Ann Thorac Surg 2009;88:651-653. doi:10.1016/j.athoracsur.2008.12.057
© 2009 The Society of Thoracic Surgeons
Case Reports
Distinctive Presentation of a Diaphragmatic Hernia 15 Years After A Traumatic Insult
Mohamad Khreiss, MDa,
Joseph Karam, MDa,
Khaled M. Musallam, BSca,
Ayman B. Al Harakeh, MDa,
Vivian G. Nasr, MDb,
George S. Abi Saad, MDa,*
a Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon
b Department of Anesthesia, American University of Beirut Medical Center, Beirut, Lebanon
Accepted for publication December 15, 2008.
* Address correspondence to Dr Saad, Division of General Surgery, Department of Surgery, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh, Beirut, 1107 2020, Lebanon (Email: ga17{at}aub.edu.lb).
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Abstract
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Diaphragmatic hernias are well-known sequelae of abdominal and chest wall trauma. However, they may go undiagnosed in the acute setting but present later due to gastrointestinal or respiratory complications. A distinctive presentation of a diaphragmatic hernia 15 years after a traumatic insult is herein described. Management strategies are also discussed.
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Introduction
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With the recent advances in early trauma care and on-field support, many patients are now reaching the hospital setting alive. Diaphragmatic injuries, mainly diaphragmatic hernia, are well-known sequelae of abdominal and chest wall trauma, occurring in 2% to 6% of patients [1]. However, as these patients usually present with other multi-organ manifestations requiring prompt intervention, the more subtle diaphragmatic hernia may initially go undiagnosed. In the acute setting, diaphragmatic hernias are incidentally detected in only 10% of cases, usually during exploratory laparotomy for other indications, with the remaining patients presenting months to years later with overt complications [2]. Patients may eventually experience recurrent pulmonary dysfunction, acute intestinal obstruction, incarceration or even strangulation, thus, increasing the risk of morbidity and mortality. A distinctive presentation of a diaphragmatic hernia 15 years after a traumatic insult is herein described.
A 58-year-old man presented to our care for acute abdominal pain, chest tightness, and pain, and restlessness of 8 hours duration. He also reported nausea, vomiting, abdominal distension, and obstipation. His past medical history was insignificant except for previous physical abuse and torture during the Lebanese civil war 15 years ago. The patient reported that he was repeatedly hit over his upper abdomen with his spine in extension. The patient's vital signs were within normal limits. On physical examination, the patient's abdomen was distended with a positive Murphy's sign. He had active bowel sounds with no guarding and no rebound tenderness. The left lung field was clear with good air entry, whereas the right lung field showed absence of air entry. A complete blood count with differential showed mild leukocytosis (15,000 x 106/L) with normal neutrophil count. A chest and abdomen roentgenogram showed loops of bowels, air fluid levels, and a gaseous pattern above the right hemi-diaphragm. A computed tomographic scan of the chest and abdomen subsequently showed evidence of a large diaphragmatic hernia containing large and small bowels completely occupying the right hemi-thorax and displacing the midline structures to the left. The right kidney was also noted in the retrocardiac space in the midline (Fig 1). The small bowels showed thickening consistent with a possible strangulation and vascular compromise. The complete blood count was repeated 4 hours later, and showed severe leukocytosis (24,000 x 106/L) and neutrophilia.
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Fig 1. Computerized tomographic (CT) scan of the chest showing the heart (asterisk) shifted laterally; the right kidney (black arrow); and loops of small bowl (white arrow).
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Laparoscopic reduction of the herniated viscera was first attempted followed by an exploratory laparotomy, as severely adherent and ischemic small bowel loops were encountered. At exploration, an 8-cm horizontal defect was present at the dome of the right hemi-diaphragm with herniation of the omentum, small bowels, ascending colon with its appendix, and the right kidney (Figs 2A and 2B). After gentle dissection, all herniated organs were reduced to the abdominal cavity. Gangrenous and ischemic small bowel segments were identified and measured at approximately 120 cm (Fig 2C). Segmental resection with end-to-end anastomosis was performed. After chest tube insertion, the right lung was fully inflated (Fig 2D) and the defect was primarily repaired. The patient recovered and was discharged home in good condition 15 days after the operation. A follow-up computed tomographic scan of the chest showed no remaining abnormalities.
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Fig 2. Intraoperative pictures showing (A) the ascending colon (white arrow) and the appendix (black arrow) in the right thoracic cavity. (B) The right kidney (asterisk) retrieved from the right thoracic cavity. (C) Ischemic small bowl loops. (D) The diaphragmatic leaflets (asterisks), the liver (black arrow), and the right lung (white arrow) completely replacing the defect after inflation.
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Comment
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Traumatic diaphragmatic hernias usually result from blunt (68% to 75%) or penetrating (25% to 32%) injuries, or less commonly from iatrogenic causes [1, 3]. The most encountered type of injury is blunt thoraco-abdominal trauma secondary to road traffic accidents and falls from heights. Left-sided hemi-diaphragmatic injuries are more common, accounting for 56% to 90% of cases, and these mostly occur in young men [4]. This is probably due to the protective effect of the liver to the right hemi-diaphragm during blunt trauma [2]. Moreover, the left diaphragm may be more susceptible to injury by stabbing, partly because most assailants are right-handed. In our patient, the nature of the multiple repeated assaults may have caused an injury at any part of the diaphragm.
The diagnosis and management of traumatic diaphragmatic hernias still presents a major problem, because most cases may not present with symptoms for months to years after the injury, especially if the trauma did not cause any other organ involvement to require exploratory imaging or surgery [1, 2]. The proposed reason for the delay in symptoms may be the presence of omentum and viscera plugging the diaphragmatic defect temporarily, allowing for symptomatic visceral herniation to occur months to years later. The most commonly encountered symptoms are those secondary to intestinal strangulation and respiratory distress. What is interesting in our patient is the presence of the small bowel, right colon, appendix, and a functioning right kidney in one hernial sac pushing the liver inferomedially, and the mediastinal structures to the left, without any symptoms for 15 years up until strangulation occurred.
Mortality rates have been reported to be as high as 80% when strangulation results in gangrenous bowel [5]. Hence, prompt diagnosis and intervention at presentation are essential. Serial chest and abdominal roentgenographic studies, ultrasound, and computed tomographic scan are the methods of choice [6]. When in suspicion, combining any of these modalities may aid in achieving a proper diagnosis to opt for early intervention.
The thoracic approach has been recommended for chronic diaphragmatic hernias due to dense intrathoracic adhesions, however, when strangulation is present, an abdominal or a thoraco-abdominal approach is required [2]. The choice also relies on the patient's clinical condition and the presence or absence of concomitant injuries. If intra-abdominal injuries can be excluded, a minimally invasive laparoscopic or thoracoscopic approach may be preferred [7].
In conclusion, diaphragmatic hernias are common consequences of abdominal or chest wall trauma. As these defects may be unnoticed acutely, and as their sequelae may present years later; the physician should always investigate a previous history of traumatic injury in a patient presenting with signs or symptoms of intestinal herniation or respiratory distress. If the picture is suspicious, radiologic imaging may aid in achieving a prompt diagnosis, because early and appropriate intervention remain vital.
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References
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- Sharma OP. Traumatic diaphragmatic rupture: not an uncommon entity personal experience with collective review of the 1980s J Trauma 1989;29:678-682.[Medline]
- Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma AJR Am J Roentgenol 1999;173:1611-1616.[Abstract]
- Hegarty MM, Bryer JV, Angorn IB, Baker LW. Delayed presentation of traumatic diaphragmatic hernia Ann Surg 1978;188:229-233.[Medline]
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- Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic diaphragmatic hernias Surg Endosc 2000;14:1010-1014.[Medline]
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Abstract
Introduction
