Delayed Presentation of Traumatic Diaphragmatic Hernia M. M. HEGARTY, F.R.C.S., J. V. BRYER, F.R.C.S., 1. B. ANGORN, F.R.C.S., L. W. BAKER, F.R.C.S.
Twenty-five patients with traumatic diaphragmatic hernia discovered at least five months after injury are described, of whom 18 were male and seven female. All but one hernia occurred on the left side. Stab wounds were the etiological factor in 22 patients and blunt trauma in three. The diagnosis was most often made by a chest or abdominal radiograph, but barium ingestion confirmed the diagnosis in ten patients. Intercostal drainage of gastric contents provided the diagnosis in two patients. In all nine patients initially approached by a thoracotomy or a thoracoabdominal incision, the hernia was easily reduced and the defect repaired. Although reduction and repair were easily accomplished by the abdominal route in seven patients, this approach was unsatisfactory or inadequate in six others. The colon and stomach were usually in the chest, and strangulation occurred in five patients. The mortality was 20% but rose to 80% when gangrene was present.
T RAUMATIC DIAPHRAGMATIC HERNIAS usually re-
sult from severe external blunt injury or penetrating injuries such as a knife or bullet wound. The hernias may be recognized during the period of hospitalization immediately following the trauma, the immediate type of hernia described by Carter et al.4 The mortality in this group is usually due to associated injuries which often mask the symptoms and signs of the hernia and delay diagnosis. During the past five years, 25 patients with traumatic diaphragmatic hernia presented at least five months after the diaphragmatic
injury. If the diaphragmatic injury is not recognized during the immediate posttraumatic period the patient may: 1) recover and remain symptom free, 2) suffer from chronic abdominal and/or chest symptoms, or 3) present with an acute crisis, often with signs of intestinal obstruction or strangulation. These were respectively described as the interval phase, the phase of obstruction and strangulation4 and more recently were grouped together as delayed presentation.19 With delayed presentation, the trauma which had occurred years previously may have been forgotten and the injury to the diaphragm may not be suspected. Thus, a delay in diagnosis may occur which, in the presence of obstruction and/or strangulation, is associated with a high mortality and morbidity. A careful history, examination, and awareness of the possibility of the condition and its complications are essential if these patients are to be managed successfully. Submitted for publication: November 22, 1977.
From the Department of Surgery, University of Natal, Durban, South Africa
Eighteen patients were male with a mean age of 34.2 years (range 20 to 58) and seven were female with a mean age of 24.4 years (range 21-41). The details are summarized in Table 1. All patients had been injured at least five months previously, and the longest interval between injury and presentation was eight years in a patient who had had laparotomy at the time of the original injury. Twenty-four hernias were on the left and only one on the right side. Penetrating trauma due to knife injury was the most common cause of diaphragmatic injury, occurring in 22 patients. Blunt trauma was responsible in three patients. Symptoms The symptoms in delayed presentation of traumatic diaphragmatic hernia are variable and are listed in Table 2. One patient had severe backache. X-ray revealed a markedly osteoporotic, kyphotic spine and, surprisingly, a hernia above the right diaphragm. Almost certainly the symptoms were due to the spinal pathology. Two other patients who had been completely symptom free following old chest injuries were admitted with further trauma to the trunk. The chest film showed a diaphragmatic hernia. These were attributed to recent injuries and it was not until the abdomen was entered that it was realized that the hernias had been present for a long time. Traumatic diaphragmatic hernias were discovered in five patients having investigations for chronic upper abdominal symptoms. The remaining 17 patients presented as acute emergencies. Eight had signs and symptoms of intestinal obstruction with fluid levels in the bowel present in the abdominal film, while nine patients had upper abdominal pain, some of whom had associated dyspnoea and chest pain.
Diagnosis In 15 patients the diagnosis was made immediately, primarily because the chest film showed air or fluid levels (Figs. 1 and 2). One patient had an immediate laparotomy for intestinal obstruction and it was only
0003-4932-78-0800-0229-0075 ) J. B. Lippincott Company
HEGARTY AND OTHERS
Ann. Surg. a August 1978
TABLE 1. Patients
20-58 (av 34.1)
21-42 (av 24.4)
Etiology 1 crush 1 kick 1 fall 15 stab All stab
Time from Injury - Present
1 (R) 17 (L)
6 months to 5 years
5 months to 8 years
when the abdomen was opened that the diagnosis was made. Barium contrast studies were done in 11 patients, and the diagnosis was confirmed in ten (Figs. 3-5). It was overlooked in one patient with colonic herniation because the examination was terminated once the stomach had been shown to be below the diaphragm. The diagnosis was made at postmortem in two patients, both dying within 24 hours of admission, one with gangrenous stomach in the chest and the other with gangrenous colon. Thoracentesis was performed without adverse effect in two patients in the mistaken belief that a pneumothorax was present. The correct diagnosis was made when gastric contents were drained. Operation In two patients the diagnosis was made at postmortem, and one patient refused surgery. Of the remaining 22 patients, 13 were approached through an abdominal incision. Reduction of the hernia and repair of the defect were accomplished easily in seven of these patients. In one patient, difficulty in reducing the colon resulted in perforation of that organ requiring resection and transverse colostomy. The other five hernias, initially approached through an upper abdominal incision, could not be safely reduced until the incision was extended into the chest. Seven patients had a left thoracotomy only, and two had an immediate thoracoabdominal incision. Reduction and repair of the hernia were accomplished with ease in each patient (Table 3). In the patient who refused surgery, barium contrast studies showed colon to be present above the right hemidiaphragm. In this series, the viscus commonly found in the hernia was the colon, followed by stomach, small bowel and spleen (Table 4). Gangrene of the herniated organ was present in five patients. TABLE 2. Symptomatology
Chronic dyspepsia Acute symptoms Intestinal obstruction Upper abdominal or chest symptoms 9 Total
3 5 8
FIG. 1. P.A. chest radiograph showing (R) sided diaphragmatic hemia.
Results There were five deaths in the series of 25 patients (20%). Two died within 24 hours of admission without undergoing operation, and both had gangrenous viscera within the chest. One patient in whom the diagnosis was made on admission had immediate colonic resection for gangrene of the herrriated viscus. Empyema developed and the patient subsequently succumbed. One patient was operated for intestinal obstruction and an unsuspected hernia was discovered, with colon and small bowel in the chest. The gangrenous small bowel was resected and in the colon, a constriction ring of dubious viability was oversewn. This broke down to produce a fecal fistula and the patient eventually died after two further operations on the fistula. The remaining death occurred when the colon was entered during reduction of the hernia with resulting gross pleural and peritoneal contamination.
Discussion Injuries to the diaphragm may be followed by immediate herniation of abdominal viscera into the chest. However, it is widely accepted that herniation may be delayed.8'15 and Desforges et al.6 record a patient found to have stomach within the chest six years after an accident. A barium study done four years pre-
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DELAYED HERNIA No.
viously had shown the stomach to be in its normal intra-abdominal position. Recognition of a traumatic diaphragmatic hernia in the immediate posttraumatic period is difficult, due to associated injuries and to the fact that several radiological features suggestive of hernia may mimic those of chest injuries. These hernias may present months or even many years after apparent recovery from the traumatic incident. Occasionally, such patients are symptom free and their hernias are found on a routine chest film. The majority, however, have symptoms which vary according to the organ present within the chest6 and whether or not that organ is strangulated or obstructed.4 Drews et al.7 found a 5.8% incidence of diaphragmatic injury in 765 operations for trauma, a figure
FIG. 3. Barium meal clearly showing an "hour glass" deformity of stomach, containing barium in the intra-abdominal part of the viscus, but only air and a trickle of barium above. ~~~~~~~~...1.
similar to the present experience. These authors state that any defect not repaired may result in hernia as in ME ~~~~~~~oneof the present patients. Like Ebert et al. ,8 they stress that laparotomy should include careful inspection of the diaphragm for any defects which, if present, should be repaired. There remain a significant num.ber of patients with abdominal wounds who do not require surgery, and the majority of patients with stabbed chests require only observation and/or simple under _A water drainage." Jackson et al.4 suggested that pa~~~~ ~~~~~~ ~ ~~tients with penetrating injuries below the fourth inter~~~~ ~~~~~~ ~~costal space on the left side should have routine thoracoscopy to identify those with diaphragmatic injury. More interesting is the suggestion that patients with chest wounds in that situation should have routine intra-abdominal lavage, when the diaphragmatic injury would be demonstrated blood in the reviewof27 byhaied returning Ingsto tha fluid. right.side isteroesmgpS As in all other series, males greatly outnumbered females,7'8"6'19 and the rarity of these henmias on the ...........rg side s. also ev FIG. 2. Lateral chest radiograph showing air fluid level in the patients with traumatic diaphragmatic hernia, Hood13 found only 13% on the right side. This is probably due stomach, above the (L) hemidiaphragm.
HEGARTY AND OTHERS
Ann. Surg. v August 1978
levels on abdominal films or upper abdominal and/or chest pain with vomiting and dyspnoea. The differential diagnosis includes cholecystitis, pancreatitis, exacerbation of a peptic ulcer, myocardial infarction, pneumonia or even pneumothorax, which may result in the patient having the "pneumothorax" drained into underwater drainage bottles, as occurred in two of the present patients. Although Bowditch's five diagnostic signs2 are widely quoted, Hardy'0 emphasizes that physical signs are of little aid unless the diagnosis is already suspected, and usually only in retrospect can the signs and the physical findings be related. Gravier and Freeark9 state that diaphragmatic hernia should be considered if any one of the following four criteria is present. 1) Intestinal obstruction and a history of past trauma. 2) Intestinal obstruction associated with radiological changes at the left base. 3) Small bowel obstruction in patients having no abdominal hernias or scars. 4) Large bowel obstruction in young patients. All authors agree that radiographic studies are the most useful diagnostic aids.' Plain films may show equivocal signs or signs that are only suggestive
FI G. 4. Barium follow through showing the small bowel within the chest.
to the liver
cushioning the diaphragm in blunt trauma and plugging the defect in the penetrating trauma. Most early series had a preponderance of hernias due to penetrating injuries, but recently motor vehicle and industrial accidents are the usual etiological factors." The nature of the trauma depends on the environment in which a particular hospital is situated. Three patients had been symptom free and were discovered only as the result of investigation for backache in one case and further traumatic incidents in two cases. It is possible that many patients with unrecognized traumatic diaphragmatic hernias remain symptom free, and it is only those with symptoms who return to the hospital. Few series include patients who were without symptoms.' There may be a role for routine chest films in patients with a history of a stab wound in the left lower chest or upper abdomen six months after
injury. Most patients with delayed presentation of traumatic diaphragmatic herias have acute symptoms. These may be those of classic intestinal obstruction with ab-
dominal pain and distention, vomiting, and fluid
Barium study showing both stomach and colon above the
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of diaphragmatic hernia.3 Drews et al.7 stress the diagnostic value of the chest film, but in their series, although abnormalities of the chest films were detected preoperatively in most patients, diaphragmatic hernia was not usually considered until the films had been viewed later by radiological specialists. Barium contrast studies were suggested to confirm the diagnosis in 22 of their 29 patients. The barium studies performed in 11 of the patients in the present series were of much value, and in the patient who failed to show the colon above the diaphragm, the examination was terminated before the large bowel had been outlined. In patients with suspected diaphragmatic hernia, contrast examination should continue until the whole of the alimentary tract has been demonstrated unless an abdominal organ is shown to be above the diaphragm. An abdominal film after the passage of a nasogastric tube may confirm the diagnosis,15 and the tube may also deflate an incarcerated stomach, with relief of intrapleural tension. Thoracentesis for diagnosis should be avoided because of the risk of fistula between the alimentary tract and the pleural space.20 However, Bernatz et al.' have suggested that thoracentesis may occasionally be helpful in the management of these patients, and it is likely that the life of one patient was saved by insertion of a chest tube into a hugely distended incarcerated stomach, which acted as a tension pneumothorax, with removal of 300 ml of fluid and a large amount of air. Once the diagnosis is made and the patient adequately resuscitated, operation is mandatory. Most authors agree that traumatic diaphragmatic hernias with delayed presentation should be approached through the chest,8'15 since the adhesions within the chest can be freed easily. The hernias were easily managed in only seven out of 13 patients approached through the abdomen. When the chest was opened either as the approach of choice or by extending the abdominal incision into the chest, reduction and repair of the hernia were easily accomplished. Therefore the approach in delayed presentation should be only by thoracotomy. If required, it can be extended into a thoracoabdominal incision. The stomach and colon are the organs most comTABLE 3. Initial Approach and Operative Difficulty*
Thoracotomy Thoracoabdominal Laparotomies
Operative Difficulty None None None
Tearing of bowel Reduction impossible without thoracotomy * Two patients had refused surgery.
diagnosis made post
233 TABLE 4. Herniated Viscera
Colon Stomach Small bowel Spleen
18 10 4 2
2 2 1
monly found within the chest.6'13 This is not surprising when their mobility and proximity to the diaphragm are considered. Gangrene of the herniated contents was present in five patients, with four deaths resulting. This confirms the finding of Hoffman12 and Christiansen et al.5 that strangulation of the herniated intestine is associated with mortality. This can be reduced by early diagnosis, adequate resuscitation, and immediate surgical management.
References 1. Bernatz, P. E., Burnside, A. F. and Clagett, 0. T.: Problem of the Ruptured Diaphragm. JAMA, 168:877, 1958. 2. Bowditch, H. I.: Diaphragmatic Hernia. Buffalo Med. J., 9: 65, 1853. 3. Bryer, J. V., Hegarty, M. M., Howe, C., et al.: Traumatic Diaphragmatic Hernias. Br. J. Surg. 65:69, 1978. 4. Carter, B. N., Guiseffi, J. and Felson, B.: Traumatic Diaphragmatic Hernia. Am. J. Roentgenol., 65:56, 1951. 5. Christiansen, L. A., Blichert-Toft, M. and Bertelsen, S.: Strangulated Diaphragmatic Hernia. A Clinical Study. Am. J. Surg., 129:574, 1975. 6. Desforges, G., Strieder, J. W., Lynch, J. P. and Madoff, I. M.: Traumatic Rupture of the Diaphragm. Clinical Manifestations and Surgical Treatment. J. Thorac. Surg., 34:779, 1957. 7. Drews, J. A., Mercer, E. C. and Benfield, J. R.: Acute Diaphragmatic Injuries. Ann. Thorac. Surg., 16:67, 1973. 8. Ebert, P. A., Gaertner, R. A. and Zuidema, G. D.: Traumatic Diaphragmatic Hernia. Surg. Gynecol. Obstet., 125:59, 1967. 9. Gravier, L. and Freeark, R. J.: Traumatic Diaphragmatic Hernia. Arch. Surg., 86:363, 1963. 10. Hardy, K. J.: Closed Traumatic Rupture of the Diaphragm. Aust. N.Z. J. Surg., 35:222, 1966. 11. Hegarty, M. M.: A Conservative Approach to Penetrating Injuries of the Chest. Experience with 131 Successive Cases. Injury, 8:53, 1976. 12. Hoffman, E.: Strangulated Diaphragmatic Hernias. Thorax, 23:541, 1969. 13. Hood, M.: Traumatic Diaphragmatic Hernia. Ann. Thorac. Surg., 12:311, 1971. 14. Jackson, A. M. and Ferreira, A. A.: Thoracoscopy as an Aid to the Diagnosis of Diaphragmatic Injury in Penetrating Wounds of the Left Lower Chest. A Preliminary Report. Injury, 7:213, 1975. 15. Orringer, M. B., Kirsh, M. M. and Swan, H.: Congenital Traumatic Diaphragmatic Hernia Exclusive of the Hiatus. Curr. Probl. Surg., March 1975. 16. Pomerantz, M., Rodgers, B. M. and Sabiston, D. C.: Traumatic Diaphragmatic Hernia. Surgery, 64:529, 1968. 17. Samaan, H. A.: Undiagnosed Traumatic Diaphragmatic Hernia. Br. J. Surg., 58:257, 1971. 18. Schwindt, W. D. and Gale, J. W.: Late Recognition and Treatment of Traumatic Diaphragmatic Hernias. Arch. Surg., 94:330, 1967. 19. Strug, B., Noon, G. P. and Beall, A. C.: Traumatic Diaphragmatic Hernia. Ann. Thorac. Surg., 17:444, 1974. 20. Sullivan, R. E.: Strangulation and Obstruction in Diaphragmatic Hernia due to Direct Trauma. Report of Two Cases and Review of the English Literature. J. Thorac. Cardiovasc. Surg., 52:725, 1966.