Strangulated Diaphragmatic Hernia A Clinical Study
L. A. Chrlstiansen, MD, Copenhagen, Denmark, M. Bllchert-Toft, MD, Copenhagen, Denmark S. Bertelsen, MD, Copenhagen, Denmark
Diaphragmatic hernia occurs most frequently at the site of the esophageal hiatus as a sliding hernia or paraesophageal hernia, less frequently through a traumatic defect or iatrogenic lesion, and rarely through a congenital posterolateral defect (Bochdalek) or substernal defect (Morgagni). In cases of hiatal and substernal hernia there is a hernial sac; this, however, is absent in cases of posterolateral and traumatic defects. Thus, herniation or prolapse of the abdominal organs, mesentery, and omentum may occur. In diaphragmatic hernia other than the sliding type, complications such as incarceration and/or strangulation, which may prove fatal, may supervene. Incarceration and strangulation are often erroneously used synonymously. In the present report we use the definitions of Skinner et al [I]. Incarceration is the term used for an irreducible hernia adherent to the hernial ring and surrounding structures without compromise of the vascular supply. The patient may be free of symptoms or present evidence of gastrointestinal obstruction, Strangulation is the term applied to an irreducible hernia with compromised venous and, possibly, arterial blood supply. In diaphragmatic hernia the. stomach often forms part of the hernial contents. When a considerable portion of the stomach is displaced into the mediastinum the result may be vo1vu1us, that is, rotation of the stomach at least 180 degrees causing obstruction of the cardia and the pylorus. Rotation of less than 180 degrees without obstruction is designated as incomplete volvulus. Rotation of the stomach around its longitudinal axis, From the Department of Thoracic Surgery, Rigshospitalet, Copenhagen, Denmark. Reprint requests should be addressed to L. A. Christiansen, MD. Da pariment of Surgical Gastroenterology C, Rigshospltelet, Copenhagen, Denmark.
574
called organoaxial vo1vu1us, is seen with greater frequency than is rotation around an axis perpendicular to the cardiopyloric line, called mesenterioaxial volvulus [Z]. Clinical Data No definitive symptoms characterize strangulated diaphragmatic hernia. However, a distinction can be made between local symptoms referable to the diaphragm, those referable to the pleural cavity, and those referable to the gastrointestinal tract. Pain in the chest is a constant symptom, predominantly caused by irritation of the diaphragm and pleura. Pain is localized in the lower half of the chest, the apex of the epigastrium, or both. The patient frequently complains of radiation of pain to the back and shoulder. Strangulation of the omentum provokes severe abdominal pain. Dyspnea is caused by compression atelectasis of various portions of the lungs secondary to the herniated abdominal organs and pleural exudate. Depending on which part of the gastrointestinal tract is herniated, there may be signs of high or low mechanical ileus. When the stomach is involved there often is bloody vomiting; however, when the cardioesophageal junction is blocked, which frequently occurs, only saliva is regurgitated. The patient is commonly febrile. When a complicating perforation of the strangulated viscus with empyema formation occurs, the patient becomes highly febrile and demonstrates signs of sepsis. As a rule, the diagnosis may be arrived at by radiologic study of the chest, which typically shows a dilated viscus with fluid level intrathoracically and a more or less blurred pulmonary area. X-ray study after a barium meal discloses herniation of
The American Journal of Surgery
Strangulated
Diaphragmatic
Figure IA and B. Case I. Roentgenograms of the chest shortly after the trauma show left-sided basal atektasis pleural exudate. Left diaphragmatic dome is indistinctly outlined.
Hernia
and
Figure 2. Case I. Roentgenogram three months aHer the trauma shows gastric gas over the left diaphragmatic dome, atelectasis, and pleural exudate.
the organs. The differential diagnoses are pneumothorax, pleural exudates of various types, and cyst or abscess of the lung. The treatment is emergency operation as soon as the fluid and electrolyte status of the patient permits. The approach can be either transthoracic or thoracoabdominal. In either case the hernial ring is slit to reduce the organs and remove all devitalized tissue. The diaphragm is closed with double interrupted silk sutures. Case Reports Within the past three years four patients with acute strangulation, two of whom had perforation, underwent operation in the department of thoracic surgery of Rigshospitalet. The case histories are briefly reported. Case I. The patient, a fifty-eight year old man, sustained blunt trauma in a car accident three months prior to admission to our department. The patient was admitted to his local hospital with bilateral fractures of the lower ribs. Treatment was conservative. Roentgenologic examination of the chest at that time showed both basal atelectasis and an indistinctly outlined diaphragmatic dome on the left, which persisted unchanged at discharge. (Figure 1A and B.) After discharge symptoms of gastritis developed with slight oppression in the epigastrium, pyrosis, and ructus; there was no nausea or vomiting. Three months later, while gardening, the patient had a sudden episode of severe pain in the upper epigastrium. The pain subsided but recurred the next day. The patient was admitted to the local hospital, and radiologic examination revealed gastric gas above the left diaphragmatic dome. (Figure 2.) The patient was transferred to Rigshospitalet. Leftsided thoracotomy disclosed incomplete organoaxial vol-
Volume 129, May 1975
vulus of the stomach, which was displaced into the left thoracic cavity. There was obvious venous stasis, edema, and slight evidence of cyanosis. The arterial blood supply was not compromised. The left flexure of the colon, transverse colon, spleen, and gastrocolic ligament were also displaced into the left thoracic cavity. After reduction of the herniated viscera, a defect, measuring 7 by 7 cm, in the posterolateral part of the diaphragm was closed with double interrupted silk sutures. The postoperative course was uneventful. Two months later, at follow-up examination, the radiograph of the chest revealed no abnormalities.
Comment: In this fifty-eight year old man with overlooked traumatic diaphragmatic rupture, thoracotomy showed strangulation of the stomach with incomplete organoaxial volvulus. Case II. The patient, a seventy-six year old woman, was admitted in acute distress with thoracic pain and dyspnea. She denied having previous thoracic trauma or episodes of dyspepsia. Physical examination revealed absent respiration and tympany over the left half of the thorax. X-ray study of the chest showed a viscus with fluid level in the left thoracic cavity, pleural exudate, and displacement of the mediastinum to the right. (Figure 3A and B.) On intubation of the left pleura only a small amount of fluid was aspirated. Radiography after a barium meal showed a dilated esophagus and compromised passage into the stomach. (Figure 4.) The patient had pronounced kyphoscoliosis with car pulmonale, and her general condition was critical. After rehydration, left-sided thoracotomy disclosed a dilated hernial sac, 15 by 15 cm, containing the colon and a discolored gastric fundus. When the viscera were dissected free, a diaphragmatic defect, 12 by 15 cm, was found, which was believed to be a posterolateral hernia. Organoaxial volvulus of the stomach was present. Since pri-
575
Christiansen, Blichert-Toft, and Bertelsen
Figure 3A and 6. Case ii. Roentgenograms of the chest show a viscus with fluid level in the left thoracic cavity, ieksided ateiectasis, and pleural exudate. The mediastinum is displaced toward the right. Figure 4. Case ii. Roentgenogram after barium swallow shows a dilated esophagus with arrested passage into the stom-
Figure 5. Case ii/. Roentgenogram immediately after trauma shows normai lung fieids without ateiectasis or pieurai exudate. Diaphragmatic domes are sharply outlined. Figure 6. Case iii. Roentgenoiogic Survey of the abdomen, including the tower part of the chest, shows the left diaphragmatic dome eievated and indistinctiy outlined. Density and an apparent/y air- and fiuidfilled viscus are seen at the left base. mary closure of the diaphragmatic defect was not possible, a Dacron@’ graft was implanted. Cardiac arrest occurred twice intraoperatively. Postoperatively the patient’s condition deteriorated and she died on the tenth postoperative day. Necropsy was not permitted. Comment: This seventy-six year old woman had a strangulated
posterolateral
hernia and organoax-
ial volvulus.
Figure 7. Case iii. Roentgenoiogic examination of the chest ten months later shows blurred left lung field with a loop of intestine intrathoracicaiiy. The mediastinum is displaced to the right.
576
Case III. The patient, a twenty-one year old man, was injured ten months prior to admission to our department in a traffic accident, which caused fracture of the first and second lumbar vertebrae with subsequent paraparesis. On the day of admission both lung fields were normal; specifically, both diaphragmatic domes were sharply outlined. (Figure 5.) On the third day the left lung field was blurred with an indistinct diaphragmatic dome, basal density, and a clear fluid level. (Figure 6.) His symptoms began forty-eight hours before admission to Rigshospitalet with sudden episodes of epigastric pain and regurgitation. Radiologic examination of the chest at the local hospital showed a blurred left lung field with distinct bowel loops intrathoracically. (Figure
The American Journalof Surgery
Strangulated Diaphragmatic Hernia
Figure 8A and 8. Case IV. Roentgen&g/c examination bf the chest on admission shows dlsptacement of the stomach into the lefl thoraclc cavity and blurred Ml thoraclc cavity. The medlastlnumis displaced to the rfght.
Figure #A and B. Case IV. Roentgenoiogic examination of the stomach wtth contrast medium shows herniatbn of the stomach through the diaphragm.
7.) On intubation of the pleura in the second left intercostal space, gas and large amounts of turbid sanguinolent fluid were evacuated. The patient’s condition was precarious and during transfer to Rigshospitalet it deteriorated further. On arrival the patient was severely dehydrated and moribund. Blood pressure was unobtainable, and there was anuria. Intensive fluid therapy of short duration was instituted, and left-sided thoracotomy revealed a completely atelectatic lung with previous and more recent pleural formation of fibrin. The transverse colon, small intestine, omentum, spleen, and stomach were dislocated into the left thoracic cavity through an anterolateral defect in the left diaphragm. There appeared to be incomplete organoaxial volvulus of the stomach with strangulation. A perforation, 3 by 3 cm in size, was seen in the lesser curvature. The spleen was removed and the stomach resected. The remaining organs were reduced, and the diaphragmatic defect was closed with a double layer of interrupted silk sutures. The postoperative course was uneventful.
Comment: overlooked racotomy
In a twenty-one traumatic
disclosed
lus of the stomach tion.
Volume 129, May 1075
year
diaphragmatic incomplete
old man
rupture, tho-
organoaxial
with strangulation
with volvu-
and perfora-
Case IV. The patient, a sixty-six year old woman, underwent thoracoabdominal splenectomy in another department in treatment of myelofibrosis, seven months prior to admission to our department. She was admitted to a local hospital because of pain in the chest and episodes of vomiting. Pyopneumothorax was initially diagnosed, and the patient was transferred to our hospital eight days later. Radiologic examination demonstrated displacement of the stomach into the left thoracic cavity and a blurred left lung field. (Figure 8A and B.) Figure 9A and B shows the bariumfilled stomach herniated through a defect in the diaphragm. After rehydration, left-sided thoracotomy disclosed a defect, 7 by 7 cm, anteriorly in the diaphragm at the site of the anterior part of the cicatrix from the previous splenectomy. The colon, omentum, and stomach were situated in the left thoracic cavity. The major part of the stomach was gangrenous with incomplete mesenterioaxial volvulus. Resection of the stomach back to viable tissue was carried out. After reduction of the viscera, the diaphragmatic defect was closed with a double layer of interrupted silk sutures. Postoperatively the patient had recurring left-sided empyema and a gastrothoracic fistula. Approximately
577
Christiansen,
Blichert-Toft,
and Bertelsen
two months later, irregular resection of the stomach according to Billroth II criteria was performed. The postoperative course was prolonged, and the pa-
tient died three months after the first operation from bilateral intractable bronchopneumonia. Comment: In this sixty-six year old woman with an iatrogenic defect of the diaphragm, thoracotomy revealed an incomplete mesenterioaxial volvulus of the stomach with strangulation and perforation. Comments
For accurate diagnosis it is essential that surgeons are fully familiar with the picture of this entity. It is of major importance, in support of the diagnosis, to obtain accurate information about the incidence of adequately forceful thoracic, abdominal, or thoracoabdominal trauma in the patient’s history or information about previous transdiaphragmatic surgery. Posterolateral and substernal hernias are rare. Posterolateral hernia is generally large and associated with pronounced herniation and subsequent pulmonary symptoms. Normally it is diagnosed during the first days of an infant’s life, but it has been noted in children as well as in adults [3]. Substernal hernia seldom causes complications and has been described in both children and adults. In 1948, in a survey of thirty-eight cases from the literature [4], it was stated that strangulated diaphragmatic hernia origmates from traumatic lesions in 90 per cent of the cases. In a recent series of sixty-four cases compiled from the literature [5], the incidence of strangulation is reported to be the same in traumatic diaphragmatic hernia and paraesophageal hernia. The mortality in the latter series was about 40 per cent. In our own patients, strangulation on a traumatic basis occurred in three of four, including one patient with iatrogenie hernia (cases I, III, and IV). Two of the four patients died. Patients with congenital or paraesophageal diaphragmatic hernia should undergo operation as soon as the diagnosis is established, even if they are asymptomatic. Since overlooked traumatic diaphragmatic hernia is responsible for about half the cases of strangulation, it is imperative that this lesion be diagnosed and treated promptly. When displacement of the viscera into the chest occurs immediately after the trauma, diagnosis usually is not difficult. The presence of viscera filled with gas and fluid intrathoracically indicates the diagnosis.
578
In uncharacteristic cases or in cases of minor diaphragmatic lesions without primary herniation, it is important to recognize the following clinical and radiologic signs that, singly or in combination, indicate the diagnosis: apparently elevated and rigid diaphragm, blurred lung fields due to pleural exudate and/or basal atelectasis, and displacement of the mediastinum to the opposite side. In three of our patients (cases I, III, and IV) these changes were present and might have contributed to the correct diagnosis before complications occurred. (Figures IA and B, 6, and 8A and
B.) In cases of suspected traumatic diaphragmatic hernia, diagnostic pneumoperitoneum is advocated if x-ray study of the chest fails to confirm the diagnosis [6]. Summary
Symptoms, signs, and definitions of strangulation and incarceration in diaphragmatic herniation are surveyed, and four patients with strangulated diaphragmatic hernia are reported on. Although the symptoms may be uncharacteristic, the diagnosis is easily made, if kept in mind. X-ray examination of the chest, possibly supplemented by a barium meal, usually indicates the diagnosis. The mortality rate in our series was high, similar to the findings in other series in the literature. Since approximately half of the cases of incarcerated and/ or strangulated diaphragmatic hernia are due to overlooked traumatic diaphragmatic rupture, we stress the importance of diagnosing and treating such rupture promptly to reduce the mortality rate. Strangulated diaphragmatic hernia is a clinical entity on the borderline between the fields of thoracic and general surgery. The disorder is often overlooked or improperly treated, possibly because most units have limited experience with this particular phenomenon. References 1. Skinner EF. Carr D. Duncan JT. Hall JR: Strangulated diaphragmatic hernia. J Thorac Surg 36: 102, 1956. 2. Dalaaard JB: Volvulus of the stomach. Acfa Chir Stand 103: l31, 1952. 3. Gibbon JH, Sabristone DC, Spencer FC: Surgery of the Chest, 2nd ed. Philadelphia. Saunders, 1969. D 262. 4. Carter BN, Guiseffi J: Strangulated diaphragmatic hernia. Ann Surg 128: 210, 1948. 5. Hoffman E: Strangulated diaphragmatic hernia. Thorax 23: 541, 1969. 6. Christiansen LA, Brahe NEB. Stage P, Bertelsen S: Rupture of diaphragma. Thorax 29: 559, 1974.
The Amerkan Journal of Surgery
L. A. Chrlstiansen, MD, Copenhagen, Denmark, M. Bllchert-Toft, MD, Copenhagen, Denmark S. Bertelsen, MD, Copenhagen, Denmark
Diaphragmatic hernia occurs most frequently at the site of the esophageal hiatus as a sliding hernia or paraesophageal hernia, less frequently through a traumatic defect or iatrogenic lesion, and rarely through a congenital posterolateral defect (Bochdalek) or substernal defect (Morgagni). In cases of hiatal and substernal hernia there is a hernial sac; this, however, is absent in cases of posterolateral and traumatic defects. Thus, herniation or prolapse of the abdominal organs, mesentery, and omentum may occur. In diaphragmatic hernia other than the sliding type, complications such as incarceration and/or strangulation, which may prove fatal, may supervene. Incarceration and strangulation are often erroneously used synonymously. In the present report we use the definitions of Skinner et al [I]. Incarceration is the term used for an irreducible hernia adherent to the hernial ring and surrounding structures without compromise of the vascular supply. The patient may be free of symptoms or present evidence of gastrointestinal obstruction, Strangulation is the term applied to an irreducible hernia with compromised venous and, possibly, arterial blood supply. In diaphragmatic hernia the. stomach often forms part of the hernial contents. When a considerable portion of the stomach is displaced into the mediastinum the result may be vo1vu1us, that is, rotation of the stomach at least 180 degrees causing obstruction of the cardia and the pylorus. Rotation of less than 180 degrees without obstruction is designated as incomplete volvulus. Rotation of the stomach around its longitudinal axis, From the Department of Thoracic Surgery, Rigshospitalet, Copenhagen, Denmark. Reprint requests should be addressed to L. A. Christiansen, MD. Da pariment of Surgical Gastroenterology C, Rigshospltelet, Copenhagen, Denmark.
574
called organoaxial vo1vu1us, is seen with greater frequency than is rotation around an axis perpendicular to the cardiopyloric line, called mesenterioaxial volvulus [Z]. Clinical Data No definitive symptoms characterize strangulated diaphragmatic hernia. However, a distinction can be made between local symptoms referable to the diaphragm, those referable to the pleural cavity, and those referable to the gastrointestinal tract. Pain in the chest is a constant symptom, predominantly caused by irritation of the diaphragm and pleura. Pain is localized in the lower half of the chest, the apex of the epigastrium, or both. The patient frequently complains of radiation of pain to the back and shoulder. Strangulation of the omentum provokes severe abdominal pain. Dyspnea is caused by compression atelectasis of various portions of the lungs secondary to the herniated abdominal organs and pleural exudate. Depending on which part of the gastrointestinal tract is herniated, there may be signs of high or low mechanical ileus. When the stomach is involved there often is bloody vomiting; however, when the cardioesophageal junction is blocked, which frequently occurs, only saliva is regurgitated. The patient is commonly febrile. When a complicating perforation of the strangulated viscus with empyema formation occurs, the patient becomes highly febrile and demonstrates signs of sepsis. As a rule, the diagnosis may be arrived at by radiologic study of the chest, which typically shows a dilated viscus with fluid level intrathoracically and a more or less blurred pulmonary area. X-ray study after a barium meal discloses herniation of
The American Journal of Surgery
Strangulated
Diaphragmatic
Figure IA and B. Case I. Roentgenograms of the chest shortly after the trauma show left-sided basal atektasis pleural exudate. Left diaphragmatic dome is indistinctly outlined.
Hernia
and
Figure 2. Case I. Roentgenogram three months aHer the trauma shows gastric gas over the left diaphragmatic dome, atelectasis, and pleural exudate.
the organs. The differential diagnoses are pneumothorax, pleural exudates of various types, and cyst or abscess of the lung. The treatment is emergency operation as soon as the fluid and electrolyte status of the patient permits. The approach can be either transthoracic or thoracoabdominal. In either case the hernial ring is slit to reduce the organs and remove all devitalized tissue. The diaphragm is closed with double interrupted silk sutures. Case Reports Within the past three years four patients with acute strangulation, two of whom had perforation, underwent operation in the department of thoracic surgery of Rigshospitalet. The case histories are briefly reported. Case I. The patient, a fifty-eight year old man, sustained blunt trauma in a car accident three months prior to admission to our department. The patient was admitted to his local hospital with bilateral fractures of the lower ribs. Treatment was conservative. Roentgenologic examination of the chest at that time showed both basal atelectasis and an indistinctly outlined diaphragmatic dome on the left, which persisted unchanged at discharge. (Figure 1A and B.) After discharge symptoms of gastritis developed with slight oppression in the epigastrium, pyrosis, and ructus; there was no nausea or vomiting. Three months later, while gardening, the patient had a sudden episode of severe pain in the upper epigastrium. The pain subsided but recurred the next day. The patient was admitted to the local hospital, and radiologic examination revealed gastric gas above the left diaphragmatic dome. (Figure 2.) The patient was transferred to Rigshospitalet. Leftsided thoracotomy disclosed incomplete organoaxial vol-
Volume 129, May 1975
vulus of the stomach, which was displaced into the left thoracic cavity. There was obvious venous stasis, edema, and slight evidence of cyanosis. The arterial blood supply was not compromised. The left flexure of the colon, transverse colon, spleen, and gastrocolic ligament were also displaced into the left thoracic cavity. After reduction of the herniated viscera, a defect, measuring 7 by 7 cm, in the posterolateral part of the diaphragm was closed with double interrupted silk sutures. The postoperative course was uneventful. Two months later, at follow-up examination, the radiograph of the chest revealed no abnormalities.
Comment: In this fifty-eight year old man with overlooked traumatic diaphragmatic rupture, thoracotomy showed strangulation of the stomach with incomplete organoaxial volvulus. Case II. The patient, a seventy-six year old woman, was admitted in acute distress with thoracic pain and dyspnea. She denied having previous thoracic trauma or episodes of dyspepsia. Physical examination revealed absent respiration and tympany over the left half of the thorax. X-ray study of the chest showed a viscus with fluid level in the left thoracic cavity, pleural exudate, and displacement of the mediastinum to the right. (Figure 3A and B.) On intubation of the left pleura only a small amount of fluid was aspirated. Radiography after a barium meal showed a dilated esophagus and compromised passage into the stomach. (Figure 4.) The patient had pronounced kyphoscoliosis with car pulmonale, and her general condition was critical. After rehydration, left-sided thoracotomy disclosed a dilated hernial sac, 15 by 15 cm, containing the colon and a discolored gastric fundus. When the viscera were dissected free, a diaphragmatic defect, 12 by 15 cm, was found, which was believed to be a posterolateral hernia. Organoaxial volvulus of the stomach was present. Since pri-
575
Christiansen, Blichert-Toft, and Bertelsen
Figure 3A and 6. Case ii. Roentgenograms of the chest show a viscus with fluid level in the left thoracic cavity, ieksided ateiectasis, and pleural exudate. The mediastinum is displaced toward the right. Figure 4. Case ii. Roentgenogram after barium swallow shows a dilated esophagus with arrested passage into the stom-
Figure 5. Case ii/. Roentgenogram immediately after trauma shows normai lung fieids without ateiectasis or pieurai exudate. Diaphragmatic domes are sharply outlined. Figure 6. Case iii. Roentgenoiogic Survey of the abdomen, including the tower part of the chest, shows the left diaphragmatic dome eievated and indistinctiy outlined. Density and an apparent/y air- and fiuidfilled viscus are seen at the left base. mary closure of the diaphragmatic defect was not possible, a Dacron@’ graft was implanted. Cardiac arrest occurred twice intraoperatively. Postoperatively the patient’s condition deteriorated and she died on the tenth postoperative day. Necropsy was not permitted. Comment: This seventy-six year old woman had a strangulated
posterolateral
hernia and organoax-
ial volvulus.
Figure 7. Case iii. Roentgenoiogic examination of the chest ten months later shows blurred left lung field with a loop of intestine intrathoracicaiiy. The mediastinum is displaced to the right.
576
Case III. The patient, a twenty-one year old man, was injured ten months prior to admission to our department in a traffic accident, which caused fracture of the first and second lumbar vertebrae with subsequent paraparesis. On the day of admission both lung fields were normal; specifically, both diaphragmatic domes were sharply outlined. (Figure 5.) On the third day the left lung field was blurred with an indistinct diaphragmatic dome, basal density, and a clear fluid level. (Figure 6.) His symptoms began forty-eight hours before admission to Rigshospitalet with sudden episodes of epigastric pain and regurgitation. Radiologic examination of the chest at the local hospital showed a blurred left lung field with distinct bowel loops intrathoracically. (Figure
The American Journalof Surgery
Strangulated Diaphragmatic Hernia
Figure 8A and 8. Case IV. Roentgen&g/c examination bf the chest on admission shows dlsptacement of the stomach into the lefl thoraclc cavity and blurred Ml thoraclc cavity. The medlastlnumis displaced to the rfght.
Figure #A and B. Case IV. Roentgenoiogic examination of the stomach wtth contrast medium shows herniatbn of the stomach through the diaphragm.
7.) On intubation of the pleura in the second left intercostal space, gas and large amounts of turbid sanguinolent fluid were evacuated. The patient’s condition was precarious and during transfer to Rigshospitalet it deteriorated further. On arrival the patient was severely dehydrated and moribund. Blood pressure was unobtainable, and there was anuria. Intensive fluid therapy of short duration was instituted, and left-sided thoracotomy revealed a completely atelectatic lung with previous and more recent pleural formation of fibrin. The transverse colon, small intestine, omentum, spleen, and stomach were dislocated into the left thoracic cavity through an anterolateral defect in the left diaphragm. There appeared to be incomplete organoaxial volvulus of the stomach with strangulation. A perforation, 3 by 3 cm in size, was seen in the lesser curvature. The spleen was removed and the stomach resected. The remaining organs were reduced, and the diaphragmatic defect was closed with a double layer of interrupted silk sutures. The postoperative course was uneventful.
Comment: overlooked racotomy
In a twenty-one traumatic
disclosed
lus of the stomach tion.
Volume 129, May 1075
year
diaphragmatic incomplete
old man
rupture, tho-
organoaxial
with strangulation
with volvu-
and perfora-
Case IV. The patient, a sixty-six year old woman, underwent thoracoabdominal splenectomy in another department in treatment of myelofibrosis, seven months prior to admission to our department. She was admitted to a local hospital because of pain in the chest and episodes of vomiting. Pyopneumothorax was initially diagnosed, and the patient was transferred to our hospital eight days later. Radiologic examination demonstrated displacement of the stomach into the left thoracic cavity and a blurred left lung field. (Figure 8A and B.) Figure 9A and B shows the bariumfilled stomach herniated through a defect in the diaphragm. After rehydration, left-sided thoracotomy disclosed a defect, 7 by 7 cm, anteriorly in the diaphragm at the site of the anterior part of the cicatrix from the previous splenectomy. The colon, omentum, and stomach were situated in the left thoracic cavity. The major part of the stomach was gangrenous with incomplete mesenterioaxial volvulus. Resection of the stomach back to viable tissue was carried out. After reduction of the viscera, the diaphragmatic defect was closed with a double layer of interrupted silk sutures. Postoperatively the patient had recurring left-sided empyema and a gastrothoracic fistula. Approximately
577
Christiansen,
Blichert-Toft,
and Bertelsen
two months later, irregular resection of the stomach according to Billroth II criteria was performed. The postoperative course was prolonged, and the pa-
tient died three months after the first operation from bilateral intractable bronchopneumonia. Comment: In this sixty-six year old woman with an iatrogenic defect of the diaphragm, thoracotomy revealed an incomplete mesenterioaxial volvulus of the stomach with strangulation and perforation. Comments
For accurate diagnosis it is essential that surgeons are fully familiar with the picture of this entity. It is of major importance, in support of the diagnosis, to obtain accurate information about the incidence of adequately forceful thoracic, abdominal, or thoracoabdominal trauma in the patient’s history or information about previous transdiaphragmatic surgery. Posterolateral and substernal hernias are rare. Posterolateral hernia is generally large and associated with pronounced herniation and subsequent pulmonary symptoms. Normally it is diagnosed during the first days of an infant’s life, but it has been noted in children as well as in adults [3]. Substernal hernia seldom causes complications and has been described in both children and adults. In 1948, in a survey of thirty-eight cases from the literature [4], it was stated that strangulated diaphragmatic hernia origmates from traumatic lesions in 90 per cent of the cases. In a recent series of sixty-four cases compiled from the literature [5], the incidence of strangulation is reported to be the same in traumatic diaphragmatic hernia and paraesophageal hernia. The mortality in the latter series was about 40 per cent. In our own patients, strangulation on a traumatic basis occurred in three of four, including one patient with iatrogenie hernia (cases I, III, and IV). Two of the four patients died. Patients with congenital or paraesophageal diaphragmatic hernia should undergo operation as soon as the diagnosis is established, even if they are asymptomatic. Since overlooked traumatic diaphragmatic hernia is responsible for about half the cases of strangulation, it is imperative that this lesion be diagnosed and treated promptly. When displacement of the viscera into the chest occurs immediately after the trauma, diagnosis usually is not difficult. The presence of viscera filled with gas and fluid intrathoracically indicates the diagnosis.
578
In uncharacteristic cases or in cases of minor diaphragmatic lesions without primary herniation, it is important to recognize the following clinical and radiologic signs that, singly or in combination, indicate the diagnosis: apparently elevated and rigid diaphragm, blurred lung fields due to pleural exudate and/or basal atelectasis, and displacement of the mediastinum to the opposite side. In three of our patients (cases I, III, and IV) these changes were present and might have contributed to the correct diagnosis before complications occurred. (Figures IA and B, 6, and 8A and
B.) In cases of suspected traumatic diaphragmatic hernia, diagnostic pneumoperitoneum is advocated if x-ray study of the chest fails to confirm the diagnosis [6]. Summary
Symptoms, signs, and definitions of strangulation and incarceration in diaphragmatic herniation are surveyed, and four patients with strangulated diaphragmatic hernia are reported on. Although the symptoms may be uncharacteristic, the diagnosis is easily made, if kept in mind. X-ray examination of the chest, possibly supplemented by a barium meal, usually indicates the diagnosis. The mortality rate in our series was high, similar to the findings in other series in the literature. Since approximately half of the cases of incarcerated and/ or strangulated diaphragmatic hernia are due to overlooked traumatic diaphragmatic rupture, we stress the importance of diagnosing and treating such rupture promptly to reduce the mortality rate. Strangulated diaphragmatic hernia is a clinical entity on the borderline between the fields of thoracic and general surgery. The disorder is often overlooked or improperly treated, possibly because most units have limited experience with this particular phenomenon. References 1. Skinner EF. Carr D. Duncan JT. Hall JR: Strangulated diaphragmatic hernia. J Thorac Surg 36: 102, 1956. 2. Dalaaard JB: Volvulus of the stomach. Acfa Chir Stand 103: l31, 1952. 3. Gibbon JH, Sabristone DC, Spencer FC: Surgery of the Chest, 2nd ed. Philadelphia. Saunders, 1969. D 262. 4. Carter BN, Guiseffi J: Strangulated diaphragmatic hernia. Ann Surg 128: 210, 1948. 5. Hoffman E: Strangulated diaphragmatic hernia. Thorax 23: 541, 1969. 6. Christiansen LA, Brahe NEB. Stage P, Bertelsen S: Rupture of diaphragma. Thorax 29: 559, 1974.
The Amerkan Journal of Surgery
![[Strangulated diaphragmatic hernia: a trap not to ignore].](/assets/img/hold.png)
