The British Journal of Surgery Vol. 65 :No. 2 :February 1978 Br. J. Surg. Vol. 65 (1978) 69-73

Traumatic diaphragmatic hernia J. V. BRYER, M. M. HEGARTY, C. HOWE, D. R U B I N A N D I. B. ANGORN* SUMMARY

A series of 58 cases of traumatic diaphragmatic hernia following blunt and penetrating injury is reviewed. The problems of radiodiagnosis are outlined and the need for barium contrast studies of the entire gastrointestinal tract to ensure recognition of isolated small bowel herniation is emphasized. Surgical access via laparotomy is recommended in the immediate post-traumatic presentation, whereas thoracotomy is preferable in cases diagnosed after a latent interval. Penetrating injury resulted in smaller diaphragmatic defects, greater morbidity and higher mortality due mainly to infective complications. TRAUMATIC diaphragmatic hernia was first reported by Sennertus in 1591 (Reid, 1840) but only in the past three decades has the condition been commonly recognized, although few published series contain more than 30 cases (Ebert et al., 1967; Pomerantz et al., 1968; Samaan, 1971; Drew et al., 1973; Strug et al., 1974; Mansour et al., 1975). Diaphragmatic hernia is due to blunt (Desforges et al., 1957; Williams, 1969; Struget al., 1974) or penetrating (Mansour et al., 1975) injuries and the incidence of each reflects the socioeconomicstatus of the population involved (Ebert et al., 1967; Strug et al., 1974). The hernia occasionally follows surgical incision of the diaphragm and rarely erosion by a drainage tube (Mansour et al., 1975). We report an experience of 58 cases of traumatic diaphragmatic hernia seen during a 3-year period which emphasizes problems in diagnosis and difficulties in management.

Classification We have followed the classification recommended by Carter et al. (1951). Stage 1: The immediate or traumatic phase The diagnosis is made immediately following the traumatic incident and embraces the period of recovery of the patient. The diaphragmatic injury may be masked by signs referable to the pleural cavity or gastrointestinal tract. Stage 2: The interval or latent phase After recovering from the original injury, which may have occurred days or even years before, the patient 6

presents with vague upper abdominal or chest symptoms which may be variously attributed to the cardiac, gastrointestinal or biliary systems. This phase also includes those cases discovered on routine chest radiography. Stage 3: The phase of obstruction or strangulation After full recovery from the original injury the patient presents with acute intestinal obstruction. This is often complicated by perforation or gangrene of the herniated organ resulting in chest pain, dyspnoea or a pleural effusion. Hood (1971) recommends a more detailed classification, whilst Strug et al. (1974) simply divide their cases into immediate and delayed categories. The latter covers stages 2 and 3 of Carter’s classification.

Patients and methods Forty-six patients were male and 12 female, with a mean age of 29 years (range 12-68 years). Blunt trauma was responsible for the injury in 20 patients and penetrating trauma in 38 patients. All the penetrating injuries were caused by a knife. Forty-one patients were diagnosed in the traumatic phase and 17 patients in the interval phase (Table I).In the latter group 13 patients presented with signs of intestinal obstruction, 1 with vague dyspepsia, 2 with respiratory distress and 1 was diagnosed after a routine chest X-ray. The correct diagnosis was made within 48 h of admission in 44 patients, with 5 deaths (11.3 per cent). Diagnostic delay of more than 48 h occurred in 14 patients, with 5 deaths (36 per cent). Two patients died before elective surgery and diagnostic confirmation was obtained at post-mortem examination (Table I I ) . Hernias through the right hemidiaphragm, all of which were due to blunt trauma, occcurred in 5 patients. Traumatic hernia through the left hemidiaphragm occurred in 53 patients. Diagnosis Clinical examination did not contribute to the diagnosis. Chest aspiration yielded gastric contents in 3 patients. Diagnosis was facilitated by an awareness of the possibility of traumatic diaphragmatic hernia and confirmed by radiological examination (Table IIZ). Radiodiagnosis was occasionally misleading. The initial chest X-ray was normal in 3 patients and barium studies revealed no abnormality in 5. In 3 patients a homogeneous translucent area thought to be a herniated fundus of the stomach was proved at laparotomy to be a raised left dome of

* Department of Surgery, University of Natal, Durban, South Africa.

70

J. V. Bryer et al.

Fig. 1. Intrathoracic air-fluid level containing a nasogastric tube (arrowed).

Fig. 3. Panaortogram demonstrating a left hemidiaphragmatic rupture, avulsion of the left kidney (white arrow) and the splenic artery ascending into the chest (black arrow).

Fig. 4. Lateral decubitus chest X-ray showing supradiaphragmatic air-fluid levels.

Fig. 2. A fibreoptic endoscope in the left hemithorax.

Table I: TIME OF PRESENTATION Type of injury Phase Traumatic Interval Total

Blunt

Table 111: X-RAY FINDINGS IN PATIENTS WITH SUSPECTED TRAUMATIC DIAPHRAGMATIC HERNIA Total

Penetratinc 25 13 38

16 4

20

41 17 58

Table 11: CLASSIFICATION OF PATIENT AND TIME OF DIAGNOSIS Traumatic phase Interval phase Penetrating Blunt Diagnosed 48 h Total

Penetrating

Blunt

Total

13 (1)

7 (1)

1 (0) 44 ( 5 )

5(1)

1(0)

6 (4)

2 (0)

1415)

28 (4)

14 (1)

13 ( 5 )

3 (0)

58 (10)

23 (3)*

Figures in brackets represent the number of deaths.

Pathognomonic Positive barium o r Gastrografin studies Gas bubbles in chest Positive Ryles tube o r endoscope in chest Arteriogram Associated Pleural findings (collapse, air and/or fluid in chest) Tracheal shift Raised diaphragm Extrapleural air (surgical emphysema, pneumopericardium and air under diaphragm) Fractured ribs Misleading Normal chest X-rays Normal barium studies Pneumoperitoneum Chest X-ray suggestive but laparotomy negative

15 13 3 1 33 9

7 5

3 3 5 4 3

Traumatic diaphragmatic hernia the diaphragm. A definite diagnosis may be made by positive contrast radiography o r by the visualization of a Ryles tube (Fig. 1) or endoscope (Fig. 2) in the chest. Barium contrast studies of the entire gastrointestinal tract are necessary to ensure accurate diagnosis, as occasionally the small intestine may be the only herniated viscus. In 1 patient an arteriogram performed for possible injury to the kidney showed avulsion of the left kidney and displacement of the spleen into the chest (Fig. 3). A pneumoperitoneum performed in 4 patients proved to be more confusing than helpful. Surgical access Surgical exploration was performed via a laparotomy incision in 35 patients and a thoracotomy in 15 patients. A thoracoabdominal approach was used in 6 patients, the abdominal incision being extended into the thorax to facilitate reduction of the viscera and division of adhesions under direct vision (Table I V ) . Two patients died before operation. Operative findings The contents of the hernia were varied (Table V ) .The stomach had herniated in 37 patients and the colon in 26. In 5 patients the small bowel only had herniated into the chest with the stomach and colon remaining in their normal positions in the abdomen . Injury to the herniated viscera was discovered in half the patients presenting during the traumatic phase, especially those presenting after penetrating injury. Gastric perforation occurred in 14 patients. Small bowel gangrene occurred as a result of vascular compromise in 2 patients following blunt trauma (Table V I ) . After full recovery from the original injury, 5 patients presented with gangrene of the herniated viscus. This involved the stomach in 2 patients, the colon in 2 and the small intestine in 1 (Table V I ) . Strangulation was more frequent in those patients sustaining penetrating injury who presented after a latent period (Table VZ). Organo-axial volvulus of the stomach occurred in 5 patients. The diaphragmatic defect was smaller in patients having suffered penetrating injuries and usually measured more than 5 cm in patients with blunt injuries (Table VII). Management An approach via the abdomen was considered preferable in the traumatic phase because of the high incidence of intraperitoneal injury, and this approach was used in 70 per cent of our cases. Visceral injuries were treated on their merits. The thoracic and peritoneal cavities were thoroughly lavaged with warm saline and the diaphragm was repaired with interrupted non-absorbable sutures. The thoracic cavity was routinely drained.

Results Postoperative complications, especially those due to infection, developed in half the patients (Table VZZZ). Ten of 58 patients died, a mortality rate of 17.2 per cent. Death followed penetrating injury in 9 patients (4 dying in the traumatic phase and 5 in the interval phase) and blunt injury in 1 (dying in the traumatic phase). All deaths were due to gross infection.

Discussion In all reported series traumatic diaphragmatic hernia occurs more commonly on the left side (Bowditch, 1853; Strug et al., 1974). In blunt trauma the cushioning effect of the liver may protect the right leaf of the diaphragm (Desforges et al., 1957). In a personal series of penetrating chest injuries reported by Hegarty (1976) the ratio of left side to right side stab wounds of the chest was 3 : 2. In all 38 patients with penetrating injury in the present series the diaphragmatic hernia was on the left side. One must conclude

Table 1V: SURGICAL ACCESS Traumatic phase Penetrating Laparotoniy Thoracotomy Thoracoabdominal Total

21

5 1 27

Blunt

Interval phase Penetrating

1

4 1 4

16

9

9 6

71

Blunt

Total

1

3 0

35 15 6

4

56

Table V: CONTENTS OF HERNIA Traumatic Interval phase phase 29 8 Stomach Colon 16 10 Omentum 13 5 Spleen I1 2 Small bowel 4 4 Liver 4 1 Kidnev 1

Total 37 26 18 13 8 5 1

~~

Table VI: VISCERAL INJURIES Traumatic phase Interval phase Visceral injury Stomach perforation Stomach gangrene Stomach volvulus Colon perforation Colon gangrene Splenic rupture Small gut gangrene Liver laceration Kidney avulsion Total

Penetrating Blunt 14

Blunt

Total

-

-

14

2

-

2

-

-

1

-

2

2

5

1

-

-

-

1

-

-

2

1

2 2

-

-

-

1

-

2 3 3

1

-

-

1 5

-

-

1 1 32

18

Table VII: SIZE O F DEFECT Penetrating < 5 cm > 5 cm Total

Penetrating

7

2

BIunt

Total

24

1

14 38

19

25 33 58

20

Table VIII: POSTOPERATIVE COMPLICATIONS Empyema Intra-abdominal abscess Small bowel fistula Large bowel fistula Haematemesis Intestinal obstruction

12 3 1 1 1 1

that the liver plugs the defect in the right hemidiaphragm and prevents herniation of the abdominal contents into the chest. Physical signs may be related to the chest or abdomen and vary according to the organ herniated into the chest, or to whether presentation is immediate or delayed. Immobility of the left chest, tympany, diminished air entry and bowel sounds in the chest with displacement of the heart to the right are the five clinical signs ‘which may be missed or only associated with the diagnosis in retrospect’ (Bowditch, 1853). Aspiration of gastric contents from the chest has facilitated diagnosis (Orringer et al., 1975).

72

J. V. Bryer et al.

Fig. 5. Elevated left hemidiaphragm (arrowed) with subdiaphragmatic air-fluid level in the gastric fundus. Fig. 7. Barium-filled small bowel in the left hemithorax.

Gas bubbles above the diaphragm must be distinguished from a loculated pneumothorax (Fig. 4) or a subdiaphragmatic air-fluid level (Fig. 5). Barium studies may show a barium-filled organ in the chest (Fig. 6), or a ‘cut-off’ of the barium column at the diaphragm. If the stomach and/or colon is below the diaphragm, the small bowel should always be displayed, as it may be the only part of the gastrointestinal tract above the diaphragm (Fig. 7). Arteriography has been used to demonstrate traumatic diaphragmatic hernias (Pomerantz et al., 1968; Mansour et al., 1975). Pneumoperitoneum has been recommended as an aid to diagnosis (Schwindt and Gale, 1967), but adherence of gut or omentum to the edges of the defect may prevent the passage of air from the peritoneum into the pleural space. If either the pleura or peritoneum is intact, a hernia may occur without its being demonstrable by pneumoperitoneum (Orringer et al., 1975). Our findings of a high incidence of associated abdominal injuries and a low incidence of intrathoracic injuries have been stressed by other authors (Mansour et al., 1975; Orringer et al., 1975). We Pig. 6. Herniation resulting in hourglass deformity of the consider a laparotomy preferable in the traumatic stomach. phase (Carter et al., 1951; Strug et al., 1974); the hernial contents can be easily reduced and intraThe diagnosis is made by clinical suspicion and peritonea1 injuries adequately treated. In the interval radiological investigation. Delay in diagnosis increases phase, including the phase of strangulation, because the mortality (Samaan, 1971 ; Christiansen et al., of adhesions to the diaphragmatic defect and intra1975). The present series was collected prospectively thoracic structures, a thoracotomy is mandatory by two of the authors, and because of their interest the (Ebert et al., 1967; Schwindt and Gale, 1967; Le Roux surgical staff made the diagnosis early and pre- and Williams, 1969). Both incisions can, if necessary, operatively in the majority of cases. be extended into a thoracoabdominal incision (Melzig X-ray findings suggestive of traumatic diaphrag- et al., 1976). matic hernia have been well described (Carter et al., The size of the defect is larger in blunt trauma and 1951; Mansour et al., 1975; Orringer et al., 1975). the small defects due to penetrating injuries are more Initial chest X-ray examination may be normal but likely to be associated with strangulation and gangrene serial films wilI show distinctive changes (Table 111). (Sullivan, 1966; Ebert et al., 1967). It must be

Traumatic diaphragmatic hernia emphasized that the whole diaphragm should be carefully examined for minor defects to avoid later complications. Any upper abdominal organ may herniate through the left hemidiaphragm, whereas on the right side the liver (Samaan, 1971) is usually the only herniated viscus. The stomach (Strug et al., 1974) or colon (Schwindt and Gale, 1967; Mansour et al., 1975) are the commonest organs to herniate. In acute penetrating trauma there is a high incidence of gastric perforation (Table VZ). Perforation of a hollow viscus with contamination of either the pleural or peritoneal cavity is associated with a high incidence of complications. Ten patients died of gross sepsis (17.2 per cent); this compares favourably with other reported series (Hood, 1971; Strug et al., 1974). In only 2 of our 10 patients was an ante-mortem diagnosis not made, whereas in Hood’s (1971) collective review the diagnostic error was 40 per cent in fatal cases. Early diagnosis with the aid of thoracoscopy (Jackson and Ferreira, 1975) or paracentesis abdominis, followed by early operation with meticulous closure of all defects, will reduce the mortality and avoid late complications. References BOWDITCH L.

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and ZUIDEMA G. D. (1967) Traumatic diaphragmatic hernia. Surg. Gynecol. Obstet. 125, 59-65. HEGARTY M. M. (1976) A conservative approach to penetrating injuries of the chest: experience with 131 successive cases. Injury 9, 53-59. HOOD M . (1971) Traumatic diaphragmatic hernia. Ann. Thorac. Surg. 12, 3 11-324. JACKSON A . M. and FERREIRA A. A. (1975) Thoracoscopy as an aid to the diagnosis of diaphragmatic injury in penetrating wounds of the lower left chest: a preliminary report. Injury I, 213-217. LE ROUX B. T. and WILLIAMS M. A. (1969) Diaphragmatic trauma. S. Afr. J. Surg. 7 , 109-122. MANSOUR K . , CLEMENTS J. L., HATCHER c. R. et al. (1975) Diaphragmatic hernia caused by trauma : experience with 35 cases. Am. Surg. 41, 97-102. MELZIG E. P., SWANK M. and SALZBERG A. M. (1976) Acute blunt traumatic rupture of the diaphragm in children. Arch. Surg. 111, 1009-1011. ORRINGER M. B., KIRSH M. M. and SLOAN H. (1975) Congenital and traumatic diaphragmatic hernias exclusive of the hiatus. Curr. Probl. Surg. March. POMERANTZ M . , RODGERS B. M. and SABISTON D . c. (1968) Traumatic diaphragmatic hernia. Surgery 64, 529-534. REID J. (1840) Diaphragmatic hernia produced by a penetrating wound. Edinb. Med. Surg. J. 53, 104-107. SAMAAN H. A. (1971) Undiagnosed traumatic diaphragmatic hernia. Br. J. Surg. 58, 257-261. SCHWINDT w. D. and GALE J. w. (1967) Late recognition and treatment to traumatic diaphragmatic hernias. Arch. Surg. 94, 330-334. STRUG B., NOON c. P. and BEALL A. c. (1974) Traumatic diaphragmatic hernia. Ann. Thorac. Surg. 17, 444-449. SULLIVAN R. E. (1966) Strangulation and obstruction in diaphragmatic hernia due to direct trauma: report of 2 cases and reviewing of the English literature. J. Thorac. Cardiovusc. Surg. 52, 725-734. EBERT P. A . , GAERTNER R. A.

Paper accepted 17.8.1977.