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.

A Novel Intubation Technique: Bougie Introduction Via Ducanto Suction Catheter.

BACKGROUND: Airway management is a defining skill that demands mastery by emergency physicians. Airway emergencies pose considerable morbidity and mortality risks. Familiarity with, and mastery of, a variety of airway management approaches and equipment can prove invaluable for management of anatomically and physiologically difficult airways. CASE REPORT: A 67-year-old woman presented to a level II trauma after a motor vehicle collision. Emergency medical services reported left-sided injuries, including diminished breath sounds. She arrived in extremis with dyspnea and hypoxia refractory to supplemental oxygen. A portable chest x-ray study showed a considerable traumatic diaphragmatic hernia. Initial attempts at intubation via video laryngoscopy were unsuccessful. Difficulties were attributed to anatomic variation, possibly due to the traumatic diaphragmatic hernia, and hematemesis. The airway was repositioned after removal of a cervical collar and suction-assisted laryngoscopy airway decontamination was performed under video guidance. During airway decontamination, the tip of a DuCanto suction catheter (SSCOR) became located at the level of the vocal cords, prompting the decision to control the airway via utilization of the DuCanto suction catheter and a bougie. The suction tubing was disconnected, a bougie was inserted through the catheter, and the DuCanto was subsequently removed and replaced with a cuffed endotracheal tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Airway emergencies are imminent life threats. Familiarity with a variety of tools and techniques allows for definitive airway management via primary, back-up, and contingency plans to secure anatomically or physiologically difficult airway.

Repair of diaphragmatic hernias: Retrospective analysis of 70 cases.

BACKGROUND: Congenital and traumatic diaphragmatic hernias (DH) can lead to respiratory and gastrointestinal complications that can be the cause of serious morbidity and mortality. In this study, we aimed to share our experience with the surgical repair of complicated or non-complicated DH. METHODS: Patients who were operated on under emergency or elective conditions with the diagnosis of DH between 2009 and 2023 were analyzed retrospectively. Demographic characteristics, histories, symptoms, etiology of DH, computed tomography find-ings, surgical techniques, and postoperative outcomes of the patients were recorded. RESULTS: The mean age of the cases was 51.5±18.5, and 29 were female and 41 were male. Hernia etiology was found to be con-genital (40%), traumatic (32.8%), spontaneous (14.3%), and iatrogenic (12.8%), respectively. The mean diameter of the defects was 7.3±2.76 cm (range: 3-15 cm), and 84% of the defects were on the left side. Sixty percent of the cases were treated by laparoscopic surgery and 11.4% by laparotomy. The conversion rate from laparoscopic to open was 24.3%. Dual mesh was used in 48% of the pa-tients, and primary suturing was applied in 34%. The postoperative mortality rate was 7.1%. CONCLUSION: DH is an important cause of morbidity and mortality due to abdominal organ strangulation and pulmonary and cardiac complications. When a DH is diagnosed, laparoscopic or open surgery is the treatment that should be preferred.

[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.

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.

Complications and outcome of traumatic diaphragmatic hernia repair without post-operative chest drain: Retrospective study in 90 cats.

Background: Diaphragmatic herniorraphy is the treatment of choice for traumatic diaphragmatic hernia (TDH). Several methods have been described for the removal of residual air and fluid during and after surgery, such as the insertion of chest drains, intercostal thoracentesis, and transdiaphragmatic thoracentesis. However, there are no indications regarding the most useful technique and the impact that choice of technique could have in the immediate postoperative period. Aim: To evaluate the development of complications and outcomes associated with the use of intraoperative transdiaphragmatic thoracentesis in cats undergoing diaphragmatic herniorrhaphy for TDH. Methods: Medical records of cats treated for acute and chronic TDH between 2010 and 2019 were reviewed. Cats were included if intraoperative pneumothorax was treated with transdiaphragmatic thoracentesis, without the use of intercostal chest drain. Outcome, intra- and post-operative complications were recorded. Results: Intraoperative and postoperative complication rates were 3.3% and 12.4%, respectively. Development of postoperative pneumothorax was associated with the presence of comorbidities (p = 0.046). The overall survival rate was 93.3%. Long-term survival had a significant association with the presence of comorbidities (p = 0.045), if the procedure was performed as an emergency (p = 0.041) or in older cats (p = 0.011). Conclusion: Intraoperative transdiaphragmatic thoracentesis could be considered an effective method for the removal of residual air after surgery for TDH, because it ensures a good outcome for the patient, with low development of complications, especially for uncomplicated cases. The presence of comorbidities, the need to perform a surgical procedure in emergency, and the age of the patient can be considered factors influencing the development of complications. Critical patient selection, based on assessment of potential risk factors for complications is warranted to understand which patient will benefit from thoracostomy tube placement.

[Clinical analysis of laparoscopic treatment of chronic traumatic diaphragmatic hernia in 29 cases].

Objective: To examine the safety and effectiveness of laparoscopic individualized surgical treatment for chronic traumatic diaphragmatic hernia (CTDH). Methods: The clinical data and follow-up data of 29 CTDH cases admitted to the Qilu Hospital of Shandong University or the First Affiliated Hospital of Shandong First Medical University from June 2015 to January 2023 were retrospectively analyzed. There were 21 males and 8 females, aged (49.4±17.8) years (range: 19 to 79 years). The main clinical manifestations were symptoms of the digestive system and respiratory system, and only 4 cases were asymptomatic. All patients received laparoscopic treatment (conversion to open surgery was not excluded). Intraoperative exploration (location of the hernia, contents of the hernia, diameter of the hernia ring), surgical conditions (surgical repair plan, operation time, blood loss, postoperative complications) and postoperative follow-up were analyzed and discussed. Results: Laparoscopic repair was successfully completed in 27 cases, including simple suture in 6 cases, suture and patch repair in 17 cases, the anterior abdominal wall muscle flap reversal suture and patch repair of in 3 cases, and patch bridge repair in 1 case. The operation time was (112.8±44.7) minutes (range: 60 to 200 minutes). The amount of bleeding (M(IQR)) was 35 (58) ml (range: 10 to 300 ml). The other 2 patients were converted to laparotomy. Except for one patient with transverse colon strangulation necrosis who died of aggravated pulmonary infection after surgery, the remaining 28 patients were discharged successfully. The follow-up time was 36 (24) months (range: 1 to 60 months). During the follow-up period, only two patients had occasional left upper abdominal discomfort. Twenty-seven patients with left diaphragmatic hernia had no recurrence, and the symptoms of 1 patient with right diaphragmatic hernia were relieved. Conclusion: Customized laparoscopic surgical repair for CTDH according to the location and size of the diaphragmatic defect can achieve good surgical results.

Imaging characteristics and treatment strategies of traumatic diaphragmatic hernia with aortic dissection: a report of 3 cases.

BACKGROUND: Traumatic aortic dissection with traumatic diaphragmatic hernia is a rare traumatic disease. The purpose of this article is to investigate the imaging characteristics and treatment strategies for traumatic diaphragmatic hernia with aortic dissection. CASE PRESENTATION: The imaging and clinical data of 3 patients with traumatic diaphragmatic hernia combined with aortic dissection were analyzed retrospectively. Of the three cases, two were males, and one was female; their mean age was 52.7 years (range, 47-62 years). Plain chest CT scans revealed diaphragmatic hernia in 2 patients, but no traumatic aortic dissection was found. Diaphragmatic hernia repair was performed in all patients. Aortic dilatation was found during intraoperative exploration, and aortic dissection was confirmed by postoperative enhanced CT. One patient underwent stent implantation and recovered smoothly (Case 1). The other patient refused stent implantation and died of thoracic hemorrhage (Case 2). The third patient underwent preoperative enhanced CT to identify traumatic diaphragmatic hernia with aortic dissection (Case 3). Aortic covered stent implantation was performed immediately, and diaphragmatic hernia repair was performed at a selected time. The patient's postoperative recovery was good. CONCLUSION: A preoperative plain chest CT scan indicated diaphragmatic hernia in major blunt thoracic trauma patients with a history of trauma and blurred periaortic spaces accompanied by hematocele and other imaging manifestations. Chest-enhanced CT should be performed to improve the diagnostic accuracy of aortic dissection.

Clinical analysis of laparoscopic treatment of chronic traumatic diaphragmatic hernia in 29 cases / 中华外科杂志

Objective: To examine the safety and effectiveness of laparoscopic individualized surgical treatment for chronic traumatic diaphragmatic hernia (CTDH). Methods: The clinical data and follow-up data of 29 CTDH cases admitted to the Qilu Hospital of Shandong University or the First Affiliated Hospital of Shandong First Medical University from June 2015 to January 2023 were retrospectively analyzed. There were 21 males and 8 females, aged (49.4±17.8) years (range: 19 to 79 years). The main clinical manifestations were symptoms of the digestive system and respiratory system, and only 4 cases were asymptomatic. All patients received laparoscopic treatment (conversion to open surgery was not excluded). Intraoperative exploration (location of the hernia, contents of the hernia, diameter of the hernia ring), surgical conditions (surgical repair plan, operation time, blood loss, postoperative complications) and postoperative follow-up were analyzed and discussed. Results: Laparoscopic repair was successfully completed in 27 cases, including simple suture in 6 cases, suture and patch repair in 17 cases, the anterior abdominal wall muscle flap reversal suture and patch repair of in 3 cases, and patch bridge repair in 1 case. The operation time was (112.8±44.7) minutes (range: 60 to 200 minutes). The amount of bleeding (M(IQR)) was 35 (58) ml (range: 10 to 300 ml). The other 2 patients were converted to laparotomy. Except for one patient with transverse colon strangulation necrosis who died of aggravated pulmonary infection after surgery, the remaining 28 patients were discharged successfully. The follow-up time was 36 (24) months (range: 1 to 60 months). During the follow-up period, only two patients had occasional left upper abdominal discomfort. Twenty-seven patients with left diaphragmatic hernia had no recurrence, and the symptoms of 1 patient with right diaphragmatic hernia were relieved. Conclusion: Customized laparoscopic surgical repair for CTDH according to the location and size of the diaphragmatic defect can achieve good surgical results.

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.

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.

[Diaphragmatic rupture and right ipsilateral intercostal hernia in chronic cough]. / Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë.

INTRODUCTION: We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. CASE REPORT: The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. CONCLUSION: These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

[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.

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.

Identification of Delayed Traumatic Diaphragmatic Injury: A Concise Review.

OBJECTIVE: To provide a concise review of the literature on both the difficulty and subtly of identifying a traumatic diaphragmatic hernia in the delayed phase of injury. DATA SOURCES: Source data were obtained from PubMed and Open Access Journals. STUDY SELECTION: Studies addressing traumatic diaphragmatic injury in the delayed phase of diaphragmatic injury. PubMed was searched using the MeSH term "delayed diaphragmatic rupture." DATA EXTRACTION: Relevant studies were reviewed and included on the basis of the preponderance of diaphragmatic injury cases that presented in the delayed phase. The following aspects of each study were identified, abstracted, and analyzed: study population, study design, methods, results, and relevant implications for practice. A few case studies were included to illustrate the importance of a careful medical history and patient evaluation necessary to identify a delayed diaphragmatic hernia presentation. DATA SYNTHESIS: Diaphragmatic herniation can occur days and weeks to decades after the initial trauma as a small diaphragmatic tear can evolve into a larger one over time. Follow-up after the acute phase is essential to assess for occult diaphragmatic injury and potential herniation. Meticulous patient history and evaluation are important considerations when the patient presents after the acute phase of injury with vague respiratory or abdominal complaints. During the triage phase of care, trauma nurses have an important role in assessing trauma history. CONCLUSIONS: The available evidence suggests that diaphragmatic injury should be on the differential list during and after trauma presentation for both providers and trauma nurses. Other critical injuries may portend a possible diaphragmatic injury. Diaphragmatic injury, though relatively rare, has high morbidity and mortality.