EDITORIALS

Blunt Traumatic Rupture of the Diaphragm Panagiotis N. Symbas, M.D.

isting injuries or are minimal or absent, the possibility of diaphragmatic rupture must be considered carefully in all patients who suffer blunt, particularly major, trauma. Chest roentgenography is the best screening test. Obscure or abnormal diaphragmatic shadow, unusual air fluid levels, pneumothorax or hemopneumothorax, or a combination of these, with or without mediastinal shifting, all strongly suggest diaphragmatic rupture [4, 6 , 71. Also, a change in the diaphragmatic shadow several days or weeks after injury may be due to diaphragmatic rupture since abdominal viscera do not always herniate into the thorax when the injury occurs. In patients with signs of intraperitoneal or intrathoracic injury indicating the necessity for exploratory laparotomy or thoracotomy, other diagnostic tests for diaphragmatic rupture are not indicated and may be hazardous. In such patients, the diaphragm should be carefully inspected during the exploratory procedure. In the majority of patients not requiring emergency exploratory operation, the introduction of pneumoperitoneum establishes the diagnosis when pneumothorax or pneumopericardium is demonstrated on a repeat chest roentgenogram [l]. This test, however, has some disadvantages. In addition to the two minor disadvantages mentioned by Brooks, it may be falsely negative in rare cases when the diaphragmatic defect is obliterated by the herniated organs, and it may not be helpful when an intrapleural air leak from lung injury is present or when there is a chest tube connected to suction. When the diagnosis cannot be definitely excluded by pneumoperitoneum, barium studies of the upper and lower gastrointestinal tract are indicated. In patients with chronic rupture of the diaphragm, the diagnostic accuracy of pneumoperitoneum is greatly decreased because the diaphragmatic defect is From the Joseph B. Whitehead Department of Surgery, more frequently obliterated by adhesions beThoracic and CardiovascularSurgery Division, Emory University School of Medicine, and Grady Memorial Hospital, tween the herniated organs and the diaphragm. Atlanta, GA 30303. In these patients, barium studies of the gasWith the advent of high-speed vehicular travel, the number of patients injured in highway accidents has increased. These traumatized patients can receive many injuries, among them diaphragmatic rupture, which frequently is obscured by other injuries or may be asymptomatic. The timely article by Brooks (p 199, this issue) calls attention to the presence of this often obscured and serious injury. The type of trauma causing tear of the diaphragm ranges from minimal blunt to massive crushing injury. The tear usually occurs in the left diaphragm in the posterior central area and extends medially, but avulsion of the diaphragm from the rib cage may be found [3, 51. Because of the significant pressure gradient between thoracic and peritoneal cavities, particularly during inspiration, and the absence of a hernial sac in patients with diaphragmatic rupture, progressive abdominal visceral h’erniation into the thorax frequently occurs. Depending on the size of the diaphragmatic opening, the abdominal viscera may or may not become strangulated. During the acute postinjury period, the symptoms and signs of diaphragmatic injury vary depending on the magnitude of herniation of abdominal organs in the pleural space and the presence or absence of impairment of perfusion of the herniated organs. The patient may have no symptoms of diaphragmatic injury or may have symptoms and signs of varying degrees of cardiorespiratory impairment. Less frequently, there may be symptoms and signs of intestinal obstruction or strangulation. The common clinical manifestations of chronic diaphragmatic rupture are those of intestinal obstruction or strangulation and less commonly those of respiratory embarrassment. Because the symptoms of diaphragmatic injury either are often obscured by other coex-

193 0003-4975/78/0026-0301$01.00 @ 1978 by Panagiotis N. Symbas

194 The Annals of Thoracic Surgery Vol 26

No 3 September 1978

trointestinal tract are usually required for confirmation of chronic diaphragmatic rupture. The treatment for diaphragmatic injury is surgical repair. The decision, however, as to when and how a corrective procedure should be undertaken is somewhat controversial. Because of the danger of development or progression of respiratory embarrassment, visceral incarceration, or strangulation, repair of the diaphragmatic injury should be performed as soon as possible after the diagnosis is established and when the patient’s clinical condition permits. Although the diaphragm can be best exposed through the chest, the approach chosen should be based on the clinical conditions in each patient. During the acute postinjury period, in patients with intrathoracic or intraabdominal injuries, the diaphragmatic rupture is repaired through the incision, thoracic or abdominal, used for the emergency repair of other organ injuries. However, in patients with no trauma to other organs requiring surgical care, the diaphragmatic repair should be done through the chest. Similarly, in patients with chronic diaphragmatic repair is easier to do through the through the chest because in most of these patients, the herniated viscera are adherent to the lung. During repair, when access to both the abdominal and thoracic cavity is needed, two

separate incisions rather than a thoracoabdominaI one should be made because of the high morbidity of the thoracoabdominal incision. For this reason, both the lower thorax and upper abdomen should be prepared and draped in the field so that if the chosen incision proves to be insufficient for a safe repair of the diaphragmatic or other organ injury, an additional incision can be made. Diaphragmatic repair in the vast majority of patients can be done primarily, although occasionally a prosthesis may be needed [2].

References 1. Clay RC, Hanlon CR: Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. J Thorac Cardiovasc Surg 21:57, 1951 2. Ebert PA, Gaertner RA, Zuidema GD: Traumatic diaphragmatic hernia. Surg Gynecol Obstet 125:59, 1967 3. Epstein LI, Lempke RE: Rupture of the right hemidiaphragm due to blunt trauma. J Trauma 8:19, 1968 4. Gibson FS: The diagnosis of diaphragmatic hernia with acute obstruction. JAMA 93:719, 1929 5. Hood RM: Traumatic diaphragmatic hernia. Ann Thorac Surg 12:311, 1971 6. Peck WA Jr: Right-sided diaphragmatic liver hernia following trauma. Am J Roentgen01 78:99,1957 7. Sutton JP, Carlisle RB, Stephenson SE Jr: Traumatic diaphragmatic hernia: a review of 25 cases. Ann Thorac Surg 3:136, 1967

Blunt traumatic rupture of the diaphragm.

EDITORIALS Blunt Traumatic Rupture of the Diaphragm Panagiotis N. Symbas, M.D. isting injuries or are minimal or absent, the possibility of diaphrag...
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