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Traumatic rupture of diaphragm
Traumatic rupture of diaphragm Surgical reconstruction with special reference to delayed closure Thirteen cases of diaphragmatic rupture following blunt trauma or gunshot wounds are presented. In to cases the diagnosis of diaphragmatic rupture was made immediately following the injury, and the defect was closed by primary diaphragmatic suture. In three cases, the diagnosis was delayed for 3 to /6 years after the initial trauma. In all of them, abdominal organs such as the colon or liver had migrated into the thoracic cavity. One of them had acute intestinal obstruction and died following several unsuccessful operations. The remaining two patients required plastic repair of the diaphragmatic hernia by a Dacron patch, and both recovered. The clinical and pathological aspects of diaphragmatic rupture, the importance of early diagnosis and surgical correction, and the surgical approach to this entity are considered. The use of Dacron fabric in delayed closure of diaphragmatic defects is described.
Z. Feigenberg, M.D., 1. Salomon, M.D., and M. J. Levy, M.D.,* Petach-Tikva, Israel
UndiagnOsed rupture of the diaphragm may present both diagnostic and therapeutic problems. The patient's complaints are usually nonspecific, and in only thirty to sixty percent of the cases are the x-ray findings characteristic.!- 2 In some cases the rupture is diagnosed only several years later, the diaphragm meanwhile having undergone atrophic changes; thus its reconstruction without the use of synthetic materials is difficult. Between 1965 and 1975, 13 patients were operated upon in the Beilinson Hospital for traumatic diaphragmatic rupture, with or without herniation of the abdominal contents. In 10 patients, the rupture was diagnosed on admission; in the remaining three, diagnosis was delayed. Of the latter three patients, one died as a result of strangulation of the colon in the chest 15 years after the primary trauma; in the other two patients, rupture was diagnosed 3 and 4 years, respectively, after the trauma. In both cases it was necessary to use a synthetic patch to close the gap in diaphragm, the diameter of the gap being 15 and 25 ern. , From the Thoracic and Cardiovascular Surgery Department and Surgery Department "A," Beilinson Hospital, University of Tel-Aviv Medical School, Petach-Tikva, Israel. Received for publication Jan. 10, 1977. Accepted for publication Feb. 15, 1977. *Professor of Surgery, University of Tel-Aviv Medical School.
respectively. A Dacron patch proved effective, and there were no signs of recurrent herniation during follow-up. Excellent results were obtained in the remaining cases of primary repair. The importance of early diagnosis and repair of traumatic rupture, the risks of delayed diagnosis, and the methods for its surgical repair with a synthetic patch constitute the basis of this communication.
Patients and methods Thirteen patients, II men and two women, were operated upon for traumatic rupture of the diaphragm during a 10 year period from 1965 to 1975. Their ages ranged from 18 to 54 years, the average age being 34 years. The causes of the trauma were road accidents in six cases, war wounds in four, accidental pistol-shot wounds in two, and a stab wound in the remaining patient. Perforating wounds of the chest or upper abdomen occurred in eight of the patients, whereas in the remaining five the trauma was blunt. The left hemidiaphragm was involved in eight cases and the right in five. All the patients sustained additional injuries: lung injury in four; splenic rupture in four; hepatic tear in four; rib fractures in four; additional limb, pelvic, and vertebral fractures in four; head injury in three; tearing of the colon in one case; and tearing of the heart with cardiac tamponade in another. 249
250 Feigenberg, Salomon, Levy
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Case 3. Left. Chest radiography showing elevation of the right hemidiaphragm. Right. Radiograph after the operation showing the reconstructed hemidiaphragm.
Fig. 2. Case 3. A barium-filled loop of colon is demonstrated in the right hemithorax.
Case reports CASE I. A 43-year-old man sustained a bullet wound during the Israeli War of Independence (1948). The bullet penetrated the left axilla, chest, and abdomen and emerged through the left loin. Ten years later, the man was admitted with abdominal pain in the left upper quadrant which radiated to the left loin. X-ray examination of the colon showed a narrowed segment involving 15 em. of the left hemicolon near the splenic flexure. Laparotomy was performed, and severe adhesions were found to have caused partial obstruction of the colon. In addition, there was a 5 ern. defect in the diaphragm on the left. The adhesions were freed and the colon was replaced in the abdomen, but it was not possible to close the diaphragmatic defect primarily. The patient was advised to undergo a further operation via a thoracotomy, but he refused. Six years later, signs of acute intestinal obstruc-
tion developed with x-ray evidence of a segment of colon in the left side of the chest. At an emergency laparotomy, it proved impossible to identify the diaphragmatic defect. A thoracotomy revealed a gangrenous segment of colon which had herniated into the left side of the chest through the defect. Partial colectomy, splenectomy, and closure of the tear in the diaphragm were performed. The patient's condition remained critical, and 3 weeks later he died in a state of shock from peritonitis and empyema. CASE 2. A 41-year-old man was severely injured in a road accident in Iran, 3 years prior to his admission to our department. At that time, he sustained a head injury with loss of consciousness, right-sided rib fractures, and a fractured pelvis. An urgent laparotomy was performed in Iran immediately after the accident. Since then he continued to have right-sided chest pain and dyspnea. Three years after the accident, the chest x-ray film showed a shadow in the right lower lung field. Radioactive scan showed this to be the liver, which was elevated and rotated into the right hemithorax. Pulmonary function tests demonstrated a slight restrictive disturbance with mild hypoxia. At thoracotomy, the right side of the diaphragm was found to be elevated and atrophic, with a defect, 15 cm. in diameter, in its central and anterior portion. The liver was adherent to the defect, and two thirds of that organ occupied the right lower hemithorax. The lower lobe of the lung was atelectatic. After the adhesions between the right side of the diaphragm and the liver were .freed, the latter organ was replaced in the abdomen, and the defect in the diaphragm was closed with Dacron strips. Following this procedure, the lower lobe of the right lung expanded easily. The postoperative course was uneventful, and follow-up examination 4 years after the operation showed a slightly elevated right diaphragm with a fully expanded lung. The patient was well and free of symptoms. CASE 3. A 29-year-old male truck driver was injured in a road accident 4 years prior to his admission to our department. He sustained a head injury with loss of consciousness, superficial facial wounds, a fractured left elbow, and blunt trauma to the right side of the chest, with closed fractures of the fifth to eighth ribs. After being hospitalized for several days, he was discharged in good condition. Since the acci-
Volume 74 Number 2
August,19n
Traumatic rupture of diaphragm
25 I
Fig. 3. Case 3. Picture taken during the operation, showing part of the liver and several loops of large bowel which herniated into the thoracic cavity.
Fig. 4. Picture showing the diaphragmatic defect closed by a Dacron patch after the herniated liver and colon had been replaced into the abdominal cavity.
dent, he had had right-sided chest pain, which increased in severity with the passage of time. More recently, he also noted shortness of breath. A chest x-ray film 3 years after the accident showed elevation of the right hemidiaphragm (Fig. I ) which moved paradoxically on fluoroscopy . Pulmonary function studies at this stage showed a mixed ventilatory and restrictive disturbance with mild hypoxia. Six months later, chest x-ray film suggested the presence of bowel in the right side of the thorax. A barium study showed a loop of large bowel contained in a right-sided diaphragmatic hernia (Fig. 2). Through a right thoracotomy, a defect, 25 em, in diameter, was found in the anterior part of the right hemidiaphragm. Through this defect, several loops of large bowel and most of the liver, which was rotated, had herniated into the chest (Fig. 3). Parts of these organs were adherent to the pleura and lower lobe of the right lung. After the adhesions were divided, all abdominal organs were returned to the abdominal cavity. Because it was not possible to close the diaphragmatic defect by direct suture, the defect was reconstructed by means of a large Dacron patch (Fig. 4). The postoperative course was uneventful, and the patient was discharged on the eleventh postoperative day. He has remained well and symptom free one year after operation. On chest roentgenogram, the right hemidiaphragm is in the normal position and there are no signs of recurrent hernia (Fig. I) .
water on normal deep inspiration, and during severe trauma this pres sure may be tenfold higher. The area of the diaphragm most commonly injured is the apex of the left hemidiaphragm, this part being the weakest" and the only sector relatively unprotected by the abdominal organs. 7 Diaphragmatic hernia from blunt injury occurs twenty times more commonly on the left side than on the right. 6-11 In a review of the literature , Epstein and colleagues" found onl y 36 cases of right-sided diaphragmatic rupture as a result of blunt injury to the thorax . In the present stud y, in five of the 13 cases , the rupture was on the right side . This can be ascribed to the higher incidence of penetrating injury owing to bullet or shrapnel wounds in our series. Diaphragmatic injury is accompanied by additional injuries in 66 percent of cases.P The most common associated injuries are laceration of other organs in the chest or abdomen and fractures of the ribs, spinal column , and pelvis. More than 50 percent of the cases of diaphragmatic rupture are diagnosed during emergency operation, and the hernia is then easily repaired by means of dire ct primary suture . When the patient does not undergo immediate operation , the diagnosis of diaphragmatic rupture and hernia is more difficult, and frequently it is overlooked for years. Bekassy and assoelates" found that, in 50 percent of these patients, the diagnosis was made 5 or more years after the original injury. Rare cases are described in the literature in which the diagnosis was made 27 to 44 years after the injury." 11 , 12 The difficulty in establishing an early diagnosis is due to the fact that these patients do not have specifi c complaints, and the chest x-ray film is often unremarkable. Wise and co-workers' found a normal che st x-ray film in 37 percent of patients in
Discussion The frequency of diaphragmatic rupture owing to penetrating or blunt injury of the chest or the upper abdomen is 4.5 percent of all such injuries." In recent years, with high-speed road accidents having become more common," Drews and associates found that this structure sustained injury in 5.8 percent of all cases." The mechanism by which traumatic diaphragmatic hernia develops is explained by the significant difference in pressure between the abdominal and thoracic cavities. This pressure difference can reach 100 em. of
252
The Journal of Thoracic and Cardiovascular
Feigenberg, Salomon, Levy
Surgery
whom diaphragmatic rupture was found at operation or necrospy; Andrus and associates" found an abnormal chest x-ray film in only four of 25 such patients. It is of great importance to establish an early diagnosis and to undertake immediate treatment of any diaphragmatic rupture. When the hernia is discovered at a later stage, or when there are signs of incarceration of intestine within the hernia, the mortality rate can reach 66 percent.!' The patients described by Waldhausen" and Bekassy, 6 who died after undergoing intestinal resection, are similar to our first patient, who also died following resection of gangrenous colon. In chronic cases following trauma, it is often difficult to differentiate between a hernia and diaphragmatic paralysis caused by nerve injury, unless bowel is found in the thoracic cavity. 13 In the three patients who underwent operation in our hospital several years after their injuries, a significant portion of the remaining diaphragm was found to be atrophied, paralyzed, and functionless. This progressive muscle atrophy results in an increase in the size of the initial hernial opening until repair by primary suture becomes impossible. This finding is relatively rare, and in the more recent literature only 10 similar cases have been described. In these cases, the defect should be closed by means of a patch or graft. Several authors have used the patient's own tissue, such as pericardiumv 12. 13 or intercostal muscles with fascia. Others have employed synthetic materials such as Marlex or other types of plastic mesh.": 8 In our series, the use of Dacron fabric for this purpose is reported for the first time. There is a difference of opinion in the literature concerning the best surgical approach for the repair of traumatic diaphragmatic hernia. Immediately after the injury, the tear is usually linear and can be repaired through either an abdominal or thoracic incision. Thus the surgical approach would depend on the site of additional injuries. Repair of a diaphragmatic hernia diagnosed at a later stage must be undertaken through a thoracotomy. As a result of the injury, adhesions form between those abdominal organs which rise into the thorax, and the pleura, pericardium, or lung. These adhesions cannot safely be freed through an abdominal approach. In our series, as in others,"- 8. 13 attempts to repair the hernia through the abdomen proved unsuccessful, and in all cases the final repair had to be undertaken through the thorax at an additional operation. It is generally accepted that early diagnosis of the
diaphragmatic hernia is no less important than the repair itself, which can then easily be performed by direct suture. Because of the difficulties in accurate diagnosis from a plain chest x-ray film, Drews and colleagues" advocate that barium studies of the stomach and intestine be performed in all cases of trauma to the area between the fourth rib and the umbilicus and in those patients in whom chest or upper abdominal pain continues for a longer period than usual. When a hernia is diagnosed, its repair should be undertaken as soon as possible to prevent complications and to avoid the need for more complex operations, occasionally under emergency conditions. REFERENCES
2 3
4
5
6
7
8
9
10 11 12
13
Wise, L., Connors, J., Hwang, Y. H., et al.: Traumatic Injuries to the Diaphragm, J. Trauma 13: 946, 1973. Andrus, C. H., Morton, J. H.: Rupture of the Diaphragm After Blunt Trauma, Am. J. Surg. 119: 686, 1970. Epstein, L. I., and Lempke, R. E.: Rupture of the Right Hemidiaphragm due to Blunt Injury, J. Trauma 8: 19, 1968. Salomon, 1., Feller, N., and Levy, M. 1.: A Case of Spontaneous Rupture of the Diaphragm, J. THORAC. CARDIOV xsc. SURG. 58: 221, 1969. Drews, 1. A., Mercer, E. c., and Benfield, J. R.: Acute Diaphragmatic Injuries, Ann. Thorac. Surg. 16: 67, 1973. Bekassy, S. M., Dave, K. S., Wooler, G. H., et a1.: Spontaneous and Traumatic Rupture of the Diaphragm, Ann. Surg. 177: 320, 1973. Lucido, J. L., and Wall, C. A.: Rupture of the Diaphragm Due to Blunt Trauma, Arch. Surg. 86: 989, 1963. Waldhausen, J. A., Kilman, J. W., Helman, C. H., et al.: The Diagnosis and Management of Traumatic Injuries of the Diaphragm Including the Use of Marlex Prostheses, J. Trauma 6: 332, 1966. Ebert, P. A., Gaertner, R. A., and Zuidema, G. D.: Traumatic Diaphragmatic Hernia, Surg. Gynecol. Obstet. 125: 59, 1967. Wren, H. B., Texada, P. J., and Krementz, F. T.: Traumatic Rupture of the Diaphragm, 1. 'Trauma 2: 117, 1962. Grimes, O. F.: Traumatic Injuries of the Diaphragm, Am. 1. Surg. 128: 175, 1974. Schwindt, W. D., and Gale, S. W.: Late Recognition and Treatment of Traumatic Diaphragmatic Hernia, Arch Surg. 94: 330, 1976. Probert, W. R., and Havard, C.: Traumatic Diaphragmatic Hernia, Thorax 16: 99, 1961.
Z. Feigenberg, M.D., 1. Salomon, M.D., and M. J. Levy, M.D.,* Petach-Tikva, Israel
UndiagnOsed rupture of the diaphragm may present both diagnostic and therapeutic problems. The patient's complaints are usually nonspecific, and in only thirty to sixty percent of the cases are the x-ray findings characteristic.!- 2 In some cases the rupture is diagnosed only several years later, the diaphragm meanwhile having undergone atrophic changes; thus its reconstruction without the use of synthetic materials is difficult. Between 1965 and 1975, 13 patients were operated upon in the Beilinson Hospital for traumatic diaphragmatic rupture, with or without herniation of the abdominal contents. In 10 patients, the rupture was diagnosed on admission; in the remaining three, diagnosis was delayed. Of the latter three patients, one died as a result of strangulation of the colon in the chest 15 years after the primary trauma; in the other two patients, rupture was diagnosed 3 and 4 years, respectively, after the trauma. In both cases it was necessary to use a synthetic patch to close the gap in diaphragm, the diameter of the gap being 15 and 25 ern. , From the Thoracic and Cardiovascular Surgery Department and Surgery Department "A," Beilinson Hospital, University of Tel-Aviv Medical School, Petach-Tikva, Israel. Received for publication Jan. 10, 1977. Accepted for publication Feb. 15, 1977. *Professor of Surgery, University of Tel-Aviv Medical School.
respectively. A Dacron patch proved effective, and there were no signs of recurrent herniation during follow-up. Excellent results were obtained in the remaining cases of primary repair. The importance of early diagnosis and repair of traumatic rupture, the risks of delayed diagnosis, and the methods for its surgical repair with a synthetic patch constitute the basis of this communication.
Patients and methods Thirteen patients, II men and two women, were operated upon for traumatic rupture of the diaphragm during a 10 year period from 1965 to 1975. Their ages ranged from 18 to 54 years, the average age being 34 years. The causes of the trauma were road accidents in six cases, war wounds in four, accidental pistol-shot wounds in two, and a stab wound in the remaining patient. Perforating wounds of the chest or upper abdomen occurred in eight of the patients, whereas in the remaining five the trauma was blunt. The left hemidiaphragm was involved in eight cases and the right in five. All the patients sustained additional injuries: lung injury in four; splenic rupture in four; hepatic tear in four; rib fractures in four; additional limb, pelvic, and vertebral fractures in four; head injury in three; tearing of the colon in one case; and tearing of the heart with cardiac tamponade in another. 249
250 Feigenberg, Salomon, Levy
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Case 3. Left. Chest radiography showing elevation of the right hemidiaphragm. Right. Radiograph after the operation showing the reconstructed hemidiaphragm.
Fig. 2. Case 3. A barium-filled loop of colon is demonstrated in the right hemithorax.
Case reports CASE I. A 43-year-old man sustained a bullet wound during the Israeli War of Independence (1948). The bullet penetrated the left axilla, chest, and abdomen and emerged through the left loin. Ten years later, the man was admitted with abdominal pain in the left upper quadrant which radiated to the left loin. X-ray examination of the colon showed a narrowed segment involving 15 em. of the left hemicolon near the splenic flexure. Laparotomy was performed, and severe adhesions were found to have caused partial obstruction of the colon. In addition, there was a 5 ern. defect in the diaphragm on the left. The adhesions were freed and the colon was replaced in the abdomen, but it was not possible to close the diaphragmatic defect primarily. The patient was advised to undergo a further operation via a thoracotomy, but he refused. Six years later, signs of acute intestinal obstruc-
tion developed with x-ray evidence of a segment of colon in the left side of the chest. At an emergency laparotomy, it proved impossible to identify the diaphragmatic defect. A thoracotomy revealed a gangrenous segment of colon which had herniated into the left side of the chest through the defect. Partial colectomy, splenectomy, and closure of the tear in the diaphragm were performed. The patient's condition remained critical, and 3 weeks later he died in a state of shock from peritonitis and empyema. CASE 2. A 41-year-old man was severely injured in a road accident in Iran, 3 years prior to his admission to our department. At that time, he sustained a head injury with loss of consciousness, right-sided rib fractures, and a fractured pelvis. An urgent laparotomy was performed in Iran immediately after the accident. Since then he continued to have right-sided chest pain and dyspnea. Three years after the accident, the chest x-ray film showed a shadow in the right lower lung field. Radioactive scan showed this to be the liver, which was elevated and rotated into the right hemithorax. Pulmonary function tests demonstrated a slight restrictive disturbance with mild hypoxia. At thoracotomy, the right side of the diaphragm was found to be elevated and atrophic, with a defect, 15 cm. in diameter, in its central and anterior portion. The liver was adherent to the defect, and two thirds of that organ occupied the right lower hemithorax. The lower lobe of the lung was atelectatic. After the adhesions between the right side of the diaphragm and the liver were .freed, the latter organ was replaced in the abdomen, and the defect in the diaphragm was closed with Dacron strips. Following this procedure, the lower lobe of the right lung expanded easily. The postoperative course was uneventful, and follow-up examination 4 years after the operation showed a slightly elevated right diaphragm with a fully expanded lung. The patient was well and free of symptoms. CASE 3. A 29-year-old male truck driver was injured in a road accident 4 years prior to his admission to our department. He sustained a head injury with loss of consciousness, superficial facial wounds, a fractured left elbow, and blunt trauma to the right side of the chest, with closed fractures of the fifth to eighth ribs. After being hospitalized for several days, he was discharged in good condition. Since the acci-
Volume 74 Number 2
August,19n
Traumatic rupture of diaphragm
25 I
Fig. 3. Case 3. Picture taken during the operation, showing part of the liver and several loops of large bowel which herniated into the thoracic cavity.
Fig. 4. Picture showing the diaphragmatic defect closed by a Dacron patch after the herniated liver and colon had been replaced into the abdominal cavity.
dent, he had had right-sided chest pain, which increased in severity with the passage of time. More recently, he also noted shortness of breath. A chest x-ray film 3 years after the accident showed elevation of the right hemidiaphragm (Fig. I ) which moved paradoxically on fluoroscopy . Pulmonary function studies at this stage showed a mixed ventilatory and restrictive disturbance with mild hypoxia. Six months later, chest x-ray film suggested the presence of bowel in the right side of the thorax. A barium study showed a loop of large bowel contained in a right-sided diaphragmatic hernia (Fig. 2). Through a right thoracotomy, a defect, 25 em, in diameter, was found in the anterior part of the right hemidiaphragm. Through this defect, several loops of large bowel and most of the liver, which was rotated, had herniated into the chest (Fig. 3). Parts of these organs were adherent to the pleura and lower lobe of the right lung. After the adhesions were divided, all abdominal organs were returned to the abdominal cavity. Because it was not possible to close the diaphragmatic defect by direct suture, the defect was reconstructed by means of a large Dacron patch (Fig. 4). The postoperative course was uneventful, and the patient was discharged on the eleventh postoperative day. He has remained well and symptom free one year after operation. On chest roentgenogram, the right hemidiaphragm is in the normal position and there are no signs of recurrent hernia (Fig. I) .
water on normal deep inspiration, and during severe trauma this pres sure may be tenfold higher. The area of the diaphragm most commonly injured is the apex of the left hemidiaphragm, this part being the weakest" and the only sector relatively unprotected by the abdominal organs. 7 Diaphragmatic hernia from blunt injury occurs twenty times more commonly on the left side than on the right. 6-11 In a review of the literature , Epstein and colleagues" found onl y 36 cases of right-sided diaphragmatic rupture as a result of blunt injury to the thorax . In the present stud y, in five of the 13 cases , the rupture was on the right side . This can be ascribed to the higher incidence of penetrating injury owing to bullet or shrapnel wounds in our series. Diaphragmatic injury is accompanied by additional injuries in 66 percent of cases.P The most common associated injuries are laceration of other organs in the chest or abdomen and fractures of the ribs, spinal column , and pelvis. More than 50 percent of the cases of diaphragmatic rupture are diagnosed during emergency operation, and the hernia is then easily repaired by means of dire ct primary suture . When the patient does not undergo immediate operation , the diagnosis of diaphragmatic rupture and hernia is more difficult, and frequently it is overlooked for years. Bekassy and assoelates" found that, in 50 percent of these patients, the diagnosis was made 5 or more years after the original injury. Rare cases are described in the literature in which the diagnosis was made 27 to 44 years after the injury." 11 , 12 The difficulty in establishing an early diagnosis is due to the fact that these patients do not have specifi c complaints, and the chest x-ray film is often unremarkable. Wise and co-workers' found a normal che st x-ray film in 37 percent of patients in
Discussion The frequency of diaphragmatic rupture owing to penetrating or blunt injury of the chest or the upper abdomen is 4.5 percent of all such injuries." In recent years, with high-speed road accidents having become more common," Drews and associates found that this structure sustained injury in 5.8 percent of all cases." The mechanism by which traumatic diaphragmatic hernia develops is explained by the significant difference in pressure between the abdominal and thoracic cavities. This pressure difference can reach 100 em. of
252
The Journal of Thoracic and Cardiovascular
Feigenberg, Salomon, Levy
Surgery
whom diaphragmatic rupture was found at operation or necrospy; Andrus and associates" found an abnormal chest x-ray film in only four of 25 such patients. It is of great importance to establish an early diagnosis and to undertake immediate treatment of any diaphragmatic rupture. When the hernia is discovered at a later stage, or when there are signs of incarceration of intestine within the hernia, the mortality rate can reach 66 percent.!' The patients described by Waldhausen" and Bekassy, 6 who died after undergoing intestinal resection, are similar to our first patient, who also died following resection of gangrenous colon. In chronic cases following trauma, it is often difficult to differentiate between a hernia and diaphragmatic paralysis caused by nerve injury, unless bowel is found in the thoracic cavity. 13 In the three patients who underwent operation in our hospital several years after their injuries, a significant portion of the remaining diaphragm was found to be atrophied, paralyzed, and functionless. This progressive muscle atrophy results in an increase in the size of the initial hernial opening until repair by primary suture becomes impossible. This finding is relatively rare, and in the more recent literature only 10 similar cases have been described. In these cases, the defect should be closed by means of a patch or graft. Several authors have used the patient's own tissue, such as pericardiumv 12. 13 or intercostal muscles with fascia. Others have employed synthetic materials such as Marlex or other types of plastic mesh.": 8 In our series, the use of Dacron fabric for this purpose is reported for the first time. There is a difference of opinion in the literature concerning the best surgical approach for the repair of traumatic diaphragmatic hernia. Immediately after the injury, the tear is usually linear and can be repaired through either an abdominal or thoracic incision. Thus the surgical approach would depend on the site of additional injuries. Repair of a diaphragmatic hernia diagnosed at a later stage must be undertaken through a thoracotomy. As a result of the injury, adhesions form between those abdominal organs which rise into the thorax, and the pleura, pericardium, or lung. These adhesions cannot safely be freed through an abdominal approach. In our series, as in others,"- 8. 13 attempts to repair the hernia through the abdomen proved unsuccessful, and in all cases the final repair had to be undertaken through the thorax at an additional operation. It is generally accepted that early diagnosis of the
diaphragmatic hernia is no less important than the repair itself, which can then easily be performed by direct suture. Because of the difficulties in accurate diagnosis from a plain chest x-ray film, Drews and colleagues" advocate that barium studies of the stomach and intestine be performed in all cases of trauma to the area between the fourth rib and the umbilicus and in those patients in whom chest or upper abdominal pain continues for a longer period than usual. When a hernia is diagnosed, its repair should be undertaken as soon as possible to prevent complications and to avoid the need for more complex operations, occasionally under emergency conditions. REFERENCES
2 3
4
5
6
7
8
9
10 11 12
13
Wise, L., Connors, J., Hwang, Y. H., et al.: Traumatic Injuries to the Diaphragm, J. Trauma 13: 946, 1973. Andrus, C. H., Morton, J. H.: Rupture of the Diaphragm After Blunt Trauma, Am. J. Surg. 119: 686, 1970. Epstein, L. I., and Lempke, R. E.: Rupture of the Right Hemidiaphragm due to Blunt Injury, J. Trauma 8: 19, 1968. Salomon, 1., Feller, N., and Levy, M. 1.: A Case of Spontaneous Rupture of the Diaphragm, J. THORAC. CARDIOV xsc. SURG. 58: 221, 1969. Drews, 1. A., Mercer, E. c., and Benfield, J. R.: Acute Diaphragmatic Injuries, Ann. Thorac. Surg. 16: 67, 1973. Bekassy, S. M., Dave, K. S., Wooler, G. H., et a1.: Spontaneous and Traumatic Rupture of the Diaphragm, Ann. Surg. 177: 320, 1973. Lucido, J. L., and Wall, C. A.: Rupture of the Diaphragm Due to Blunt Trauma, Arch. Surg. 86: 989, 1963. Waldhausen, J. A., Kilman, J. W., Helman, C. H., et al.: The Diagnosis and Management of Traumatic Injuries of the Diaphragm Including the Use of Marlex Prostheses, J. Trauma 6: 332, 1966. Ebert, P. A., Gaertner, R. A., and Zuidema, G. D.: Traumatic Diaphragmatic Hernia, Surg. Gynecol. Obstet. 125: 59, 1967. Wren, H. B., Texada, P. J., and Krementz, F. T.: Traumatic Rupture of the Diaphragm, 1. 'Trauma 2: 117, 1962. Grimes, O. F.: Traumatic Injuries of the Diaphragm, Am. 1. Surg. 128: 175, 1974. Schwindt, W. D., and Gale, S. W.: Late Recognition and Treatment of Traumatic Diaphragmatic Hernia, Arch Surg. 94: 330, 1976. Probert, W. R., and Havard, C.: Traumatic Diaphragmatic Hernia, Thorax 16: 99, 1961.