traumatic diaphragmatic injury...traumatic diaphragmatic injury nefertiti a. brown, md suny...

Traumatic Diaphragmatic Injury

Nefertiti A. Brown, MD SUNY Downstate Medical Center

Department of Surgery Morbidity and Mortality Conference

December 13, 2012

www.downstatesurgery.org

Case Presentation

19 yo male BIBEMS as a trauma code

• Backseat passenger

(-seatbelt)

• MVA collision/rollover. + extrication

• GCS 15. BP 96/45 112/76.

• HR 93 RR 31 O2 91%

PE

• Decreased BS on the left

• Thin, scaphoid abdomen

• No obvious deformities

CXR


Presenter

Presentation Notes

The patient is a 19-year-old African American male who was brought in by EMS as a trauma code status post a motor vehicle accident collision and rollover with extrication where he was the passenger within the car. At the time when he presented, he presented with a GCS of 15 with hypoxia and hypotension to the upper 90s/40s. He transiently responded to IV fluid resuscitation and improved to systolic >100. PE exam was significant for ____ A chest x-ray was obtained in the trauma bay which

Case Presentation www.downstatesurgery.org

Presenter

Presentation Notes

showed a left hemidiaphragm elevation with bowel contents and subsequent mediastinal shift to the right consistent with diaphragmatic injury in addition to a right scapular fracture. He was then intubated for worsening hypoxia and immediately taken to OR for exploration.

Intraoperatively

• Midline incision • Moderate amt of hemoperitoneum • transverse colon, small bowel, and stomach herniated into the left chest • Reduction, chest tube placement • Diaphragmatic defect: 10 cm tear that extending

from the left dome into the right crus of the diaphragm. No tissue loss (Grade 3)


Presenter

Presentation Notes

Once the abdominal cavity was entered, we visualized a moderate amount of hemoperitoneum. At that point, we elected to sequentially pack the abdomen and as we removed the packs, we turned our attention to the left upper quadrant where we saw the transverse colon, small bowel, and stomach herniated into the left chest. At that point, we manually reduced the abdominal visceral contents back into the abdominal cavity and placed a left 36-French chest tube under direct vision. We could then see the diaphragmatic defect which was quite extensive as you can see here, but there was no tissue loss present. This would be classified as a grade 3 diaphragmitic injury as it was 2-10cm defect without evidence of tissue loss.

Intraoperatively

• Assessed reduced contents • Zones 1 and 2 inspected to r/o retroperitoneal

injury • Assessed for additional visceral and thoracic

injuries • Primary repair of the diaphragm • EGD

Procedure: Exploratory Laparotomy, reduction of abdominal contents, repair of diaphragmatic injury, left tube thoracostomy, EGD


Presenter

Presentation Notes

Examination of the stomach as well as the colon and the small bowel contents revealed evidence of a mesenteric hematoma. There was no obvious evidence of visceral injury to the structures. Given the presence of mesenteric hematoma, the decision was made to perform bilateral visceral medial rotation to rule out retroperitoneal injury. At that point, we did perform the visceral medial rotation to the right to visualize the aorta and zone 1 of the retroperitoneum and found no evidence of hematoma. Visceral medial rotation to the contralateral side to observe the IVC and also zone 2 of the retroperitoneum revealed no evidence of hematoma. The pelvic region was also palpated and there was no evidence of hematoma. The bladder also felt normal. At that point, we returned our attention to the diaphragmatic injury and with long Allises, clamped the opposing ends and using #1 Prolene suture we repaired the diaphragm primarily using running interlocking Prolene sutures. With the diaphragm been repaired, we returned our attention to the remainder of the small bowel and we ran the small bowel from the ligament of Treitz to the ileocecal valve and found no evidence of visceral injury. The appendix appeared normal. We also palpated the colon as well as the liver and the spleen and there was no evidence of any visceral trauma. The mesenteric hematoma remained stable. There was no evidence of any expansion. At that time, to assure restoration of the continuity of the GE junction, we performed a EGD at bedside after obtaining a GI consultation, the endoscopy will be recorded separately under endoscopy by the GI Team, but as a prelude, the EGD was performed. The GE junction was intact. There was some evidence of petechia and trauma to the stomach likely from the blunt force of the trauma, but there was no obvious evidence of bleeding. The duodenum also appeared normal so we concluded the case. So the final procedure was:

Postoperatively

• CT scan

• Transferred to SICU

• NSGY and Ortho c/s

• Extubated POD #7

• Diet advanced POD#8

• Chest tube d/c’d POD# 11

-PTX , anterior pigtail

• Pigtail d/c’d POD#16

• Currently awaiting subacute rehab placement


Presenter

Presentation Notes

With the patient stabilized we took him from the OR for CT to rule out other sources of injury and subsequently transferred him to the ICU for further care. NSGY and Orthopedic c/s’ were called as it was found that he’d sustained a right scauplar fx, multiple pelvic fx’s and a C6 facet fx. He remained intubated till POD# 7 where he was succesfully extubated. He c/o of my breathing difficulties and was saturating well on RA. L superior pubic rami and ischial tuberosity fractures, bilateral C6 lamina fx, R scapula fx involving acromion process, possible nondisplaced fx of R 6-8 ribs

Questions?


Objectives

• Definition • History • Anatomy and Physiology • Epidemiology • Pathophysiology of blunt injury • Presentation • Diagnosis • Management


Definition • A tear in the diaphragm that allows the

abdominal organs to enter the chest cavity • Transfer of energy across the diaphragm - penetrating ballistic fragment - stab wound - pressure gradient from compressive blunt trauma • Diaphragmatic injury ≠ Diaphragmatic hernia


Presenter

Presentation Notes

TDI reflects transfer of energy across the diaphragm which may be a penetrating ballistic fragment, stab wound or a pressure gradient from compressive blunt trauma and by definition represents the possibility of visceral injury in either cavity; it is the likely associated visceral injury that will dictate the diagnostic and therapeutic approach to the casualty and contribute to the morbidity and mortality. Previously a variety of terms such as diaphragmatic hernia, diaphragmatic injury or thoracoabdominal trauma have been used interchangeably, but it is now recognised that herniation of abdominal contents through a diaphragmatic injury occurs in less than 50%of injuries [9]and thus the two entities are not necessarily synonymous. In addition, diaphragmatic herniaemay occur and be recognised at the time of diaphragmatic injury or be chronic, in which case the recognition of visceral herniation, but not necessarily its occurrence, is delayed.

History

• Sennertus (1541)

• Paré (1579)

• Bowdich (1853) – antemortem

• Riolfi (1886) – First successful repair

• Hedbloe (1925) – case series


Presenter

Presentation Notes

The entity of diaphragmatic rupture post-trauma was first described by Sennertus in 1541. Similiarly, Pare described the consequences of diaphragmatic injuries in both penetrating and blunt trauma in 1579, The first of which was a French artillery captain sustaining a GSW to the left chest & 8 months later dies from colonic obstruction. Autopsy: diaphragmatic rent “no largerthan the tip of the finger”. Gastric incarceration from blunt rupture of the diaphragm was also described by Pare. It wasn’t until 1853 that we could identify these injuries antemortem. In 1886 Riolfi successfully repaired a laceration involving omental herniation. Hedblom conducted a literature-based study consisting of a series of 378 cases, which has been considered as the beginning of the modern surgical era of DI management

Anatomy & Physiology

• 3mm thick, dome shaped • Musculotendinous • 4-10th wks gestation • Three parts -sternal, costal & lumbar • Site of insertion at the

central tendon • Right dome higher than

left dome • Pierced at the crura by

IVC, Esophagus and Aorta


Presenter

Presentation Notes

The diaphragm is basically a 3mm thick dome shaped musculotendinous structure which separates the thoracic from the abdominal cavity. It arises embryologically from the pleuroperitoneal membranes and body wall, the dorsal mesentery of the esophagus and the septum transversum and develops between the 4-10th week of gestation. It is composed of 3 parts: The sternal part - which is attached to posterior side of xyphoid process. The costal part – attached to inferior six costal cartilages and ribs and form R & L domes of diaphragm And the lumbar part from med/lat arcuate ligaments, L1-3, form R & L crura It’s circumferential parts as you can see here are muscular and these fibers arise radially from the margins of the thoracic aperture and converge into a large central tendon which is fused to the pericardium above via the pericardiphrenic ligament. The posterior attachments are lower than those anteriorly and the right dome lies higher than the left. It is pierced at the crura by the passage of the inferior vena cava (T8), esophagus(T10) and aorta(T12) from in front backwards. It is covered by parietal pleura and peritoneum except at the ‘bare area’ of the liver which lies immediately adjacent to the diaphragm itself. It receives motor and sensory supply from the phrenic nerves (C3-5 of the spinal cord). Aside from those structures that traverse it, the diaphragm’s immediate anatomical relations are the pleural space, lungs, pericardium and heart above and the liver spleen, stomach and splenic flexure of colon inferiorly.

Anatomy

• Blood supply

- Internal Thoracic Artery (Musculophrenic & Pericardiophrenic branches)

- Aorta (Sup/inf phrenic)

• Innervation Phrenic nerve -C3, C4, C5 -sensory and motor • Lymphatic drainage To parasternal, lateral

aortic, and posterior mediastinal lymph nodes


Physiology

Actions: Work of breathing

1. Contraction

2. Relaxation

At rest, right dome is at ICS 4 and left dome is ~ 1 to 2 cm lower Maximal inhalation at ICS 6 on right and ICS 7 on left


Presenter

Presentation Notes

Contraction = diaphram desc, causing inc thoracic volume, by inc vert diameter of thoracic cavity –> dec intrathoracic pressure –> Lungs EXPAND 2. Relaxation = diaphram asc, causing dec thoracic volume, by dec vert diameter of thoracic cavity –> inc intrathoracic pressure –> Lungs DEFLATE An intact diaphragm is the most important muscle of respiration, performing up to 70% of the work of breathing at rest by creating a negative intrathoracic pressure during inspiration by contraction of the striated muscle which shortens and flattens the diaphragm, increasing intrathoracic volume and lowering intrathoracic pressure. The converse happens in expiration and this mechanism contributes to ensuring the venous return to the heart. Disruption of the mechanism coupled with compression of the IVC at the diaphragmatic hiatus by herniated intrathoracic abdominal viscera will significantly reduce cardiac venous return and may cause catastrophic cardiovascular collapse

Epidemiology

• Incidence unclear - studies range ~0.8-8%, overall 0.63% • 35% related to blunt injury • ~ 15% discovered > 48hrs s/p injury • Up to 65% are diagnosed at surgery • Right vs. left sided considerations - ¾ Lt. sided, 23% Rt. Sided, 2% bilateral - Liver - Pressure requirements less on the left

(anatomic)


Presenter

Presentation Notes

Diaphragmatic injuries are infrequent, even in busy trauma centers. The true incidence of diaphragmatic injuries is hard to estimate because of high number of missed or delayed diagnoses and pre-hospital deaths. The incidence of diaphragmatic injuries (blunt and penetrating) reported in the literature ranged from 0.8% to 8% of all abdominal injuries. According to the National Trauma Data Base (NTDB) data from 565 Hospitals from Year 2000 to 2004 revealed an overall incidence of 0.63%. ; 35% from blunt trauma and 65% from penetrating diaphragmatic injuries. Approximately 15% of TDI diagnoses are made more than 48 hours after injury due to necessary resuscitation and stabilization preventing further investigation and up to 65% may still be diagnosed at surgery. Three quarters of TDI occur on the left side, with 23% right sided injury and only 2% occurring bilaterally. Diaphragmatic rents due to penetrating trauma are rarely more than 2cm long, vs those caused by blunt are more entensive and can results in tears up to and beyond 10 cm. Left sided rupture is three times more common than on the right; diagnosis is easier on the left as the liver may well plug the diaphragmatic defect making plain radiography diagnosis less likely. Cadaveric studies demonstrate the pressure required to rupture the left hemidiaphragm is consistently lower than that on the right due to the relative weakness on the left from the lumbocostal trigone and the point of embryological fusion.

Pathophysiology of Blunt Injury

• Compression

-Anterior

- Pressure differences blow out

- Lateral

- Shearing force posterlateral rupture

Lateral >>>Anterior

• Commonly assoc w/ multiple injuries (>80%)


Presenter

Presentation Notes

Blunt injury is associated with significant transfer of kinetic energy.23 Up to 90% of diaphragmatic ruptures from blunt trauma occur in young men after motor vehicle accidents. Diaphragmatic rupture may occur by either anterior or lateral compression. Anterior compression results in a rupture of the central tendon, whereas lateral compression most often causes a tearing of the diaphragm away from its body wall attachments. Lateral injury is 3xxs more likely to be the causative factor vs. anterior compression. That being said, TDI hardly ever occurs in isolation . More than 80% of these patients have major associated injuries, with chest, splenic and hepatic injuries being the commonest concurrent injuries.

Presentation

• Chest and abdominal pain

• Orthopnea/Dyspnea

• Reduced breath sounds in the lower lung fields

• Respiratory failure

• Bowel sounds heard in the chest

• Scaphoid abdomen

• Peritonitis

• Palpation of abdominal viscera during insertion of chest tube

• Hemodynamic instability and/or respiratory decompensation


Presenter

Presentation Notes

The clinical picture of patients sustaining diaphragmatic injury from thoracoabdominal trauma encompasses the entire spectrum of acuity. Presentations may range from hemodynamic stability with few or no physical findings to shock. The presenting symptoms in cases of diaphragmatic hernia can be described as thoracic or abdominal. Dyspnea, orthopnea, and chest pain are the primary symptoms experienced. Pain may be diaphragmatic, and be referred to the shoulder area (Kehr's sign), or may be related to chest wall injury or pleural violation. In the instance of progressive gastric dilatation with obstruction, respiratory distress may become extreme as the lung collapses, producing symptoms resembling those of tension pneumothorax, whereas abdominal symptoms may range from mild and localized to diffuse with severe abdominal pain. Physical findings can also be described as thoracic or abdominal. Thoracic signs include decreased breath sounds, or even bowel sounds on chest auscultation, dullness to percussion of the chest, crepitus from rib fractures, and paradoxical chest wall motion from a flail chest. Abdominal signs may include a scaphoid abdomen from displaced viscera, localized or severe and diffuse abdominal tenderness, with guarding and rebound.

Diagnosis

• History

-mechanism of injury

• Physical exam

- Usually limited, but may have thoracic or abdominal findings

• Radiology


Presenter

Presentation Notes

There is no ‘‘gold standard’’ for early diagnosis of traumatic diaphragmatic rupture. Mechanism of injury can raise the suspicion for diaphragmatic injury. Blunt: Fall from height, direct impact to the thoracoabdominal area from vehicles, or history of crush injury. Penetrating: wound in the thoracoabdominal area (lower chest/upper abdomen) immediately alerts us to the possibility of diaphragmatic injury. Physical: Blunt usually shows no external signs of injury, but thoracic symptoms such as: decreased breath sounds, multiple assoc. rib fx’s. Abdominal findings: Localized vs. diffuse peritonitis, progressive abdominal distention from abdominal vascular injuries may be present.

Diagnosis CXR

• Nml/nonspecific in 20%-50%

• Variable accuracy (Left>>Right sided injury)

• Elevated diaphragm

• Gastric or colonic bubble in the left chest

• Coiled NGT


Presenter

Presentation Notes

Cxr findings may range from minimal to dramatic. The initial approach to the diagnosis of a diaphragmatic injury includes portable chest radiograph (CXR). Normal or nonspecific CXRs are seen in 20% to 50% of patients with diaphragmatic injury on initial evaluation. The diagnostic accuracy of the initial CXR for diaphragmatic injury is reported as 27% to 62% for left-sided injuries but only 17% of right-sided injuries. The initial chest radiograph may reveal the gastric or colonic bubble in the left chest. Occasionally, in acute ruptures of the left hemidiaphragm, nasogastric tubes placed during the resuscitative phase are found coiled in the left hemithoracic cavity (Fig. 31-5). Other findings may include an elevated diaphragm, fractured ribs with or without displacement, flail segments, and/or sternal fractures.

Diagnosis

• UGI series/Barium enema • CT (Conventional) - 61% sensitivity, Specificity 76-99% • Helical CT - diagnoses 78% of left-sided injuries & 50% of right-sided injuries w/ PPV & NPV ~ 80-100% • MRI -can be useful; provides direct coronal and

saggital images & delineates the diaphragm


Presenter

Presentation Notes

If the patient is hemodynamically stable, contrast studies have proven valuable in cases where the initial CXR fails to yield the diagnosis. These are normally employed in chronic. Longstanding hernias, but may be proven valuable in acute situations. Contrast studies have been proven useful in cases in which the initial chest x-ray has failed to yield a diagnosis of diaphragmatic injury. The vast majority of such studies will be done to investigate chronic, long-standing herniation of intra-abdominal viscera, although they have also proven valuable in the acute situation. Clearly, the patient must be hemodynamically stable in order to undergo these studies. An upper gastrointestinal series will often delineate the presence of the stomach within the left hemithoracic cavity. A barium enema, as either a single-column or a double-contrast study, will also outline a herniated colon within the thoracic cavity Conventional computed tomography (CT) scans have a reported sensitivity of 14–61% and specificity of 76–99% in diagnosing diaphragmatic rupture20 (Fig. 31-6). This variability reflects limitations of the relatively thick axial slices (10 mm) with patient and respiratory motion and poor quality reconstructions. Advanced helical CT scanners, which provide greater diagnostic accuracy, have been reported to have positive and negative predictive values and accuracy in diagnosing diaphragmatic injury of 80–100%.38,39 In one series, the multidetector-row CT was found to be useful in the diagnosis of right hemidiaphragm injury.40 The use of magnetic resonance imaging (MRI) to diagnose diaphragmatic rupture has been reported and can be useful due to its image quality, but can prove impractical for routine use in diagnosis.

Diagnosis

• DPL

-25-35% false neg. rate

• Laparoscopy and thoracoscopy


Presenter

Presentation Notes

DPL is overall poor in evaluation of diaphragmatic injury resulting in falsenegative rates as high as 25-35% when studied retrospectively. This lack of sensitivity may be because the diaphragmatic rupture is the only abdominal injury itself and the negative intrathoracic pressure has a tendency to pull intra-abdominal fluid and blood into the thorax. However, today it has mostly been replaced by the FAST exam and the use of helical CT. DPL is used currently as a diagnostic technique for diaphragmatic injury only following penetrating wounds (see Chap. 30). The real time ultrasonography (US) may occasionally reveal a diaphragmatic rupture in expert hands. Focused Abdominal Sonography for Trauma (FAST) is supposed to be the more accurate technique for trauma settings, but no definitive reports have emerged describing its usefulness in the diagnosis of DI, but now Laparoscopy and thoracoscopy are now the diagnostic and therapeutic choices of trauma surgeons. Minimally invasive technology (laparoscopy and thoracoscopy) has been established as an effective means of evaluating the diaphragm for injury. Ivatury and associates43 reported experience with laparoscopy in a series of 100 hemodynamically stable patients with penetrating abdominal trauma, 60 of which had sustained wounds in the thoracoabdominal area or upper abdominal quadrants, and identified 17 diaphragmatic lacerations. They concluded that the diagnostic accuracy of laparoscopy was excellent for hemoperitoneum, solid-organ injuries, and diaphragmatic lacerations and validated laparoscopy as an excellent tool for evaluating the diaphragm in thoracoabdominal injuries. A prospective study to evaluate penetrating left thoraco-abdominal injury utilized laparoscopy with the aim to determine the incidence of diaphragmatic injuries in penetrating left thoracoabdominal trauma.44 In this study, 119 consecutive patients sustaining penetrating left thoracoabdominal injury were evaluated with clinical examination, chest radiography, and laparoscopy. Of these patients, 107 were fully evaluated, 50 required emergent laparotomy, and 57 underwent laparoscopy. The overall incidence of diaphragmatic injuries was 42% (59% incidence from gunshot wounds and a 32% incidence for stab wounds). Among the group of patients with diaphragmatic injuries, 31% had no abdominal tenderness, 40% had a normal chest x-ray, and only 49% had an associated hemopneumothorax. Fifteen (26%) of the patients undergoing laparoscopy had occult diaphragmatic injuries. This study concluded that the incidence of diaphragmatic injuries in association with penetrating left thoracoabdominal trauma is high and that clinical and radiographic findings are unreliable at detecting occult diaphragmatic injuries. Laparoscopy proved to be accurate for detecting these injuries among patients who have no other indications for laparotomy. In a prospective study of 34 hemodynamically normal, asymptomatic patients with thoracoabdominal penetrating injuries, all patients underwent diagnostic laparoscopy to evaluate the diaphragm for the presence of injury, followed by a confirmatory laparotomy or video-assisted thoracoscopy.45 Specificity, sensitivity, and negative predictive value were 100%, 87.5%, and 96.8%, respectively. It was concluded that laparoscopy alone is sufficient to exclude diaphragmatic injury in asymptomatic, hemodynamically normal patients with penetrating thoracoabdominal injury. Ochsner et al.46 reported the use of video-thoracoscopy to diagnose diaphragmatic injuries in a series of 14 patients. This technique successfully identified all injuries that were subsequently confirmed by laparoscopy and exploratory laparotomy, although video-thoracoscopy is less frequently used than laparoscopy.

Laparoscopy/Thoracoscopy

• Allows diaphragmatic assessment and repair

• Used when open surgery is not mandated

-Asx, hemodynamically stable

• Thoracoscopy

- highly specific and sensitive

- more useful in Rt. Sided injury

• Diagnostic Laparoscopy for Lt. sided injury

**The evaluation of the diaphragm by laparotomy in the acute setting remains the gold standard for diagnosis.


Presenter

Presentation Notes

Laparoscopy allows assessment and repair of the diaphragm.[1,14] If open surgery is not required, suspected patients should undergo either diagnostic laparoscopy or video-assisted thoracoscopy. Thoracoscopy is a very sensitive and specific diagnostic tool in DI, with a very high accuracy of between 98 and 100%Thoracoscopy is probably more useful in obvious thoracic injuries and in right-sided penetrating thoracoabdominal injuries. Laparoscopy proved itself a vital tool for detecting these injuries among patients who had no other indications for laparotomy.[17] For haemodynamically stable patients, diagnostic laparoscopy is utilized for patients sustaining left thoracoabdominal penetrating trauma. However, in the acute setting evaluation of the diaphragm by laparotomy remains the gold standard for diagnosis, and also to r/o associated visceral injuries.

GRADE INJURY DESCRIPTION

I Contusion

II Laceration 2 cm

III Laceration 2–10 cm

IV Laceration >10 cm with tissue loss 25 cm2

V Laceration with tissue loss >25 cm2

Adapted from American Association for the Surgery of Trauma-Organ Injury Scale for Diaphragmatic Injuries

Grading/Staging www.downstatesurgery.org

Presenter

Presentation Notes

Injuries to the diaphragm are graded according to severity. The classification system was devised as part of the overall Injury Severity Score from the American Association for the Surgery of Trauma. Diaphragm injuries are graded by the degree of laceration and the overall amount of tissue loss. Regardless of the mechanism or grade of injury, ruptures of the diaphragm, however small, are unlikely to close spontaneously. All known diaphragmatic injuries must be repaired to prevent the possibility of long-term complications such as herniation and strangulation of abdominal viscera .

Management

• Immediate: ABC’s

• Focused assessment

- Identify/treat associated injuries

- CXR, other studies

•OR


Presenter

Presentation Notes

Immediate management is often resuscitative, due to the associated injuries, and should follow ATLS protocol, even in the absence of a diagnosed TDI. Maintenance of adequate oxygenation, ventilation and perfusion is essential to allow the best chance of recovery. After the patient has been resuscitated, a more focused assessment begins. In patients suspected of having diaphragmatic injury, meticulous attention must be paid to the insertion of a nasogastric tube. The tube should not be forced, as herniation of the stomach into the chest may distort the GE junction and cause the tube to lacerate the esophagus, stomach, or both. If the tube cannot be passed easily, it is recommended that it be left in the distal esophagus and suction applied to help with the evacuation of swallowed air. Likewise, if PTX is present due to compression on lung by abdominal contents, added caution must be taken when placing a thoracostomy tube if herniated viscera are located by digital exploration prior to placement of a chest tube. If a chest x-ray has been obtained and suspicious shadows are located in either thoracic cavity, caution must be exercised in chest insertion. All the injuries requiring surgical repair associated with diaphragmatic injury are intra-abdominal and a thorough exploration of the abdominal cavity is mandatory. The evaluation of the diaphragm by laparotomy remains the gold standard for diagnosis.

• Control of hemorrhage and shock

• Control of GI spillage

• Identify associated visceral injuries

• Reduce herniated abdominal contents

• Assess extent of diaphragmatic injury

• Inspect the thorax

• +/- Debridement

• Repair

Surgical Goals www.downstatesurgery.org

Presenter

Presentation Notes

Most, if not all, acute diaphragmatic injuries can be approached through a midline laparotomy incision. The basic principles of trauma surgery, including control of exsanguinating hemorrhage and gastrointestinal spillage, should be closely followed. Thorough exploration of the abdominal cavity and retroperitoneum will avoid missed injuries . Then, attention should be shifted to a thorough inspection and visualization of the diaphragm. The central tendon of the diaphragm should also be examined, along with the esophageal hiatus. The edges of the diaphragmatic laceration should be grasped with Allis' clamps and the laceration is then further spread apart to inspect the chest cavity. This allows for evaluation for ongoing hemorrhage from within the thoracic cavity, as well as to determine the degree of contamination between the abdominal and thoracic cavities. Blood and any enteric contamination should be evacuated from the chest. All herniated viscera must be carefully reduced and relocated to their original positions within the abdominal cavity . It is necessary to carefully debride the edges of a laceration if devitalized tissue is found, and all injuries of the diaphragm should be repaired. The right hemidiaphragm is best inspected after transection of the falciform ligament and downward traction of the liver. The left hemidiaphragm can be inspected by applying gentle downward retraction of the spleen and greater curvature of the stomach. nterrupted or horizontal mattress suture are commonly used, but some surgeons advocate running, suture repair (Fig. 31-11). Some surgeons prefer 0 or 1 monofilament sutures of nonabsorbable material (polypropylene), but absorbable suture may be used as well.32 In cases of laceration through the central tendon in which the inferior aspect of the heart is exposed, meticulous attention is given to the placement of the sutures to prevent inadvertent punctures or lacerations of the myocardium (see Chap. 28). At completion of the repair, the integrity of the suture line may be tested by increasing intrathoracic pressure with the administration of large tidal volumes and assessment of diaphragmatic motion. This maneuver is repeated with the field flooded with sterile saline to determine if there is escape of air or pleural fluid through the suture line. A diaphragmatic injury diagnosed by laparoscopy in the absence of other injuries mandating laparotomy or thoracotomy can be repaired with this approach. This requires that the trauma surgeon be skillful in laparoscopic suturing. Alternatively, they may also be repaired with staples.22,44 Evacuation of the air and blood within the chest may be accomplished by placing a tube thoracostomy. The chest tube is classically placed in the fifth intercostal space in the midclavicular line, but may be placed lower under direct observation. Alternatively, with small diaphragmatic injuries, a catheter may be inserted through the laceration and placed to suction. After all the repair sutures are placed, the catheter is quickly withdrawn as the last suture is being tied. Repair of acute diaphragmatic injuries can be approached via thoracotomy. However, almost all the injuries requiring surgical repair associated with diaphragmatic injury are intra-abdominal and a thorough exploration of the abdominal cavity is mandatory. Massive diaphragmatic destruction, such as that caused by thoracoabdominal shotgun injuries, merits special mention. Bender and Lucas49 described the immediate reconstruction of the chest wall following this type of injury by detachment of the affected hemidiaphragm anteriorly, laterally, and posteriorly, thus effectively translocating to a position above the full-thickness chest wall defect and converting the defect functionally into an abdominal wall defect (Fig. 31-12). The diaphragm is then resutured to the muscle of a higher intercostal space, while the abdominal wall defect is managed with local wound care in anticipation of further reconstruction with either split-thickness skin grafts or myocutaneous flaps at a later date (Fig. 31-13). Another technique involves the utilization of prosthetic nonabsorbable mesh material to reconstruct the diaphragm (Fig. 31-14); however, utilization of this material in the presence of contamination in either the thoracic or abdominal cavity poses a risk of infection to the patient. � ��

Rationale for early repair

• Lack of a hernia sac allows the herniated viscera to become adherent to the thoracic contents.

- surgical repair in cases in which the diagnosis is delayed or the repair is deferred requires a thoracic approach

• Associated abdominal injuries identified and addressed

• Early repair reduces the likelihood of respiratory compromise and long-term complications associated with incarceration and strangulation of the intraabdominal viscera.


Presenter

Presentation Notes

Associated abdominal injuries identified at the initial exploration are also addressed at this time. In contrast to nontraumatic diaphragmatic hernias, a hernia sac is present only occasionally in traumatic hernias. The lack of a hernia sac allows the herniated viscera to become adherent to the thoracic contents. Therefore, surgical repair in cases in which the diagnosis is delayed or the repair is deferred requires a thoracic approach to safely divide the resulting adhesions, reduce the hernia contents, and evaluate the intrathoracic organs. Early repair reduces the likelihood of respiratory compromise and long-term complications associated with incarceration and strangulation of the intraabdominal viscera.

Surgical techniques

• Edges grasped w/ Allis clamps

• Single layer interrupted or horizontal mattress suture

• Complex lacerations (>5cm)

- running suture

- mesh repair (rare)

• Use 0 or 1 monofilament sutures

• Central tendon repair considerations

• Tube thoracostomy


Presenter

Presentation Notes

Early repair consists of : Diaphragmatic lacerations may be repaired with a variety of suture material and technique. Interrupted or horizontal mattress suture are commonly used, but some surgeons advocate running, suture repair. Some surgeons prefer 0 or 1 monofilament sutures of nonabsorbable material (polypropylene), but absorbable suture may be used as well.32 In cases of laceration through the central tendon in which the inferior aspect of the heart is exposed, meticulous attention is given to the placement of the sutures to prevent inadvertent punctures or lacerations of the myocardium (see Chap. 28). At completion of the repair, the integrity of the suture line may be tested by increasing intrathoracic pressure with the administration of large tidal volumes and assessment of diaphragmatic motion. This maneuver is repeated with the field flooded with sterile saline to determine if there is escape of air or pleural fluid through the suture line. Complex lacerations greater than 5 cm long may require a running suture for reinforcement. One may use 0 or 1 monofilament sutures of nonabsorbable material (polypropylene) or absorbable suture. An alternative means of repairing diaphragmatic injuries involves a continuous running suture. Patients in whom the initial diaphragmatic injury goes undiagnosed may present with large diaphragmatic defects. In general, as time progresses, this defect tends to enlarge due to the constant motion of the diaphragm and negative intrathoracic pressure. It is recommended to attempt a primary repair of the diaphragm, if the diaphragm is mobile. In cases in which the gap cannot be bridged, prosthetic materials, such as the mesh will be necessary. The use of nonabsorbable prosthetic meshes (Marlex, Dacron, or Prolene) has been recommended as adjuncts to repair and/or substitute in cases of chronic injury through biologic mesh can be used in acute settings. Evacuation of the air and blood within the chest may be accomplished by placing a tube thoracostomy if there isn’t one already present. (If asked) It is very rare to need to use mesh in an acute trauma bc the tissue ruptures and there is tissue loss. In contrast to nontraumatic diaphragmatic hernias, a hernia sac is present only occasionally in traumatic hernias. The lack of a hernia sac allows the herniated viscera to become adherent to the thoracic contents. Therefore, surgical repair in cases in which the diagnosis is delayed or the repair is deferred requires a thoracic approach to safely divide the resulting adhesions, reduce the hernia contents, and evaluate the intrathoracic organs. Early repair reduces the likelihood of respiratory compromise and long-term complications associated with incarceration and strangulation of the intraabdominal viscera.

Morbidity

• Pneumonia, Empyema, Subphrenic or Intrabdominal abscess

• Dehiscence, hemidiaphragm paralysis, Respiratory insufficiency, Pulmonary Embolism


Presenter

Presentation Notes

Despite early repair, a complication of DI is perforation of viscera into the thoracic cavity, leading to infections like pneumonia, empyemas and sub-phrenic or intra-abdominal abscesses. To avoid this, the vigorous irrigation of the thoracic and abdominal cavity with adequate drainage is recommended.[4,5] The morbidity includes complications like suture-line dehiscence, hemi diaphragmatic paralysis secondary to iatrogenic phrenic nerve injuries, respiratory insufficiency, empyemas and subphrenic abscess. The underlying trauma and associated injuries may be the cause of late morbidity.[1] Pulmonary embolism is now rare as a result of the aggressive use of prophylaxis

Treatment Algorithm www.downstatesurgery.org

Conclusions • Traumatic injuries of the diaphragm are often clinically silent

However, the results of a missed injury can be catastrophic. Clinical suspicion must be high.

• Chest X-ray is the initial screening option followed by helical CT

• Optimal treatment of consists of early repair via laparotomy w/ careful evaluation of other associated visceral injury

• With an increase in experience and expertise, laparoscopy and thoracoscopy, are finding their places in both diagnosis and definitive management of thoracoabdominal trauma with occult diaphragmatic injuries in stable patients


References • Sennertus RC (cited by Reed): Diaphragmatic hernia produced by a penetrating wound. Edinburgh Med Surg J

53:104, 1840. • Paré A: Oeuvres Completes d'Ambroise Paré. In Malgaigne JF, ed. accompangnees de notes historiques et critiques

et precedes d'une introduction sur l'origine et les progress de la chirurgie en Occident du Vie au XVIe siecle. Paris: Bailliere, 1840, vol 11, p. 94

• Hamby WB: The Case Reports and Autopsy Records of Ambroise Paré. Springfield, IL: Thomas, 1960, p. 50. • Bowditch HI: Diaphragmatic hernia. Buffalo Med J 9:1, 1853. • Riolfi: Bull. Della Soc. Lancisiana degli ospedali di Roma. Zantralbl Chir 1893, p 873. As cited by Hedblom CA:

Diaphragmatic hernia. A study of three hundred and seventy-eight cases in which operation was performed. JAMA 85:947, 1925.

• Naumann G: Hernia diaphragmatica, laparotomie. DöD as cited by Lauenstein C. Zentralbl Chir 15:894, 1888. • Hedblom CA: Diaphragmatic hernia: A study of three hundred and seventy-eight cases in which operation was

performed. JAMA 85:947, 1925. • Iochum S, Ludig T, Frederic W, et al.: Radiographics 22: S103, (discussion S116), 2002. • National Trauma Data Base® (NTDB). American College of Surgeons, years 2000 to 2004. • Murray JA, Demetriades D, Asensio JA, et al.: Occult injuries to the diaphragm: Prospective evaluation of

laparoscopy in penetrating injuries to the lower left chest. JACS 187:626, 1998. • Shanmuganathan K, Killeen K, Mirvis SE, et al.: Imaging of diaphragmatic injuries. J Thorac Imaging 15:104, 2000. • Larici AR, Gotway MB, Litt HI, et al.: Helical CT with sagittal and coronal reconstructions: accuracy for detection of

diaphragmatic injury. Am J Radiology 179:451, 2002 • Feliciano DV, Cruse PA, Mattox KL, et al.: Delayed diagnosis of injuries to the diaphragm after penetrating wounds.

J Trauma 28:1135, 1988.


Presenter

Presentation Notes

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