7 years-delayed presentation of a traumatic diaphragmatic rupture: laparoscopic repair
© Aprea et al; licensee BioMed Central Ltd. 2013
Published: 16 September 2013
Post-traumatic diaphragmatic hernias(PDH) are possible complications of blunt and penetrating thoracic or abdominal trauma. These hernias may be diagnosed at the time of the initial trauma, but are sometimes recognized only after several months or years during examinations for their related symptoms. We here present the case of a patient in which diagnosis was obtained only after 7 years from the accident and for which a successful laparoscopic repair of the hernia was performed.
Traumatic diaphragmatic rupture is a possible life-threatening condition that occurs up to 5% of major thoraco-abdominal traumas. This kind of injury is sometimes diagnosed at the time of the initial trauma referral due to its acute presentation, but sometimes it can escape detection, especially if occurring as an isolated injury. Symptoms such as dyspnea, non-cardiac chest pain, and vasovagal symptoms may start the workup, but PDHs are sometimes discovered incidentally in apparent complete wellness. We here report the case of a massive PDH discovered incidentally during examination for an apparently not related condition.
Traumatic diaphragmatic rupturecan go unrecognized at the initial injury and present, in adelayed case, months or even years after the event. Left-sided diaphragmatic ruptures occur three timesmore frequently than right-sided ruptures, since the leftdiaphragm is structurally weaker, as it originates from thepleuro-peritoneal membrane. Right-sided rupture is seen lessfrequently because of the buffering effect of the liver. There is no radiologic gold standard to diagnose a traumaticdiaphragmatic rupture. Chest X-rays may show obliterationof the diaphragmatic shadow or elevation of the diaphragm, but up to 50% of the initial chest X-rayscan be non-diagnostic. CT scan is the preferred diagnosticmodality in cases of suspected diaphragmatic rupture with a 61% sensitivity and 87% specificity. Other diagnostic techniques suchas ultrasound and upper gastrointestinal (GI) contrast studyare not used routinely.
The first successful diaphragmatic repair wasreported by Riolfi in 1886. The surgical treatmentincludes hernia reduction, pleural drainage, and repair of thediaphragmatic tear. Diaphragmatic repair may be performedeither via laparotomy or thoracotomy or via laparoscopy orthoracoscopy. Due to the hemodynamic and respiratory stability of the patient we preferredlaparoscopy for the repair of the diaphragmaticrupture in the presented case. Most authors recommendclosing of the diaphragmatic defect with non-absorbablesutures or with a patch for large defects. We chose a combined approach to the diaphragmatic rupture( sutures plus mesh);no pleural drainage was applied.
Diaphragmatic rupture may be a not very uncommon complication of significant thoraco-abdominal trauma. Clinical presentation may be subtle, delayedand non-specific. Although plain chest radiography may be helpful inestablishing diagnosis in most cases, computedtomography (CT) is a better diagnostic choice; MRI may add important details of the diaphragmatic defect. Thepotential life-threatening complications of massive diaphragmatic hernia mandate a promptrepair. A trans-abdominal approach is preferred for surgicalclosure, as it provides good access to the tear in the diaphragm. The treatment consists of closing the defect withnon-absorbable sutures or a patch. Our experience demonstrates laparoscopy as a safe procedure.
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