphragmatic eventrations and hernias. Methods: 11 patients attended from 1998 to 2015 were presented for diaphragmatic conditions, such as hernias and chronic diaphragmatic eventrations. Of the total, 7 were operated with rings of up to 10 cm. Two were operated for rings of more than 10 cm. Results: 9 patients with diaphragmatic hernias and 2 with incisional hernias were operated. Eight hernias were on the left side. One hernia was on the right side. In 8 of the hernias, the content was multivisceral. The right hernia had a ring of more than 10 cm, and had the liver in its content. Five hernias were repaired by flaps. Four hernias required a prosthetic mesh. The eventrations were presented in two women, both partial: one was on the right and the other was on the left, and both were treated with plication of the hemidiaphragm in two planes. Conclusions: Diaphragmatic hernias and eventrations are similar entities with different characteristics and therapeutics. In eventrations, the plication of the diaphragm is the technique of choice, either openly or preferably by thoracoscopy. In diaphragmatic hernias, repair depends on the size of the ring, up to 10 cm, flap repair is preferred, and in larger defects, it is the use of prosthetic meshes, preferably by thoracotomy(AU)

Thoracotomy compared to laparotomy in the traumatic diaphragmatic hernia. Systematic review and proportional methanalysis.

PURPOSE: To evaluate the most used approach to treat traumatic diaphragmatic ruptures, and in which one the requirement to assess the second cavity is more frequent. METHODS: Systematic review, observational studies. Outcomes: moment of approach, most commonly via addressed and the requirement to open the other cavity. Bases searched: Lilacs, Pubmed, Embase, Clinicaltrials.gov and Web of Science. Statistical analysis: StatsDirect 3.0.121 software. RESULTS: Sixty eight studies (2023 participants) were included. Approach in acute phase was performed four times more than in chronic phase. Approach: abdominal 65% (IC 95% 63-67%), thoracic 23% (IC 95% 21-24%), abdominal in the acute phase 75% (IC 95% 71-78%), and chronic 24% (IC 95% 19-29%), thoracic in the acute phase 12% (IC 95% 10-14%) and chronic 69% (IC 95% 63-74%). Thorax opening in the abdominal approach: 10% (95% CI 8-14%). Abdomen opening in the thoracic approach: 15% (95% CI 7-24%). CONCLUSIONS: The most common approach was the abdominal. The approach in the acute phase was more common. In the acute phase the abdominal approach is more frequent than the thoracic approach. In the chronic phase the thoracic approach is more frequent than the abdominal one. The requirement to open the second cavity was similar in both approaches.

Thoracotomy compared to laparotomy in the traumatic diaphragmatic hernia. Systematic review and proportional methanalysis

Abstract Purpose: To evaluate the most used approach to treat traumatic diaphragmatic ruptures, and in which one the requirement to assess the second cavity is more frequent. Methods: Systematic review, observational studies. Outcomes: moment of approach, most commonly via addressed and the requirement to open the other cavity. Bases searched: Lilacs, Pubmed, Embase, Clinicaltrials.gov and Web of Science. Statistical analysis: StatsDirect 3.0.121 software. Results: Sixty eight studies (2023 participants) were included. Approach in acute phase was performed four times more than in chronic phase. Approach: abdominal 65% (IC 95% 63-67%), thoracic 23% (IC 95% 21-24%), abdominal in the acute phase 75% (IC 95% 71-78%), and chronic 24% (IC 95% 19-29%), thoracic in the acute phase 12% (IC 95% 10-14%) and chronic 69% (IC 95% 63-74%). Thorax opening in the abdominal approach: 10% (95% CI 8-14%). Abdomen opening in the thoracic approach: 15% (95% CI 7-24%). Conclusions: The most common approach was the abdominal. The approach in the acute phase was more common. In the acute phase the abdominal approach is more frequent than the thoracic approach. In the chronic phase the thoracic approach is more frequent than the abdominal one. The requirement to open the second cavity was similar in both approaches.

[Chronic hepatothorax due to right diaphragmatic rupture: an anesthetic challenge in a rare case]. / Hepatotórax crônico devido à ruptura do diafragma direito: um desafio anestésico em um caso raro.

BACKGROUND: Diaphragmatic rupture is an uncommon condition, with 90% of ruptures occurring on the left side. However, its incidence on the right side is increasing along with the increase in traffic accidents. Liver herniation may become progressive causing severe atelectasis of the right lung, resulting in impaired respiratory status and hemodynamic changes. CASE REPORT: We report the case of a 40 years old female, ASA III, scheduled for hepatothorax repair that evolved from right diaphragmatic hernia after a car accident when she was 8 years old. Clinically, she had severe restrictive respiratory syndrome caused by the hepatothorax. The anesthetic evaluation was normal, except for the chest X-ray showing elevation of the dome of the right hemidiaphragm without tracheal deviation. Diagnosis was confirmed by CT scan. After liver replacement in the abdominal cavity, a transient increase in central venous pressure, stroke volume index and flow time corrected (35%), and a decrease in systemic vascular resistance were observed. After complete hemodynamic and hepatosplenic stabilization, as well as ventilation, the patient was transferred intubated, under controlled ventilation and monitored, to the liver transplant unit. CONCLUSIONS: Hepatothorax is a rare condition and its repair may represent an anesthetic challenge. After liver replacement in the abdominal cavity during corrective surgery under general anesthesia complications may occur, particularly associated with pulmonary re-expansion. Effective teamwork and careful planning of surgery, between the surgical and anesthetic teams, are the key to success.

Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs.

PURPOSE: To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures. METHODS: Five male dogs were used in this study. Under laparoscopic approach, a defect of 7 cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period. RESULTS: All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable. CONCLUSIONS: Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.

Hernia diafragmática traumática en un niño / Diaphragmatic traumatic hernia in the little boy

La hernia diafragmática traumática es una afección poco frecuente sobre todo en edades pediátricas. El objetivo de este trabajo es reportar un caso de hernia diafragmática secundaria a un trauma toracoabdominal cerrado. Se presenta el caso de un paciente de 12 años, masculino ingresado en el Servicio de Cirugía Pediátrica de la Provincia de Santiago de Cuba, por haber sufrido un accidente en el hogar (caída de una pared de ladrillos sobre su cuerpo), que produjo traumatismos a nivel craneal, torácico y lumbar. Los estudios radiológicos confirmaron el diagnóstico de hernia diafragmática traumática izquierda. En el acto quirúrgico se comprueba defecto del diafragma izquierdo de aproximadamente 15 cm, con hernia de estómago, bazo y colon. Se realizó reducción y frenorrafia con puntos de colchonero usando poliéster 0, más pleurostomía mínima baja izquierda. El paciente evolucionó satisfactoriamente y egresó a los 10 días para seguimiento en la consulta externa durante 6 meses hasta el alta definitiva(AU)

Traumatic diaphragmatic hernia is a rare illness at pediatric ages. The objective of this paper was to report a case of diaphragmatic hernia secondary to closed thoracoabdominal trauma. This patient is a 12 years-old boy admitted to the pediatric surgery service of Santiago de Cuba province because of an accident at home (a brick wall fell down upon his body) that caused him cranial, thoracic and lumbar traumas. The radiological studies confirmed the diagnosis of traumatic diaphragmatic hernia on the left side. During the surgical act, there was observed an almost 15cm left diaphragm defect with hernias in stomach, spleen and colon. Reduction and phrenorraphy were performed using mattress sewing stitch type, polyester 0 plus left low minimal pleurostomy. The progression of the patient was satisfactory and was discharged from hospital ten days after surgery to be followed up in the outpatient service for 6 months until his complete recovery(AU)

Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs

PURPOSE:To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures.METHODS: Five male dogs were used in this study. Under laparoscopic approach, a defect of 7cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period.RESULTS:All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable.CONCLUSIONS:Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.

Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs

To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures. Five male dogs were used in this study. Under laparoscopic approach, a defect of 7cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period.RESULTS:All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable. Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.(AU)

Hernia diafragmática derecha traumática: a propósito de un caso / Hospital General Docente Capitán Roberto Rodríguez Fernández

La hernia diafragmática constituye una forma poco frecuente de afección diafragmática y se necesita un índice elevado de sospecha para su diagnóstico. Las lesiones del lado izquierdo parecen ser las más frecuentes según la literatura revisada. Se presenta una paciente de 32 años de edad que ingresa en el servicio de terapia intensiva luego de sufrir accidente en la línea férrea y recibir múltiples lesiones en diferentes órganos y sistemas, esta situación en particular se presentó clínicamente como disnea que se fue incrementando, sudoración, palidez, deterioro hemodinámico, además de las características clínicas de las demás situaciones que presentaba; se hizo el diagnóstico clínico y radiográfico de hernia diafragmática traumática del lado derecho y se realizó corrección quirúrgica inmediata, la paciente estuvo ingresada por espacio de 30 días con una evolución favorable de todas sus lesiones como consecuencia del trauma.

Diaphragmatic hernia constitutes a rare form of diaphragmatic affection and an elevated index of suspicion is needed for its diagnosis. The injuries of the left side seem to be most frequent according to reviewed literature. A patient of 32 years appears and enters in the Intensive Care Unit after suffering an accident in the railway and receiving multiple injuries in different organs and systems, this situation appeared clinically as dyspnea that it was increasing, perspiration, paleness, haemodynamic deterioration, in addition to the clinical characteristics of the other situations that presented. A clinical and X-ray diagnosis of traumatic right diaphragmatic hernia and immediate surgical correction was carried out. The patient was admitted for 30 days with a favorable evolution of all her injuries as a result of the traum.

Delayed intestinal obstruction due to posttraumatic diaphragmatic hernia.

BACKGROUND: Diaphragmatic rupture can be missed during trauma diagnosis. Different pressures between the thorax and the abdomen allow the abdominal viscera to herniate into the chest cavity. Cardiorespiratory and abdominal symptoms may appear later due to passive compression and incarceration, respectively. CLINICAL CASE: We report the case of a 52-year-old female with abdominal pain and vomiting. Chest x-ray demonstrated an elevation of the right hemidiaphragm, and computed tomography showed herniation of small bowel and colon into the chest cavity with dilated small bowel due to a diaphragmatic hernia. CONCLUSIONS: History of traumatic events should be considered with high suspicion in the diagnostic process to avoid delayed diagnosis of this condition. The nonspecific symptoms of this condition often lead the patient to consult different specialists. A multidisciplinary approach is required and aimed at preventing an unnecessary increase of morbidity and mortality.

Hérnia diafragmática à direita por trauma contuso: uma revisão bibliográfica / Right diaphragmatic hernia due to blunt trauma: a literature review

As hérnias diafragmáticas são decorrentes principalmente de traumas contusos e são mais comuns à esquerda. Essa menor frequência à direita é explicada pela contenção e proteção do fígado ao hemidiafragma homolateral. Entretanto, apesar de as lesões à esquerda serem mais frequentes, aquelas situadas à direita associam-se a lesões mais graves e resultam em mais instabilidade hemodinâmica, o que gera elevada mortalidade no momento do trauma. Além disso, a hérnia diafragmática direita, pode permanecer assintomática por longo tempo, favorecendo a aparecimento de complicações como isquemia e ruptura das vísceras herniadas dentro do tórax. Assim é fundamental um diagnóstico precoce, a fim de se realizar o tratamento cirúrgico, uma vez que o diafragma não cicatriza espontaneamente. (AU)

The diaphragmatic hernias are mainly due to blunt trauma and are more common on the left. This lower frequency on the right side is explained by liver protection of the ipsilateral hemidiaphragm. However, despite the injuries are more frequent on the left, those situated on the right are associated with more severe injuries and result in more hemodynamic instability, which leads to high mortality at the time of trauma. Furthermore, the right diaphragmatic hernia can remain asymptomatic for long time, favoring the onset of complications such as ischemia and rupture of the herniated organs inside the chest. Therefore early diagnosis is fundamental in order to perform surgical treatment, since the diaphragm does not heal spontaneously. (AU)