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Traumatic diaphragmatic hernia: review of 15 cases
94
Injury (1989) 20,94-95
Printed in
Greaf Britain
Traumatic diaphragmatic hernia: review of 15 cases M. I. Sebayel, Q. 0. Qasabi KingKhalid University Hospital, Riyadh, Kingdom of Saudi Arabia W. Katugampola and Inam Ahmed KingKhahd University Hospital and Riyadh Central Hospital,
bvtn]anuay
1985 to December 7987,292 &a~robtnies wereperfbmed
forinjuryin Riyadh
Central kbspital. of these 15 casts were associated
with diaphragmtic
injuries (5.1 per cent).
The diagnosis was missed in 5 uses (30 pm cenf) and was in&&&
(at
Kingdom of Saudi Arabia
nine patients. Decreased air entry was noted in eight patients. Other modes of presentation are shown in Table II. The chest radiograph on admission was normal in three patients. The commonest radiographic abnormalities in the
L7probmy) in 3 u7ses(20 per cm& Thert$re in about 50 per cent of the cam
the diagnosis ms not made at the initial pmmtahim.
In this ppm
we stress the importance af maintaining a high &grez of
clinical suspicia in on&r not to misr ttuumatic diaphragmak
hernia in
multiply injured patients.
Introduction Traumatic diaphragmatic hernia is seen in about 5 per cent of patients who undergo laparotomy for closed abdominal injuries (Griswold et al. 1972; Ward et al., 1981; Cox, 1984). The aim of this paper is to report our experience in dealing with traumatic diaphragmatic hernia and to highlight the diagnostic difficulties that a surgeon may face in dealing with this condition.
Clinical material Riyadh Central Hospital is the main receiving hospital for all forms of injury in the Riyadh region, serving a population of I.5 million. Over the 3 years 1985-1987,292 laparotomies were performed for closed and penetrating abdominal injury. Of these, 15 cases were associated with diaphragmatic injuries (5.1 per cent). The case notes of these 15 patients were reviewed and their analysis form the basis of this paper. There were 14 males and I female and the mean age was 37 years (range 3-68 years). The traumatic rupture of the diaphragm was on the left in 10 patients, and on the right in three patients, while the central tendon was involved in the remaining two. Most of the cases were victims of road traf%c accidents and only three cases were due to penetrating injuries. The associated injuries are shown in T&k 1.
Diagnosis The predominant symptoms in these patients were dyspnoea in seven patients and chest pain in six patients. Contusions of the abdominal and chest wall were seen in 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/0200942 $03.00 0
Table 1. Traumatic diaphragrnatic hernia, associated injures: IS cases injuries
No. of patients
Abdominal Liver wound Splenic injury Retroperitoneal haematoma Others
7 6 3 5
Associated
Thoracic Fractured ribs Haemothorax Pneumothorax Lung wound Ruptured pericardium Skeletal Fractured pelvis Fractured spine Fractured long bone Head injury
6 2 f 1 4 t 3
Table Il. Traumatic diaphragmatic hernia, clinical presentation IS CaSeS
Clinical presentation
No. of patients
Symptoms Dyspnoea Chest pain Shock Shoulder pain Asymptomatic
7 6 3 2 1
Signs Contusions (abdomen and chest) Diminished air entry Acute abdomen Bowel sounds in chest Tracheal deviation Coma Penetrating wound
9 8 3 2 1 1 3
95
Sebayel et al.: Traumatic diaphragmatic hernia
remaining 12 patients were organ hemiation in 9 patients, followed by fractured ribs in 7 patients and haemopneumothorax in 7 patients. Other radiological findings are shown in Table 111 Peritoneal lavage was performed in nine patients and was positive in eight. A preoperative diagnosis of ruptured diaphragm was made in seven patients (47 per cent). In three patients, rupture of the diaphragm was an incidental finding while exploring the abdomen (20 per cent). In five patients (33 per cent) the diagnosis was made l-10 days after admission, but none of them had strangulation of the herniated viscus or bowel obstruction. However, cardiopulmonary embarrassment was noted in all these cases. The overall mortality in this series was 27 per cent (4 out of 15 patients). Two patients died due to hypovolaemic shock as a result of severe associated injuries. The remaining two died later due to complications related to sepsis. The morbidity in this series include one abdominal wound infection, one residual pneumothorax and one residual haemothorax.
Discussion Recognition of traumatic diaphragmatic hernia is important because failure to do so may lead to strangulation of the herniated viscus, intestinal obstruction (Wise et al., 1973; McCune et al., 1976) and cardiopulmonary embarrassment (Ebert et al., 1967; Grimes, 1974). Difficulties in diagnosis are attributed to the rarity of the injury, lack of clinical suspicion and paucity of the clinical and radiological signs, at the initial presentation. In our series, the diagnosis was missed in five cases (30 per cent) with a mean delay of 6 days (range 0-18 days). In another three patients, the finding of traumatic diaphragmatic hernia was incidental during thoracotomy or laparotomy for another condition. Therefore, in 8 of our 15 patients (53 per cent) the diagnosis was not made at the initial presentation. From our study and others (Carter et al., 195 1; Lucid0 and Wall, 1963; Freeman and Fischer, 1976), it appears that physical examination and chest radiograph alone are inadequate to detect diaphragmatic rupture. Nasogastric tube insertion and upper gashointestinal contrast studies improved the diagnostic rate in our series (Brook, 1978). In the clinically suspected cases, other investigations have been used, e.g. pneumoperitoneum (Clay and Hanlon, 195 1; Brook, 1978), liver and spleen imaging using 99Tc sulphur colloid (Cheung and Meakins, 1980; Christensen et al., 1981; Kim et al., 1983), real time ultrasonography (Ammann et al., 1983) and computed tomography (Heiberg, et al., 1980). During laparotomy, it is important to feel carefully along the entire diaphragmatic surface (Morgan et al., 1986). In one of our patients, diaphragmatic rupture was missed during exploratory laparotomy and was detected later when the patient developed cardiopulmonary embarrassment. The operative approach in our series was mostly abdomiTable III. Traumatic diaphragmatichernia, radiographic findings: 15 cases Chest radiographic findings
nal and if this proved to be inadequate, a separate thoracotomy incision was made; this procedure is more appropriate for right-sided rupture of the diaphragm (Mansour et al., 1975). In two of our cases, a thoracoabdominal approach was employed. The mortality of 27 per cent in our series was due to hypovolaemic shock and multiple organ failure due to sepsis. None could be attributed to diaphragmatic rupture or to the delay in the diagnosis.
References Ammann A. B., Brewt
W. H. and Maul1 K. I. (1983) Traumatic rupture of diaphragm. AJR 140,915. Brook J. W. (1978) Blunt traumatic rupture of the diaphragm. Ann. Thorac. Surg. 26, 199. Carter B. N., Giuseffi J. and Felson B. (1951) Traumatic diaphragmatic hernia. AJR 65, 56. Cheung D. and Meakins J. L. (1980) Diagnosis of right sided diaphragmatic rupture by liver lung scanning. Can. J. Surg. 23, 302. Christensen P. B., Oester-Joergensen E., Schorbye J. et al. (1981) Scintigraphy with 99Tc imidodiacetic acid as diagnosis test in traumatic lesions of liver and biliary tract. Radiology 65,43. Clay R. C. and Hanlon, (1951) Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. J. Thoruc Curdiouusc. Srrrg. 2157. COX E. F. (1984) Blunt abdominal trauma: A five year analysis of 870 patients requiring celiotomy. Ann. Surg. 199,467. Ebert P. A. Gaertner R. A. and Zuidema G. D. (1967) Traumatic diaphragmatic hernia. Sung. Gyrzcol. C&&f. 125, 59. Freeman T. and Fischer R. P. (1976) The inadequacy of peritoneal lavage in diagnosis of acute diaphragmatic rupture. 1. Truwna 16, 538. Grimes 0. F. (1974); Traumatic injury of the diaphragm. Am. J. surg. 128,175. Griswold F. W., Warden H. E. and Gardner R. J. (1972) Acute diaphragmatic rupture caused by blunt trauma. Am. J. Surg. 124, 359. Heiberg E., Wolverson M. K. and Hurd R. N. (1980) CT recognition of traumatic rupture of diaphragm. AJR 135, 369. Kim E. E. McConnel 8. J., McConnel R. W. et al. (1983) Radionuclide diagnosis of diaphragmatic rupture with hepatic hemiation. Surgery 94,36. Locido J. L. and Wall C. A. (1963) Rupture of the diaphragm due to blunt trauma. Arch. Surg. 86 989. Mansour K. A., Clements J. L., Hatcher C. R. et al. (1975) Diaphragmatic hernia caused by trauma: experience with 35 cases. Am. _I.Surg. 97, 97. McCune R. P., Rod C. P. and Eckert C. (1976) Rupture of the diaphragm caused by blunt trauma. J. Trauma 16,531. Morgan A. S., Flancbaun L., Espositon T. et al. (1986) Blunt injury to the diaphragm: an analysis of 44 patients. J. Trauma 26,565. Ward R. E., Flynn T. C. and Clark W. P. (1981) Diaphragmatic disruption secondary to blunt abdominal trauma. J. Trauma 21, 35. Wise L., Connor J., Hwang Y. H. et al., (1973) Traumatic injury to the diaphragm. J. Trauma 13, 946.
No. of patients
Paper accepted Organ hemiation Fractured ribs Haemopneumothorax Elevated diaphragm Normal chest radiograph
9 7 7 5 3
21 October
1988.
Reqrcesfsfor reprints should be addressed to: M. I. Sebayel FRCS(Glas), Department of Surgery, King Khalid University Hospital, PO Box 6941, Riyadh, Kingdom of Saudi Arabia.
Injury (1989) 20,94-95
Printed in
Greaf Britain
Traumatic diaphragmatic hernia: review of 15 cases M. I. Sebayel, Q. 0. Qasabi KingKhalid University Hospital, Riyadh, Kingdom of Saudi Arabia W. Katugampola and Inam Ahmed KingKhahd University Hospital and Riyadh Central Hospital,
bvtn]anuay
1985 to December 7987,292 &a~robtnies wereperfbmed
forinjuryin Riyadh
Central kbspital. of these 15 casts were associated
with diaphragmtic
injuries (5.1 per cent).
The diagnosis was missed in 5 uses (30 pm cenf) and was in&&&
(at
Kingdom of Saudi Arabia
nine patients. Decreased air entry was noted in eight patients. Other modes of presentation are shown in Table II. The chest radiograph on admission was normal in three patients. The commonest radiographic abnormalities in the
L7probmy) in 3 u7ses(20 per cm& Thert$re in about 50 per cent of the cam
the diagnosis ms not made at the initial pmmtahim.
In this ppm
we stress the importance af maintaining a high &grez of
clinical suspicia in on&r not to misr ttuumatic diaphragmak
hernia in
multiply injured patients.
Introduction Traumatic diaphragmatic hernia is seen in about 5 per cent of patients who undergo laparotomy for closed abdominal injuries (Griswold et al. 1972; Ward et al., 1981; Cox, 1984). The aim of this paper is to report our experience in dealing with traumatic diaphragmatic hernia and to highlight the diagnostic difficulties that a surgeon may face in dealing with this condition.
Clinical material Riyadh Central Hospital is the main receiving hospital for all forms of injury in the Riyadh region, serving a population of I.5 million. Over the 3 years 1985-1987,292 laparotomies were performed for closed and penetrating abdominal injury. Of these, 15 cases were associated with diaphragmatic injuries (5.1 per cent). The case notes of these 15 patients were reviewed and their analysis form the basis of this paper. There were 14 males and I female and the mean age was 37 years (range 3-68 years). The traumatic rupture of the diaphragm was on the left in 10 patients, and on the right in three patients, while the central tendon was involved in the remaining two. Most of the cases were victims of road traf%c accidents and only three cases were due to penetrating injuries. The associated injuries are shown in T&k 1.
Diagnosis The predominant symptoms in these patients were dyspnoea in seven patients and chest pain in six patients. Contusions of the abdominal and chest wall were seen in 1989 Butterworth & Co (Publishers) Ltd 0020-1383/89/0200942 $03.00 0
Table 1. Traumatic diaphragrnatic hernia, associated injures: IS cases injuries
No. of patients
Abdominal Liver wound Splenic injury Retroperitoneal haematoma Others
7 6 3 5
Associated
Thoracic Fractured ribs Haemothorax Pneumothorax Lung wound Ruptured pericardium Skeletal Fractured pelvis Fractured spine Fractured long bone Head injury
6 2 f 1 4 t 3
Table Il. Traumatic diaphragmatic hernia, clinical presentation IS CaSeS
Clinical presentation
No. of patients
Symptoms Dyspnoea Chest pain Shock Shoulder pain Asymptomatic
7 6 3 2 1
Signs Contusions (abdomen and chest) Diminished air entry Acute abdomen Bowel sounds in chest Tracheal deviation Coma Penetrating wound
9 8 3 2 1 1 3
95
Sebayel et al.: Traumatic diaphragmatic hernia
remaining 12 patients were organ hemiation in 9 patients, followed by fractured ribs in 7 patients and haemopneumothorax in 7 patients. Other radiological findings are shown in Table 111 Peritoneal lavage was performed in nine patients and was positive in eight. A preoperative diagnosis of ruptured diaphragm was made in seven patients (47 per cent). In three patients, rupture of the diaphragm was an incidental finding while exploring the abdomen (20 per cent). In five patients (33 per cent) the diagnosis was made l-10 days after admission, but none of them had strangulation of the herniated viscus or bowel obstruction. However, cardiopulmonary embarrassment was noted in all these cases. The overall mortality in this series was 27 per cent (4 out of 15 patients). Two patients died due to hypovolaemic shock as a result of severe associated injuries. The remaining two died later due to complications related to sepsis. The morbidity in this series include one abdominal wound infection, one residual pneumothorax and one residual haemothorax.
Discussion Recognition of traumatic diaphragmatic hernia is important because failure to do so may lead to strangulation of the herniated viscus, intestinal obstruction (Wise et al., 1973; McCune et al., 1976) and cardiopulmonary embarrassment (Ebert et al., 1967; Grimes, 1974). Difficulties in diagnosis are attributed to the rarity of the injury, lack of clinical suspicion and paucity of the clinical and radiological signs, at the initial presentation. In our series, the diagnosis was missed in five cases (30 per cent) with a mean delay of 6 days (range 0-18 days). In another three patients, the finding of traumatic diaphragmatic hernia was incidental during thoracotomy or laparotomy for another condition. Therefore, in 8 of our 15 patients (53 per cent) the diagnosis was not made at the initial presentation. From our study and others (Carter et al., 195 1; Lucid0 and Wall, 1963; Freeman and Fischer, 1976), it appears that physical examination and chest radiograph alone are inadequate to detect diaphragmatic rupture. Nasogastric tube insertion and upper gashointestinal contrast studies improved the diagnostic rate in our series (Brook, 1978). In the clinically suspected cases, other investigations have been used, e.g. pneumoperitoneum (Clay and Hanlon, 195 1; Brook, 1978), liver and spleen imaging using 99Tc sulphur colloid (Cheung and Meakins, 1980; Christensen et al., 1981; Kim et al., 1983), real time ultrasonography (Ammann et al., 1983) and computed tomography (Heiberg, et al., 1980). During laparotomy, it is important to feel carefully along the entire diaphragmatic surface (Morgan et al., 1986). In one of our patients, diaphragmatic rupture was missed during exploratory laparotomy and was detected later when the patient developed cardiopulmonary embarrassment. The operative approach in our series was mostly abdomiTable III. Traumatic diaphragmatichernia, radiographic findings: 15 cases Chest radiographic findings
nal and if this proved to be inadequate, a separate thoracotomy incision was made; this procedure is more appropriate for right-sided rupture of the diaphragm (Mansour et al., 1975). In two of our cases, a thoracoabdominal approach was employed. The mortality of 27 per cent in our series was due to hypovolaemic shock and multiple organ failure due to sepsis. None could be attributed to diaphragmatic rupture or to the delay in the diagnosis.
References Ammann A. B., Brewt
W. H. and Maul1 K. I. (1983) Traumatic rupture of diaphragm. AJR 140,915. Brook J. W. (1978) Blunt traumatic rupture of the diaphragm. Ann. Thorac. Surg. 26, 199. Carter B. N., Giuseffi J. and Felson B. (1951) Traumatic diaphragmatic hernia. AJR 65, 56. Cheung D. and Meakins J. L. (1980) Diagnosis of right sided diaphragmatic rupture by liver lung scanning. Can. J. Surg. 23, 302. Christensen P. B., Oester-Joergensen E., Schorbye J. et al. (1981) Scintigraphy with 99Tc imidodiacetic acid as diagnosis test in traumatic lesions of liver and biliary tract. Radiology 65,43. Clay R. C. and Hanlon, (1951) Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. J. Thoruc Curdiouusc. Srrrg. 2157. COX E. F. (1984) Blunt abdominal trauma: A five year analysis of 870 patients requiring celiotomy. Ann. Surg. 199,467. Ebert P. A. Gaertner R. A. and Zuidema G. D. (1967) Traumatic diaphragmatic hernia. Sung. Gyrzcol. C&&f. 125, 59. Freeman T. and Fischer R. P. (1976) The inadequacy of peritoneal lavage in diagnosis of acute diaphragmatic rupture. 1. Truwna 16, 538. Grimes 0. F. (1974); Traumatic injury of the diaphragm. Am. J. surg. 128,175. Griswold F. W., Warden H. E. and Gardner R. J. (1972) Acute diaphragmatic rupture caused by blunt trauma. Am. J. Surg. 124, 359. Heiberg E., Wolverson M. K. and Hurd R. N. (1980) CT recognition of traumatic rupture of diaphragm. AJR 135, 369. Kim E. E. McConnel 8. J., McConnel R. W. et al. (1983) Radionuclide diagnosis of diaphragmatic rupture with hepatic hemiation. Surgery 94,36. Locido J. L. and Wall C. A. (1963) Rupture of the diaphragm due to blunt trauma. Arch. Surg. 86 989. Mansour K. A., Clements J. L., Hatcher C. R. et al. (1975) Diaphragmatic hernia caused by trauma: experience with 35 cases. Am. _I.Surg. 97, 97. McCune R. P., Rod C. P. and Eckert C. (1976) Rupture of the diaphragm caused by blunt trauma. J. Trauma 16,531. Morgan A. S., Flancbaun L., Espositon T. et al. (1986) Blunt injury to the diaphragm: an analysis of 44 patients. J. Trauma 26,565. Ward R. E., Flynn T. C. and Clark W. P. (1981) Diaphragmatic disruption secondary to blunt abdominal trauma. J. Trauma 21, 35. Wise L., Connor J., Hwang Y. H. et al., (1973) Traumatic injury to the diaphragm. J. Trauma 13, 946.
No. of patients
Paper accepted Organ hemiation Fractured ribs Haemopneumothorax Elevated diaphragm Normal chest radiograph
9 7 7 5 3
21 October
1988.
Reqrcesfsfor reprints should be addressed to: M. I. Sebayel FRCS(Glas), Department of Surgery, King Khalid University Hospital, PO Box 6941, Riyadh, Kingdom of Saudi Arabia.