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Absence of half of the left diaphragm
ABSENCE OF HALF OF THE LEFT DIAPHRAGM* CASE MILLARD
S.
ROSENBLATT,
M.D.
REPORT
PORTLAND,
filled with lxlrium shown in left thoracic
approach. The discussion of this entity by Ladd and G rosst cannot be improved upon and shouId be read by any one interested in the subject. ~LADD and GRCXS. Abdominal
and Childhood. * From the Departments
Surgery
of Surgery
OREGON
The report of this case is occxsioned by the unusual defect present. No previous report of a successfully treated defect of this nature is known to us.
diaphragmatic hernia is a not uncommon lesion in infancy. c It can be readily diagnosed. It can be successfully treated by transabdominal ONGENITAL
FI(;. I. Stomach
B. B ILDERBACK,
M.D. PI-ofessor of Pedintrics, University of Orrgon 4lrtlic;tl School
J.
AND
Assist;tnt Professor of Surgery, II nivcrsity of Orcgnn hlediwl School
CASE
cavit>. KEPORT
This two-month old \vhite male entered Doernbecher Hospital on August 14, 1942. This child had a depressed sternum and very rapid breathing, both of which were noted since birth. The chiId had to be fed small amounts at
of Infu~c~
and Pedi~~trics, University f (ospita[. 411
of Oregon
,\fedicaI
School lrnd Docrnhechel
4 12
American
Journal
of Surgery Rosenhlatt,
BiIderback-Diaphragm
FIG. 2. A considerabIe portion of the large boweI is in the left thoracic cavity. The opaque shadow seen there turned out to be spIeen.
FIG. 3. Congenital
absence
of portion of diaphragm; operation.
appearance
at
freque nt intervals, about two ounces every two hours. If fed larger amounts cyanosis developed. temperature was normal. He The t patient’s
barium meal. The heart was deviated to the right so that it lay almost entirely to the right of the dorsal spine. The stomach \vas displaced
FIG. 1. Postoperative view. The Lung has w-expanded; the heart is still considerably displaced; the edge of the diaphragm is clear and aIthough to h;rv(, separ:~tcd the thoracic _ higher _, than normal :~pne:lrs . :~nd abdominal cavities.
was a moderately well deveIoped, well nourished white male. There was very marked retraction of the sternum in the region of the xiphoid. Respirations were shaIlow and quite rapid, and on visualization something seemed to be radicaIIy wrong with the child’s breathing. Despite this the color was good. The chiId appeared very frail. Essential findings were confined to the chest. There was apparent heart shift to the right. Heart sounds were not audible in the left chest. There was tympany with absence of breath sound over the left chest posteriorly. However, there was normal lung resonance with breath sounds audibIe in the apex of the left chest. The right chest revealed normal lung resonance with normal breath sounds throughout. The liver extended 1 cm. below the right costal margin. Otherwise the abdomen was negative. Urinalysis, hematology, and sedimentation rates were normal. Blood serology was negative. An ?c-ray of the chest was taken after
upward into the left chest. The distal end of’ the esophagus nas in the normal position. The barium enema revealed prompt filling of the colon, the spIenic tlexure of \vhich was displaced into the left chest cavity. From our findings and observations in this case, we believed that there was a definite herniation of abdominal viscera into the left chest cavity pushing the heart to the right anc1 compressing the Ieft lung. The chiId was prepared for operation. He was given nothing but saline by mouth. Twenty-four hours prior to the operation he received IO per cent glucose in norma saline, 20 cc. per kilo, intravenously. In a few hours he receivecl 80 cc. of human serum intravenously. Also he leas given I $0 cc. of Ringer’s solution subcutaneousIy to secure good hydration. BIood for transfusion was secured. Prior to operation the stomach was emptied by Iavage. A continuous intravenous drip was started by cutting do\vn on the vein, tying
4 14
American
Journal
OFSurgery
Rosenblatt,
BiIderback-Diaphragm
needle into the vein, whereby he received IO per cent glucose in distilled water throughout the operation. On August 20, 1942, he was given a genera1 ether anesthesia and incision was made over the left clavicle. The Ieft phrenic nerve was isoIated and crushed. The abdomen was entered through an upper abdomina1 Ieft rectus muscIe spIitting incision. The stomach, spIeen, Iarge howeI, and a good portion of smaI1 bowe1 were withdrawn from the Ieft chest cavity. It was then found that the entire anterior portion of the Ieft diaphragm was absent. The edge of the posterior half of the Ieft diaphragm was sutured to the anterior abdominal wall and the anterior chest waI1 with interrupted cotton sutures. The defect was thus cIosed. The abdomina1 contents were abIe to be restored to the abdomina1 cavity without too great increase of intra-abdominal pressure. The abdomina1 wound was cIosed. The child withstood the procedure we11 but was immediateIy placed in an oxygen tent where he remained for six days. During the first postoperative day the chiId had transient attacks of cyanosis and dyspnea. However, from the second postoperative day on the course was uneventfu1. SmaII feedings were started on the third postoperative day which were retained. The formuIa then was a graduaIIy increased until he was taking
MAHCH, 1<).$J
norma feeding. Two transfusions of 80 cc. each were given. The continuous intravenous drip was discontinued on the third hospital day. Hydration was then maintained by subcutaneous fluid and by mouth. On September 3rd, x-ray of the chest reveaIed the heart was displaced to the Ieft to a more normal position. There was a greater expansion of the upper portion of the Ieft lung. Air couId be identified in the stomach which was in a normal position. The abdominal viscera were seen to extend upward to the sixth rib posteriorly. The lung markings were seen to extend down to the eighth rib. In the lateral view, the left diaphragm was seen to rise posteriorly to the level of the fifth dorsal vertebra. The baby has been foIlowed at intervals and the Iung has re-expanded and the abdominal viscera have remained below the diaphragm. SUMMARY
A case of a two months’ old baby with absence of haIf of the Ieft diaphragm is reported. Satisfactory separation of the pleural cavity from the peritoneal cavity was estabhshed by suturing the edge of the posterior half of the diaphragm to the chest and abdominal waIIs.
S.
ROSENBLATT,
M.D.
REPORT
PORTLAND,
filled with lxlrium shown in left thoracic
approach. The discussion of this entity by Ladd and G rosst cannot be improved upon and shouId be read by any one interested in the subject. ~LADD and GRCXS. Abdominal
and Childhood. * From the Departments
Surgery
of Surgery
OREGON
The report of this case is occxsioned by the unusual defect present. No previous report of a successfully treated defect of this nature is known to us.
diaphragmatic hernia is a not uncommon lesion in infancy. c It can be readily diagnosed. It can be successfully treated by transabdominal ONGENITAL
FI(;. I. Stomach
B. B ILDERBACK,
M.D. PI-ofessor of Pedintrics, University of Orrgon 4lrtlic;tl School
J.
AND
Assist;tnt Professor of Surgery, II nivcrsity of Orcgnn hlediwl School
CASE
cavit>. KEPORT
This two-month old \vhite male entered Doernbecher Hospital on August 14, 1942. This child had a depressed sternum and very rapid breathing, both of which were noted since birth. The chiId had to be fed small amounts at
of Infu~c~
and Pedi~~trics, University f (ospita[. 411
of Oregon
,\fedicaI
School lrnd Docrnhechel
4 12
American
Journal
of Surgery Rosenhlatt,
BiIderback-Diaphragm
FIG. 2. A considerabIe portion of the large boweI is in the left thoracic cavity. The opaque shadow seen there turned out to be spIeen.
FIG. 3. Congenital
absence
of portion of diaphragm; operation.
appearance
at
freque nt intervals, about two ounces every two hours. If fed larger amounts cyanosis developed. temperature was normal. He The t patient’s
barium meal. The heart was deviated to the right so that it lay almost entirely to the right of the dorsal spine. The stomach \vas displaced
FIG. 1. Postoperative view. The Lung has w-expanded; the heart is still considerably displaced; the edge of the diaphragm is clear and aIthough to h;rv(, separ:~tcd the thoracic _ higher _, than normal :~pne:lrs . :~nd abdominal cavities.
was a moderately well deveIoped, well nourished white male. There was very marked retraction of the sternum in the region of the xiphoid. Respirations were shaIlow and quite rapid, and on visualization something seemed to be radicaIIy wrong with the child’s breathing. Despite this the color was good. The chiId appeared very frail. Essential findings were confined to the chest. There was apparent heart shift to the right. Heart sounds were not audible in the left chest. There was tympany with absence of breath sound over the left chest posteriorly. However, there was normal lung resonance with breath sounds audibIe in the apex of the left chest. The right chest revealed normal lung resonance with normal breath sounds throughout. The liver extended 1 cm. below the right costal margin. Otherwise the abdomen was negative. Urinalysis, hematology, and sedimentation rates were normal. Blood serology was negative. An ?c-ray of the chest was taken after
upward into the left chest. The distal end of’ the esophagus nas in the normal position. The barium enema revealed prompt filling of the colon, the spIenic tlexure of \vhich was displaced into the left chest cavity. From our findings and observations in this case, we believed that there was a definite herniation of abdominal viscera into the left chest cavity pushing the heart to the right anc1 compressing the Ieft lung. The chiId was prepared for operation. He was given nothing but saline by mouth. Twenty-four hours prior to the operation he received IO per cent glucose in norma saline, 20 cc. per kilo, intravenously. In a few hours he receivecl 80 cc. of human serum intravenously. Also he leas given I $0 cc. of Ringer’s solution subcutaneousIy to secure good hydration. BIood for transfusion was secured. Prior to operation the stomach was emptied by Iavage. A continuous intravenous drip was started by cutting do\vn on the vein, tying
4 14
American
Journal
OFSurgery
Rosenblatt,
BiIderback-Diaphragm
needle into the vein, whereby he received IO per cent glucose in distilled water throughout the operation. On August 20, 1942, he was given a genera1 ether anesthesia and incision was made over the left clavicle. The Ieft phrenic nerve was isoIated and crushed. The abdomen was entered through an upper abdomina1 Ieft rectus muscIe spIitting incision. The stomach, spIeen, Iarge howeI, and a good portion of smaI1 bowe1 were withdrawn from the Ieft chest cavity. It was then found that the entire anterior portion of the Ieft diaphragm was absent. The edge of the posterior half of the Ieft diaphragm was sutured to the anterior abdominal wall and the anterior chest waI1 with interrupted cotton sutures. The defect was thus cIosed. The abdomina1 contents were abIe to be restored to the abdomina1 cavity without too great increase of intra-abdominal pressure. The abdomina1 wound was cIosed. The child withstood the procedure we11 but was immediateIy placed in an oxygen tent where he remained for six days. During the first postoperative day the chiId had transient attacks of cyanosis and dyspnea. However, from the second postoperative day on the course was uneventfu1. SmaII feedings were started on the third postoperative day which were retained. The formuIa then was a graduaIIy increased until he was taking
MAHCH, 1<).$J
norma feeding. Two transfusions of 80 cc. each were given. The continuous intravenous drip was discontinued on the third hospital day. Hydration was then maintained by subcutaneous fluid and by mouth. On September 3rd, x-ray of the chest reveaIed the heart was displaced to the Ieft to a more normal position. There was a greater expansion of the upper portion of the Ieft lung. Air couId be identified in the stomach which was in a normal position. The abdominal viscera were seen to extend upward to the sixth rib posteriorly. The lung markings were seen to extend down to the eighth rib. In the lateral view, the left diaphragm was seen to rise posteriorly to the level of the fifth dorsal vertebra. The baby has been foIlowed at intervals and the Iung has re-expanded and the abdominal viscera have remained below the diaphragm. SUMMARY
A case of a two months’ old baby with absence of haIf of the Ieft diaphragm is reported. Satisfactory separation of the pleural cavity from the peritoneal cavity was estabhshed by suturing the edge of the posterior half of the diaphragm to the chest and abdominal waIIs.