Diaphragmatic Hernia as a Long-Term Complication of Stab Wounds of the Chest Edmund Kessler, FCS(SA), Johannesburg, South Africa Archie Stein, FCS(SA), Johannesburg, South Africa
Diaphragmatic injury is a well known complication of penetrating wounds of the chest. Since diaphragmatic lacerations on the right side are usually sealed by the liver [I], the left-sided stab wounds have interested us more particularly. The stab wounds most likely to cause diaphragmatic injury were those occurring in the left lower quadrant of the chest and included anterior, posterior, and combined anteroposterior stab wounds. The immediate and remote events that follow injury to the diaphragm may be classified into three phases. (1) Initial or Acute Phase. Although this is the time when recognition and treatment is most likely to be successful, the injury is rarely diagnosed unless detected during laparotomy of thoracotomy in the treatment of visceral. injuries [2-41. (2) Znterd Phase. If the diaphragmatic hernia is not detected in the initial phase, it progresses into the interval phase. This phase may be completely asymptomatic if no herniation has occurred. Herniation may occur at this stage, with vague upper abdominal symptoms, and may only be detected on incidental radiology. This phase may vary’from a few months to many years [4]. (3) Obstructive Phase. This is the group of patients who present with either obstruction or strangulation that may occur within the first few weeks or many years later. This phase is associated with a mortality of 16 to 20 per cent [5-71 and a significant morbidity. With strangulation the mortality ranges from 25 to 66 per cent 141. The smaller defects are more likely to cause incarceration or strangulation of the gastrointestinal From the Department of Surgery, Saragwanath Hospital and the University of the Witwatersrand, Johannesburg, South Africa. Reprint requests should be addressed to Doctor E. Kessler, Department of Suroerv. - ~.Medical School, HosDital Hill. Johannesbura 2001. ReDublic of South Africa.
34
tract and account for 90 per cent of all strangulation of bowel occurring in the thorax [B]. This is consistent with the defect caused by a penetrating injury. Therefore, some authors have advocated early exploratory procedures in all patients with penetrating wounds of the left lower chest in whom the diaphragm is likely to be injured [9-1 I] as a prophylaxis against the possible subsequent development of a diaphragmatic hernia and its related complications. Because of the vast numbers of patients with penetrating stab wounds of the chest admitted to Baragwanath Hospital, we began this study of a more surgically active approach. Each year approximately 1,400 patients with penetrating stab wounds of the chest are admitted to Baragwanath Hospital. In the absence of cardiac tamponade, persistent uncontrolled hemorrhage or signs of intra-abdominal injury, management of stab wounds is essentially conservative. This includes intercostal drainage, intravenous fluid therapy, blood transfusion if necessary, antibiotics, analgesia, and physiotherapy. The vast majority of patients fall into this category and are thus treated conservatively with a short uneventful stay in hospital of two to three days. Stab wounds in the left lower chest constituted about 13.5 per cent of 1,000 consecutive cases of penetrating stab wounds of the chest which were analyzed to assess the frequency of penetrating stab wounds liable to cause diaphragmatic injury. This means that approximately 190 patients per year of a total 1,400 patients with stab wounds of the chest admitted annually to Baragwanath Hospital are liable to sustain diaphragmatic injury. In view of these findings, just how active should a surgeon be in terms of prophylaxis against the pos._ sible subsequent development of diaphragmatic
The American Journal ol Surgery
Diaphragmatic Hernia
hernia in patients with penetrating wounds of the lower chest in the absence of intra-abdominal signs of injury? Material In the one year period, May 1973 to April 1974, thirteen patients were treated for traumatic diaphragmatic hernia consequent to previous stab wounds of the chest. None of these patients was associated with clinical evidence of intra-abdominal trauma. The time interval between injury and admission to hospital with complication was twelve days in one patient, six to nine months in five patients, two to six years in six patients, and eleven years in one patient. The diagnosis of diaphragmatic injury was not made at the time of the original admission to hospital in twelve of the thirteen patients. The modes of presentation included intestinal obstruction in nine patients, acute abdomen in two patients, and respiratory symptoms in two patients. In only two patients were there obvious precipitating factors-one a pregnancy and the other a young male who had signs of intestinal obstruction after coitus one week prior to admission. Results Operative Findings. The operative approach was transthoracic in four patients and via the abdomen in nine. Generally, the size of the defects found in the diaphragm was small,ranging from 0.5 to 2 inches in diameter, a factor favoring strangulation. At opera-
tion no hernial sac was present in any of the thirteen patients. The viscera found to have herniated into the thoracic cavity at the time of operation were: small bowel (1 patient); colon only (9, of whom 5 had gangrenous bowel); colon and liver (1); colon, stomach, and small bowel (2);. and colon and stomach (1). In all thirteen patients the old stab wounds were situated in the left lower chest. Mortality. Of the thirteen patients, three died postoperatively, a mortality of 23 per cent. One had thoracic empyema after a thoracic approach and subsequent renal and respiratory failure. The other two patients died after laparotomy, one from bronchopneumonia with respiratory failure and the other died as a result of septicemia. Of these three patients, two had gangrenous bowel in the pleural cavity, and the patient who died of septicemia had a perforation of the cecum secondary to obstruction of the colon, resulting in fecal peritonitis. Complications. Of the surviving patients, one had renal failure, six had severe chest infections, and one had empyema with respiratory failure. Five of the twelve patients required bowel resection for large bowel gangrene. The young female in the series aborted in the immediate postoperative period. The
Volume 132, July 1976
perioperative complications were similar in both the thoracic and abdominal approaches in our series. In the chronic situation, the thoracic approach is preferable to the abdominal since it provides better exposure and avoids the hazards of blind reduction of viscera that may be adherent to the diaphragm, lung, or chest wall [8]. Radiology. Drews, Mercer, and Benfield [12] report a significant incidence of missed diagnoses of acute diaphragmatic injuries radiologically. This is corroborated by our own experience. The analysis of the chest x-ray films at the time of the first admission were interesting. In five patients the original x-ray films were not available because the patients were treated at other hospitals. Of the remaining eight patients, virtually all the chest x-ray films at the time of discharge showed some evidence of a small residual hemothorax. In fact, in one patient, after review of the x-ray films, a distinct fluid level is seen in both anteroposterior and lateral views. (Figures 1 and 2.1 The x-ray features suggestive or diagnostic of a diaphragmatic hernia are well illustrated in Figures 1 through 4. These features include diaphragmatic elevation (with or without pleural effusion), atelectasis with silhouetting of the ipsilateral diaphragm, evidence of air-filled or solid viscera above the diaphragm, and shift of the mediastinum [12-E]. These diagnostic features may be confirmed with contrast studies (Figures 2C and 4B) [16] and are clearly illustrated in our series. Comments
Some surgeons feel that the herniation occurs at the time of the initial injury, whereas others feel that it requires some factor which increases the intraabdominal pressure. In our series only two of the thirteen patients had a recognizable precipitating cause, namely pregnancy in one and coitus in the other. Most authors agree that small diaphragmatic tears, if not detected and repaired, will expand to become full-blown diaphragmatic hernias and that the small diaphragmatic hernias have a greater tendency to strangulation [8,16-181. Therefore, a variety of procedures are available to detect either the defect alone or the diaphragmatic hernia that might have developed on the first admission. In a large hernia the clinical features of lung compression and signs of tympany, dullness, or audible peristalsis in the lower chest leave little doubt as to the diagnosis. It is in those patients in whom the signs are more subtle or clinically absent that more sophisticated measures are necessary. Wilkinson [19]
35
Kessler and Stein
describes a method whereby diaphragmatic perforations can be detected radiologically by means of intra-abdominal carbon dioxide insufflation. This is done by flouroscopic examination of the patient in the erect position to determine the exact position of the diaphragm. However, .positive contrast peritoneography for accurate delineation of diaphragmatic abnormalities has been reported as providing better definition than negative contrast studies with air or gaseous insufflation into the abdomen [20]. The contrast medium used is meglumine diatrizoate in a volume dependent on patient’s weight. This in injected through the skin of the abdomen in the midline approximately 2 to 3 cm below the umbilicus with the patient supine. After the patient is positioned, a single posteroanterior x-ray is obtained 5 minutes after injection. Diagnostically, free spillage of the contrast medium from the peritoneum into the thoracic cavity or a sharp angle between the diaphragm proper and the abnormality suggests a ruptured diaphragm. Thoracoscopy has been suggested as a means of assessing the extent of injury at the time of admission. This has the disadvantage of being time-consuming in an ill patient, requires operating theater
facilities and general anesthesia, but despite this may still have a place. If on thoracoscopy a hernia or even a small laceration only is noted, then repair is mandatory. The easiest and least invasive technic is probably a barium meal contrast study just prior to discharge from hospital in all suspect cases, that is, when the chest x-ray film on discharge still shows some evidence of hemothorax or some abnormality of the left base [12]. The barium meal contrast study is aided by the use of metoclopramide (Maxolon), allowing rapid transit of the barium and a rapid follow-through sequence to be studied. Increasing the intra-abdominal pressure and placing the patient in the Trendelenberg position may aid in demonstrating a suspected hernia [8]. A more active diagnostic approach is recommended at the time of first admission in high risk patients (any patient with stab wound in the left chest from the fourth interspace to the level of the umbilicus) since these should be considered as potentially involving the diaphragm [12]. Although approximately 190 patients with stab wounds of the left lower chest are admitted per year to.Baragwanath Hospital, for the relatively small number of diaphragmatic hernias that present, surgical exploration
F&we I. Cam I. Lelt, straw x-ray chest Him at the d &#ry, showtng hl+mqmwmothorax wmBsubclltaneolls em@v-ma. A dbttnct tbkt kevd Is seen tn the M hemtthorax. RlgM, taterat I&W of chest. Fhdd tevel tn bowel clearly seen In the poster&x hem!#horax.
36
The American Joomal
of Surgery
Diaphragmatic Hernia
Figure 2A. Case Ii. Sfraighf x-ray chest film, showing pieurai efh&w at left base, air-filled vlscus above the diaphragm, and mediastinal shift.
as urged by some authors purely as a prophylaxis is probably unacceptable since a very large number of patients would have to undergo unnecessary exploration. However, the significant mortality and severe morbidity associated with subsequent diaphragmatic hernia and its complications, as reflected both in the literature and this series, certainly merits a more active diagnostic approach. We do not know at this stage how many of the 13.5 per cent (190 patients per year) eventually have complications, but this can be gauged on the basis of Benfield’s findings [3], in which 43 of a series of 765 patients (5.8 per cent) explored for thoracic or abdominal injury had diaphragmatic injuries at exploration. Stein [Z] found that of 242 patients undergoing laparotomy for penetrating abdominal wounds, 46 (19 per cent) had injury to the diaphragm. This relatively high incidence may be due to the fact that the diaphragm was examined very carefully at the time of laparotomy, which should be done in all instances of penetrating wounds submitted for laparotomy or thoracotomy. It is interesting that in all patients in whom diaphragmatic injury was detected at the time of laparotomy, no herniation of bowel into the chest was found at the time of operation. The diaphragmatic defect was an incidental finding during exploration of other visceral injuries. It is thus suggested that in view of the relatively low incidence of isolated diaphragmatic injury, but in view of the significant mortality and morbidity associated with subsequent diaphragmatic hernia, it is essential that all high risk patients-those with penetrating wounds of the left lower chest and left upper abdomen-be thoroughly investigated by
Volume 132, July IS76
Flpm, 26. Case Il. Lateral view of chest with obvious bowel in thorax.
F&e 2C. Case II. Confhmation of sphwic flaxure of co&n in left hemithorax on barium enema examination.
means of intra-abdominal carbon dioxide air insufflation, positive contrast peritoneography, barium contrast study, or even thoracoscopy in selected cases, prior to discharge from hospital rather than thoracotomy as recently suggested. The review of a large series of stab wounds of the chest admitted to Baragwanath Hospital suggests that a large number of patients would undergo unnecessary thoracotomy if a policy of prophylactic exploration were undertaken in a21patients with left lower chest stab wounds.
37
Kessler and Stein
Figure 3. Case lit. Lateral view of chest with transverse colon in iafi hemithorax.
Figure 48. Case IV. Barium meal examination showing contrast in the stomach quite separate from the air-filled colon above the diaphragm. Note air in the wail of the supradiaphragmatic colon as evidence of gangrene.
38
Figure 4A. Case IV. Straight chest x-ray film, showing diaphragmatic obitteration and pleural effusion with pneumonia. The pleural eHusion was tapped in the Medical Unit with aspiration of fecal material.
_’ Figure 4C. Case IV. Air in colon wail on lateral x-ray film as further evidence of strangulation of bowel.
The Amerhn
Journal ot SurwY
Diaphragmatic
Summary
The suggestion that early exploratory operation be performed in all patients with stab wounds of the left lower chest in whom the diaphragm is likely to be injured is examined in detail. The incidence of stabs in this situation is reported on an analysis of 1,000 consecutive cases of stab wounds of the chest. Thirteen cases of diaphragmatic hernia as a longterm complication of stab wounds of the chest are discussed. Acknowledgment: We gratefully acknowledge the advice and encouragement of Professors D. J. du Plessis and H. H. Lawson in the preparation of this paper.
References Wise L, Connors J, Hwant YH, Anderson C: Traumatic injuries to the diaphragm. J Trauma 13: 946,1973. Stein A: Selective conservatism in the management of abdominal trauma. S AfrJ Surg IO: 225, 1972. Grimes OF: Traumatic injuries of the diaphmgm. Am J Swg 126: 175,1974. Benfield JR: In discussion of [ 31.
Hernia
5. Noon GA, Beak AC Jr, DeBakey MF: Surgical management of traumatic rupture of the diaphragm. J Trauma 6: 344, 1966. 6. Hood RM: Traumatic diaphragmatic hernia. Am Thorac Surg 12: 311, 1971. 7. Hill LD: Injuries of the diaphragm following blunt trauma. Surg C/in North Am 52: 611, 1972. 8. Sanford MC, Stafford ES: Diaphragmatic hernia caused by trauma. Diagnosis and treatment. PostgradMed 19: 60,1956. 9. Naclerio EA: In discussion of: Diagnostic problems in traumatic diaphragmatic hernia. NY State J Med 73: 1289, s 1973. IO. Gourin A. Garzon AA: Diagnostic problems in traumatic diaphragmatic hernia. J Trauma 14: 20, 1974. 11. Keen G: Chest injuries. Ann R Co/l Surg Engl54: 124, 1974. 12. Drews JA, Mercer EC, Benfield JR: Acute diaphragmatic injuries. Ann Thorac Surg 16: 67, 1973. 13. Klok PA: Diaphragmatic rupture following indirect trauma. Stand J Thorac Cardiovasc Surg 1: 2 12, 1967. 14. Lavender JP, Potts DG, Differential diagnosis of elevated right diaphragmatic dome. Br J Radio/ 32: 56, 1959. 15. Pomerantz M, Rodgers BM, Sabiston DC: Traumatic diaphragmatic hernia. Surgery 64: 529, 1968. 16. Gravier L, Freeark RJ: Traumatic diaphragmatic hernia. Arch Surg 86: 33, 1963. 17. Blades B: Ruptured diaphragm. Am J Surg 105: 50 1, 1963. 18. Carter R, Brewer LA Ill: Strangulating diaphragmatic hernia. Ann Thorac Surg 12: 281, 1971. 19. Wilkinson AE: Abdominal injuries. S Afr J Surg 11: 217, 1973. 20. White JJ, 0 KS, Hailer JA: Positive-contrast peritoneography for accurate delineation of diaphragmatic abnormalities. Surgery 76: 390, 1974.
39
Diaphragmatic injury is a well known complication of penetrating wounds of the chest. Since diaphragmatic lacerations on the right side are usually sealed by the liver [I], the left-sided stab wounds have interested us more particularly. The stab wounds most likely to cause diaphragmatic injury were those occurring in the left lower quadrant of the chest and included anterior, posterior, and combined anteroposterior stab wounds. The immediate and remote events that follow injury to the diaphragm may be classified into three phases. (1) Initial or Acute Phase. Although this is the time when recognition and treatment is most likely to be successful, the injury is rarely diagnosed unless detected during laparotomy of thoracotomy in the treatment of visceral. injuries [2-41. (2) Znterd Phase. If the diaphragmatic hernia is not detected in the initial phase, it progresses into the interval phase. This phase may be completely asymptomatic if no herniation has occurred. Herniation may occur at this stage, with vague upper abdominal symptoms, and may only be detected on incidental radiology. This phase may vary’from a few months to many years [4]. (3) Obstructive Phase. This is the group of patients who present with either obstruction or strangulation that may occur within the first few weeks or many years later. This phase is associated with a mortality of 16 to 20 per cent [5-71 and a significant morbidity. With strangulation the mortality ranges from 25 to 66 per cent 141. The smaller defects are more likely to cause incarceration or strangulation of the gastrointestinal From the Department of Surgery, Saragwanath Hospital and the University of the Witwatersrand, Johannesburg, South Africa. Reprint requests should be addressed to Doctor E. Kessler, Department of Suroerv. - ~.Medical School, HosDital Hill. Johannesbura 2001. ReDublic of South Africa.
34
tract and account for 90 per cent of all strangulation of bowel occurring in the thorax [B]. This is consistent with the defect caused by a penetrating injury. Therefore, some authors have advocated early exploratory procedures in all patients with penetrating wounds of the left lower chest in whom the diaphragm is likely to be injured [9-1 I] as a prophylaxis against the possible subsequent development of a diaphragmatic hernia and its related complications. Because of the vast numbers of patients with penetrating stab wounds of the chest admitted to Baragwanath Hospital, we began this study of a more surgically active approach. Each year approximately 1,400 patients with penetrating stab wounds of the chest are admitted to Baragwanath Hospital. In the absence of cardiac tamponade, persistent uncontrolled hemorrhage or signs of intra-abdominal injury, management of stab wounds is essentially conservative. This includes intercostal drainage, intravenous fluid therapy, blood transfusion if necessary, antibiotics, analgesia, and physiotherapy. The vast majority of patients fall into this category and are thus treated conservatively with a short uneventful stay in hospital of two to three days. Stab wounds in the left lower chest constituted about 13.5 per cent of 1,000 consecutive cases of penetrating stab wounds of the chest which were analyzed to assess the frequency of penetrating stab wounds liable to cause diaphragmatic injury. This means that approximately 190 patients per year of a total 1,400 patients with stab wounds of the chest admitted annually to Baragwanath Hospital are liable to sustain diaphragmatic injury. In view of these findings, just how active should a surgeon be in terms of prophylaxis against the pos._ sible subsequent development of diaphragmatic
The American Journal ol Surgery
Diaphragmatic Hernia
hernia in patients with penetrating wounds of the lower chest in the absence of intra-abdominal signs of injury? Material In the one year period, May 1973 to April 1974, thirteen patients were treated for traumatic diaphragmatic hernia consequent to previous stab wounds of the chest. None of these patients was associated with clinical evidence of intra-abdominal trauma. The time interval between injury and admission to hospital with complication was twelve days in one patient, six to nine months in five patients, two to six years in six patients, and eleven years in one patient. The diagnosis of diaphragmatic injury was not made at the time of the original admission to hospital in twelve of the thirteen patients. The modes of presentation included intestinal obstruction in nine patients, acute abdomen in two patients, and respiratory symptoms in two patients. In only two patients were there obvious precipitating factors-one a pregnancy and the other a young male who had signs of intestinal obstruction after coitus one week prior to admission. Results Operative Findings. The operative approach was transthoracic in four patients and via the abdomen in nine. Generally, the size of the defects found in the diaphragm was small,ranging from 0.5 to 2 inches in diameter, a factor favoring strangulation. At opera-
tion no hernial sac was present in any of the thirteen patients. The viscera found to have herniated into the thoracic cavity at the time of operation were: small bowel (1 patient); colon only (9, of whom 5 had gangrenous bowel); colon and liver (1); colon, stomach, and small bowel (2);. and colon and stomach (1). In all thirteen patients the old stab wounds were situated in the left lower chest. Mortality. Of the thirteen patients, three died postoperatively, a mortality of 23 per cent. One had thoracic empyema after a thoracic approach and subsequent renal and respiratory failure. The other two patients died after laparotomy, one from bronchopneumonia with respiratory failure and the other died as a result of septicemia. Of these three patients, two had gangrenous bowel in the pleural cavity, and the patient who died of septicemia had a perforation of the cecum secondary to obstruction of the colon, resulting in fecal peritonitis. Complications. Of the surviving patients, one had renal failure, six had severe chest infections, and one had empyema with respiratory failure. Five of the twelve patients required bowel resection for large bowel gangrene. The young female in the series aborted in the immediate postoperative period. The
Volume 132, July 1976
perioperative complications were similar in both the thoracic and abdominal approaches in our series. In the chronic situation, the thoracic approach is preferable to the abdominal since it provides better exposure and avoids the hazards of blind reduction of viscera that may be adherent to the diaphragm, lung, or chest wall [8]. Radiology. Drews, Mercer, and Benfield [12] report a significant incidence of missed diagnoses of acute diaphragmatic injuries radiologically. This is corroborated by our own experience. The analysis of the chest x-ray films at the time of the first admission were interesting. In five patients the original x-ray films were not available because the patients were treated at other hospitals. Of the remaining eight patients, virtually all the chest x-ray films at the time of discharge showed some evidence of a small residual hemothorax. In fact, in one patient, after review of the x-ray films, a distinct fluid level is seen in both anteroposterior and lateral views. (Figures 1 and 2.1 The x-ray features suggestive or diagnostic of a diaphragmatic hernia are well illustrated in Figures 1 through 4. These features include diaphragmatic elevation (with or without pleural effusion), atelectasis with silhouetting of the ipsilateral diaphragm, evidence of air-filled or solid viscera above the diaphragm, and shift of the mediastinum [12-E]. These diagnostic features may be confirmed with contrast studies (Figures 2C and 4B) [16] and are clearly illustrated in our series. Comments
Some surgeons feel that the herniation occurs at the time of the initial injury, whereas others feel that it requires some factor which increases the intraabdominal pressure. In our series only two of the thirteen patients had a recognizable precipitating cause, namely pregnancy in one and coitus in the other. Most authors agree that small diaphragmatic tears, if not detected and repaired, will expand to become full-blown diaphragmatic hernias and that the small diaphragmatic hernias have a greater tendency to strangulation [8,16-181. Therefore, a variety of procedures are available to detect either the defect alone or the diaphragmatic hernia that might have developed on the first admission. In a large hernia the clinical features of lung compression and signs of tympany, dullness, or audible peristalsis in the lower chest leave little doubt as to the diagnosis. It is in those patients in whom the signs are more subtle or clinically absent that more sophisticated measures are necessary. Wilkinson [19]
35
Kessler and Stein
describes a method whereby diaphragmatic perforations can be detected radiologically by means of intra-abdominal carbon dioxide insufflation. This is done by flouroscopic examination of the patient in the erect position to determine the exact position of the diaphragm. However, .positive contrast peritoneography for accurate delineation of diaphragmatic abnormalities has been reported as providing better definition than negative contrast studies with air or gaseous insufflation into the abdomen [20]. The contrast medium used is meglumine diatrizoate in a volume dependent on patient’s weight. This in injected through the skin of the abdomen in the midline approximately 2 to 3 cm below the umbilicus with the patient supine. After the patient is positioned, a single posteroanterior x-ray is obtained 5 minutes after injection. Diagnostically, free spillage of the contrast medium from the peritoneum into the thoracic cavity or a sharp angle between the diaphragm proper and the abnormality suggests a ruptured diaphragm. Thoracoscopy has been suggested as a means of assessing the extent of injury at the time of admission. This has the disadvantage of being time-consuming in an ill patient, requires operating theater
facilities and general anesthesia, but despite this may still have a place. If on thoracoscopy a hernia or even a small laceration only is noted, then repair is mandatory. The easiest and least invasive technic is probably a barium meal contrast study just prior to discharge from hospital in all suspect cases, that is, when the chest x-ray film on discharge still shows some evidence of hemothorax or some abnormality of the left base [12]. The barium meal contrast study is aided by the use of metoclopramide (Maxolon), allowing rapid transit of the barium and a rapid follow-through sequence to be studied. Increasing the intra-abdominal pressure and placing the patient in the Trendelenberg position may aid in demonstrating a suspected hernia [8]. A more active diagnostic approach is recommended at the time of first admission in high risk patients (any patient with stab wound in the left chest from the fourth interspace to the level of the umbilicus) since these should be considered as potentially involving the diaphragm [12]. Although approximately 190 patients with stab wounds of the left lower chest are admitted per year to.Baragwanath Hospital, for the relatively small number of diaphragmatic hernias that present, surgical exploration
F&we I. Cam I. Lelt, straw x-ray chest Him at the d &#ry, showtng hl+mqmwmothorax wmBsubclltaneolls em@v-ma. A dbttnct tbkt kevd Is seen tn the M hemtthorax. RlgM, taterat I&W of chest. Fhdd tevel tn bowel clearly seen In the poster&x hem!#horax.
36
The American Joomal
of Surgery
Diaphragmatic Hernia
Figure 2A. Case Ii. Sfraighf x-ray chest film, showing pieurai efh&w at left base, air-filled vlscus above the diaphragm, and mediastinal shift.
as urged by some authors purely as a prophylaxis is probably unacceptable since a very large number of patients would have to undergo unnecessary exploration. However, the significant mortality and severe morbidity associated with subsequent diaphragmatic hernia and its complications, as reflected both in the literature and this series, certainly merits a more active diagnostic approach. We do not know at this stage how many of the 13.5 per cent (190 patients per year) eventually have complications, but this can be gauged on the basis of Benfield’s findings [3], in which 43 of a series of 765 patients (5.8 per cent) explored for thoracic or abdominal injury had diaphragmatic injuries at exploration. Stein [Z] found that of 242 patients undergoing laparotomy for penetrating abdominal wounds, 46 (19 per cent) had injury to the diaphragm. This relatively high incidence may be due to the fact that the diaphragm was examined very carefully at the time of laparotomy, which should be done in all instances of penetrating wounds submitted for laparotomy or thoracotomy. It is interesting that in all patients in whom diaphragmatic injury was detected at the time of laparotomy, no herniation of bowel into the chest was found at the time of operation. The diaphragmatic defect was an incidental finding during exploration of other visceral injuries. It is thus suggested that in view of the relatively low incidence of isolated diaphragmatic injury, but in view of the significant mortality and morbidity associated with subsequent diaphragmatic hernia, it is essential that all high risk patients-those with penetrating wounds of the left lower chest and left upper abdomen-be thoroughly investigated by
Volume 132, July IS76
Flpm, 26. Case Il. Lateral view of chest with obvious bowel in thorax.
F&e 2C. Case II. Confhmation of sphwic flaxure of co&n in left hemithorax on barium enema examination.
means of intra-abdominal carbon dioxide air insufflation, positive contrast peritoneography, barium contrast study, or even thoracoscopy in selected cases, prior to discharge from hospital rather than thoracotomy as recently suggested. The review of a large series of stab wounds of the chest admitted to Baragwanath Hospital suggests that a large number of patients would undergo unnecessary thoracotomy if a policy of prophylactic exploration were undertaken in a21patients with left lower chest stab wounds.
37
Kessler and Stein
Figure 3. Case lit. Lateral view of chest with transverse colon in iafi hemithorax.
Figure 48. Case IV. Barium meal examination showing contrast in the stomach quite separate from the air-filled colon above the diaphragm. Note air in the wail of the supradiaphragmatic colon as evidence of gangrene.
38
Figure 4A. Case IV. Straight chest x-ray film, showing diaphragmatic obitteration and pleural effusion with pneumonia. The pleural eHusion was tapped in the Medical Unit with aspiration of fecal material.
_’ Figure 4C. Case IV. Air in colon wail on lateral x-ray film as further evidence of strangulation of bowel.
The Amerhn
Journal ot SurwY
Diaphragmatic
Summary
The suggestion that early exploratory operation be performed in all patients with stab wounds of the left lower chest in whom the diaphragm is likely to be injured is examined in detail. The incidence of stabs in this situation is reported on an analysis of 1,000 consecutive cases of stab wounds of the chest. Thirteen cases of diaphragmatic hernia as a longterm complication of stab wounds of the chest are discussed. Acknowledgment: We gratefully acknowledge the advice and encouragement of Professors D. J. du Plessis and H. H. Lawson in the preparation of this paper.
References Wise L, Connors J, Hwant YH, Anderson C: Traumatic injuries to the diaphragm. J Trauma 13: 946,1973. Stein A: Selective conservatism in the management of abdominal trauma. S AfrJ Surg IO: 225, 1972. Grimes OF: Traumatic injuries of the diaphmgm. Am J Swg 126: 175,1974. Benfield JR: In discussion of [ 31.
Hernia
5. Noon GA, Beak AC Jr, DeBakey MF: Surgical management of traumatic rupture of the diaphragm. J Trauma 6: 344, 1966. 6. Hood RM: Traumatic diaphragmatic hernia. Am Thorac Surg 12: 311, 1971. 7. Hill LD: Injuries of the diaphragm following blunt trauma. Surg C/in North Am 52: 611, 1972. 8. Sanford MC, Stafford ES: Diaphragmatic hernia caused by trauma. Diagnosis and treatment. PostgradMed 19: 60,1956. 9. Naclerio EA: In discussion of: Diagnostic problems in traumatic diaphragmatic hernia. NY State J Med 73: 1289, s 1973. IO. Gourin A. Garzon AA: Diagnostic problems in traumatic diaphragmatic hernia. J Trauma 14: 20, 1974. 11. Keen G: Chest injuries. Ann R Co/l Surg Engl54: 124, 1974. 12. Drews JA, Mercer EC, Benfield JR: Acute diaphragmatic injuries. Ann Thorac Surg 16: 67, 1973. 13. Klok PA: Diaphragmatic rupture following indirect trauma. Stand J Thorac Cardiovasc Surg 1: 2 12, 1967. 14. Lavender JP, Potts DG, Differential diagnosis of elevated right diaphragmatic dome. Br J Radio/ 32: 56, 1959. 15. Pomerantz M, Rodgers BM, Sabiston DC: Traumatic diaphragmatic hernia. Surgery 64: 529, 1968. 16. Gravier L, Freeark RJ: Traumatic diaphragmatic hernia. Arch Surg 86: 33, 1963. 17. Blades B: Ruptured diaphragm. Am J Surg 105: 50 1, 1963. 18. Carter R, Brewer LA Ill: Strangulating diaphragmatic hernia. Ann Thorac Surg 12: 281, 1971. 19. Wilkinson AE: Abdominal injuries. S Afr J Surg 11: 217, 1973. 20. White JJ, 0 KS, Hailer JA: Positive-contrast peritoneography for accurate delineation of diaphragmatic abnormalities. Surgery 76: 390, 1974.
39
