Traumatic diaphragmatic hernias: a report of 26 cases

Right-sided diaphragmatic hernia causing gastric outlet obstruction 1 month after trauma

Diaphragmatic hernias arising from trauma are rare, and scarcely present in a delayed manner. This case report highlights a case of delayed presentation of a right-sided post-traumatic hernia in a woman in her early 70s following a fall. The aim of this report is to shed light on the diagnostic peculiarities and management. The woman presented with a 3-day history of abdominal pain and coffee-ground vomiting. This followed a fall a month ago. CT confirmed the diagnosis of a gastric outlet obstruction secondary to a right-sided diaphragmatic rupture. At surgery, the herniated abdominal contents were reduced, and the diaphragmatic defect was fixed. The postoperative recovery was unremarkable, and the patient was discharged on day 4. This case highlights that diaphragmatic hernias should be considered as differential diagnoses following recent trauma.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Diaphragmatic rupture secondary to trauma from falling sacks: A case report

Key Clinical Message

Diaphragmatic hernia does not only occur during high velocity impact or penetrating injury, but also can occur when heavy loads impact the torso. Diaphragmatic hernia must be ruled out in a patient with polytrauma with a chest X-ray at the least.

Abstract

Trauma-induced diaphragmatic hernia is a protrusion of abdominal contents through the defect in diaphragm and is an uncommon and less heard of injury. This case report conveys that diaphragmatic hernia should be ruled out in any polytrauma case presenting with shortness of breath with the chest X-ray at the least.

Simultaneous pneumothorax and pneumoperitoneum as a late consequence of traumatic injury of the diaphragm: Multimodality imaging approach with surgical correlation and treatment

Simultaneous occurrence of pneumothorax and pneumoperitoneum is a rare event, usually related to traumas or surgical procedures involving the diaphragm.

However, clinicians should be aware of the possible onset of these two clinical conditions even in patients without a recent clinical history that can clearly explain them.

Cross-sectional imaging techniques are of great importance, providing crucial information about the patient's clinical status and guiding the following patient management.

This work describes a unique case of a sudden occurrence of simultaneous pneumothorax and pneumoperitoneum in a previous asymptomatic man with a solely clinical history of minor trauma during childhood, evaluated through a multimodality imaging approach and treated with video-assisted thoracoscopy surgery.

Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation: A case report

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Massive hemothorax due to splenic rupture is exceedingly rare.

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Delayed or missed diagnosis of massive hemothorax due to splenic rupture is fatal.

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Isolated diaphragmatic injury is very rare.

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Diaphragmatic rupture signifies underlying serious injuries.

Background

Massive left hemothorax following left diaphragmatic and splenic rupture with visceral herniation is quite an uncommon life-threatening condition usually associated with blunt thoracoabdominal trauma. Mortality is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. Timely, and proper diagnosis is mandatory as survival depends on prompt diagnosis and treatment.

Presentation of case

We describe a case of massive left hemothorax secondary to blunt thoracoabdominal injury with left diaphragmatic and splenic rupture, gastric, greater omentum and splenic herniation into the left thoracic cavity in a 32 years old male car driver after sustaining a road traffic accident and presented with shortness of breath of 4 h’ duration. He also had zone 3 retroperitoneal hematoma and left acetabular fracture. He was treated surgically and discharged home improved.

Discussion

Diaphragmatic ruptures following blunt injuries are larger leading to herniation of visceral organs into the thoracic cavity and the most common organ to herniate on the left side is the stomach followed by omentum and small intestine. Splenic rupture is a very rare cause of hemothorax and is often missed in the differential diagnosis.

Conclusion

Massive hemothorax following splenic and diaphragmatic rupture with visceral herniation following either blunt or penetrating trauma is rare. Delayed or missed diagnosis is associated with higher morbidity and mortality. A high index of suspicion and proper use of diagnostic studies are crucial for early and correct diagnosis.

Delayed presentation of left traumatic diaphragmatic hernia with displacement of spleen and stomach to left hemi thorax

We presented a case of late onset of left traumatic diaphragmatic hernia with displacement of spleen and stomach to the left hemi thorax, a year after the trauma. Gastric and respiratory complications along with herniation should be immediately managed, in order to reduce the risk of cardiac arrest and mortality.

Traumatic diaphragmatic rupture: delayed presentation following a SCUBA dive

Traumatic diaphragmatic rupture (TDR) is a rare yet life-threatening occurrence that remains a diagnostic challenge for clinicians. Delayed presentation with associated strangulation of the contents, although uncommon, requires emergent management. A 42-year-old woman presented with constant, severe left-sided shoulder and chest pain, as well as associated upper abdominal pain following a self-contained underwater breathing apparatus (SCUBA) dive. A chest radiograph (CXR) and CT showed a left-sided diaphragmatic hernia containing stomach. She subsequently underwent a laparoscopic repair of the diaphragmatic defect and recovered well postoperatively.

Clinical Manifestations of Huge Diaphragmatic Hernias

Translocation of abdominal organs into the thoracic cavity may cause dyspnea, heart disorders, and gastric symptoms. Diaphragmatic hernias can cause diagnostic difficulties, since both clinical and radiological symptoms might imitate different disorders. In these cases computed tomography of the chest is the method of choice. The aim of this study was to assess clinical manifestations, risk factors, and prognosis in patients with huge diaphragmatic hernias with displacement of abdominal organs into the thorax, depending on the action taken. We carried out a retrospective study using data of patients hospitalized in the years 2012-2016. Ten patients were qualified for the study (8 women and 2 men). The mean age of the subjects was 86.5 ± 10.5 years. Thirty percent of the hernias were post-traumatic. All of the patients reported cardiovascular or respiratory symptoms. Upper gastrointestinal symptoms occurred in half of the patients. Twenty percent of patients underwent surgery with a positive outcome, while 30% of patients, who were not qualified for surgery due to numerous co-morbidities, died. The main risk factors predisposing to the occurrence of large diaphragmatic hernias were the following: old age, female gender, and thoracic cage deformities.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Recurrence in a Laparoscopically Repaired Traumatic Diaphragmatic Hernia: Case Report and Literature Review

Introduction:

Traumatic diaphragmatic hernia (TDH) develops infrequently following a traumatic diaphragmatic rupture (TDR). As TDR is frequently missed due to lack of sensitive and specific imaging modalities, a high index of suspicion for such injuries is essential, whether immediately posttraumatic, or even decades after the trauma. We describe a rare case of recurrence in a laparoscopically repaired TDH and review the current literature on the same.

Case Presentation:

A 23-year-old male with a history of primary laparoscopic repair of left-sided TDR two years ago presented with symptoms of acute large bowel obstruction. His chest X-ray showed a left-sided pleural effusion and a loop of the bowel in the left hemithorax, but no signs of free gas. An abdominal X-ray (AXR) demonstrated massively dilated large bowel with distension of the small bowel. At laparotomy, the obstructing lesion consisted of the large bowel with omentum herniated through the left hemidiaphragm, consistent with a left recurrent/chronic diaphragmatic hernia. The diaphragmatic defect was repaired with interrupted nylon. The patient made an uneventful recovery.

Conclusions:

Recurrence after repair of TDH is a less reported condition (with only two published articles) and little is known regarding the factors responsible for this. Laparoscopy is an excellent diagnostic tool, but currently management is probably best performed via an open technique using heavy non-absorbable suture material to prevent recurrence. Long term follow up of these patients should also be considered.

Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

Purpose

Traumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre.

Methods

We used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed.

Results

Of the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury.

Conclusions

The detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

Bowel obstruction due to diaphragmatic injury after penetrating thoracic trauma

Diaphragmatic injuries due to penetrating traumas to the thorax progress insidiously. Proper diagnosis might only be performed after months. Delayed diagnosis increases morbidity and mortality. Herein, we present a case of diaphragm injury due to penetrating thoracic trauma that was diagnosed 2 years later. The case was referred to emergency service with bowel obstruction symptoms and after the examinations, first laparotomy and then thoracotomy were performed. The trace of the injury tract should be evaluated in all penetrating thoracic traumas and diaphragmatic injury should be taken into consideration. It is important to keep in mind that thoracic symptoms could be obscured and, if needed, further evaluation and surgical exploration should be performed. In the absence of early symptoms, failure to recognize diaphragmatic injuries can result in mortality.

Presentations and outcomes in patients with traumatic diaphragmatic injury: a 15-year experience

BACKGROUND

Traumatic diaphragmatic injury (TDI) is usually associated with multiple injuries. We aimed to evaluate the patterns, associated injuries, and predictors of in-hospital mortality of patients with TDI.

METHODS

The trauma registry from a Primary Adult Resource Center for Trauma was queried for patients admitted with a TDI from January 1995 to December 2009. Patient characteristics, mechanism of injury, associated injuries, management, and outcomes were analyzed. We compared morbidity and mortality in left and right diaphragmatic injuries (LDI and RDI, respectively).

RESULTS

Of the 773 patients, 650 were male (84%), with a mean (SD) age of 33 (15). Mechanism of injury was penetrating in 561 (73%) and blunt in 212 (27%) patients. LDI, RDI, and bilateral injuries were 57%, 40%, and 3%, respectively. The majority of cases were managed by exploratory laparotomy and direct suture repair. LDI was associated with higher rates of splenic, gastric, and pancreatic injuries and prolonged hospital stay in comparison with RDI. In comparison with LDI, RDI was associated with higher rates of deaths (26% vs. 17%, p = 0.003). Overall, mortality in TDI was 21%. Age (odds ratio [OR], 1.02, p = 0.008), Injury Severity Score (ISS) (OR, 1.09, p = 0.001), associated cardiac injury (OR, 2.8, p = 0.005), left diaphragmatic injury (OR, 0.53, p = 0.005), and operative interventions (OR, 0.32, p = 0.001) were independent predictors for mortality.

CONCLUSION

This largest single institution study on TDI in the literature confirms that LDI are more commonly diagnosed than RDI. Exploratory laparotomy is the most common procedure performed for these injuries. Young age and operative interventions are associated with favorable outcome, whereas high ISS, RDI, and associated cardiac injury are independent predictors for mortality.

LEVEL OF EVIDENCE

Epidemiological study, level III.

A delayed traumatic diaphragmatic hernia presenting with a bowel obstruction 20 years postinjury

A delayed Traumatic Diaphragmatic Hernia is a rare diagnosis. A 38 years old male presented to our emergency department with an acute bowel obstruction. He had a prior trauma laparotomy twenty year's prior, which was reportedly negative. He required preoperative resuscitation for his severe hypokalaemic, hypochloraemic metabolic alkalosis, and acute renal failure. He underwent operative reduction of the incarcerated contents, and a primary permanent suture repair of the defect. The principles of the diagnosis of the delayed traumatic diaphragmatic hernia, and the operative repair of this entity have been reviewed.

[Missed right post-traumatic diaphragmatic injuries: a review of six cases]

INTEREST

Right posttraumatic diaphragmatic injuries are rare; literature relates mainly isolated cases or small series and most often rupture are succeeding of blunt trauma. This series is interesting because the number of cases and the existence of two injuries following a right stab wound.

PATIENTS AND METHODS

Retrospective study between January 2002 and September 2010. We collected the data of initial trauma, clinical, radiological, operative and follow-up for six patients supported for right posttraumatic diaphragmatic injuries.

RESULTS

All injuries were in late presentation. Four injuries were secondary to road traffic accident, and two after stab wound. The time to diagnosis was between 47 days and 15 years. Right posterolateral thoracotomy was the elective approach in the cases with diaphragmatic hernia (5 patients). In one case, video-assisted thoracoscopic surgery permits the diagnosis and repair of injury. Mortality was null and morbidity was present in one case from six. Follow-up ranging from 8 months and 42 months don't objectified complications.

CONCLUSION

Right diaphragmatic hernia is terrible sequelae after thoracoabdominal trauma. Surgery becomes more complex at this stage and can be done by thoracotomy. With strong suspicious signs at the first assessment of trauma, exploration by thoracoscopy can always avoid the occurrence of long-term sequelae.

Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging

Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.

Chronic traumatic diaphragmatic hernia

Chronic traumatic diaphragmatic hernia is an uncommon but persistent diagnosis associated with significant morbidity and mortality. Chronic TDH describes a spectrum of disease in antecedent mechanism of injury, timing of presentation, size of diaphragmatic defect, and amount and type of tissue displaced into the chest. Multiplanar CT with coronal, sagittal, and axial reconstruction is most effective in making this diagnosis. Once diagnosed, repair should be undertaken. Although transabdominal approaches may be successful, the authors prefer an open transthoracic approach, recognizing that either approach may need to incorporate access into the other body cavity to complete the repair. Basic hernia principles apply including the construction of a tension-free repair, which may necessitate the use of prosthetics. As surgeons become increasingly comfortable with minimally invasive techniques, more chronic TDH are likely to be approached in this fashion. Finally, as much of the morbidity and mortality is associated with the catastrophic consequences of chronic TDH, vigilance needs to be applied in an attempt to diagnose and then repair TDH while in the latent stage prior to the development of the catastrophic complications that herald the obstructive stage.

Twenty-seven year old man presenting with a strangulated diaphragmatic hernia eight years after the initial injury

A 27-year-old man presented with a 5 day history of abdominal pain and distension, with associated constipation and vomiting. He had presented 8 years earlier following a traumatic injury to the left side of the chest, and no diaphragmatic injury was reported at that time. On this admission, a computed tomography scan showed herniation of the splenic flexure of the colon into the left hemithorax. Subsequently, he had an emergency laparotomy for resection, with formation of a loop ileostomy. The various imaging techniques all have advantages and disadvantages when diagnosing a traumatic diaphragmatic hernia. It is the clinician's role to maintain a high index of suspicion when a patient initially presents with trauma where a traumatic diaphragmatic hernia may be a possibility.

Traumatic diaphragmatic hernia: tertiary centre experience

BACKGROUND

Traumatic diaphragmatic hernia (TDH) resulting from traumatic diaphragmatic rupture (TDR) may not be easily detected and can lead to significant morbidity and mortality.

PATIENTS AND METHODS

A retrospective case note analysis was performed of all patients treated for TDR at a major teaching hospital between March 2003 and March 2008. The aetiological factors, associated injuries, management and outcome were analysed.

RESULTS

Twenty-seven patients were studied (24 males, 3 females) and their ages ranged from 16 to 72 years (median 35 years). TDR was left-sided in 85% and right-sided in 15%. Aetiology was blunt trauma in 81% and 19% had penetrating injury. Associated injuries were present in 81%. The most common approach for repair was transabdominal (89%); additional thoracotomy was needed in 11%. Herniation of abdominal contents was present in 85% and herniation of more than one organ was present in 57%. The diaphragmatic rent was repaired primarily in 89% using nonabsorbable sutures. Post-operative pulmonary complications occurred in 52% of patients. Three patients (11%) died.

CONCLUSION

Left-sided blunt traumatic diaphragmatic rupture was more common than right-sided rupture. The most commonly herniated organs were the stomach and colon. Most ruptures could be repaired by an abdominal approach, which also allowed a complete exploration of the abdominal organs. Careful attention should be given to associated intra-abdominal injuries. Most of the defects were repaired directly using nonabsorbable sutures.

[A late post-traumatic diaphragmatic hernia revealed by a tension fecopneumothorax (a case report)]

INTRODUCTION

Post-traumatic diaphragmatic hernia is a particular lesion in traumatology that may be neglected. Thus, the diagnosis may be delayed for a few days to several months and only be made following a complication. The left diaphragmatic cupola is the most touched. Tension fecopneumothorax following diaphragmatic hernia perforation in the pleural cavity is a rare but particularly severe complication of traumatic diaphragmatic hernia.

CASE REPORT

A 68-year-old man was admitted for acute intestinal occlusion with respiratory distress. A history of a violent blunt thoraco-abdominal traumatism resulting from a traffic accident eight years before was noted. The chest x-ray revealed an abundant hydropneumothorax and the thoracic scan revealed abundant effusion with heterogeneous density in the left pleural cavity, associated with an intrapleural hernia of the large intestine. An emergency thoracolaparotomy discovered tension fecopneumothorax secondary to intrathoracic perforation of the transverse colon through a left hemidiaphragm defect. The surgical treatment consisted of hernia reduction, pleural drainage, colostomy and repair of the diaphragmatic defect.

CONCLUSION

The possibility of diaphragmatic hernia should be kept in mind in case of violent blunt thoraco-abdominal traumatism or basithoracic wound. In this way, complications such as tension fecopneumothorax that could threaten the functional and vital prognosis may be prevented.

A combined laparoscopic and endoscopic approach to acute gastric volvulus associated with traumatic diaphragmatic hernia

PURPOSE

The purpose of the article was to describe a comprehensive approach to laparoscopic repair of acute intrathoracic gastric volvulus in acquired diaphragmatic hernia.

BACKGROUND

Traumatic diaphragmatic hernias are observed in 10% of diaphragmatic injuries, which include blunt trauma, penetrating trauma, and iatrogenic injuries. It is of utmost importance because of its high morbidity and mortality. Minimally invasive approaches are considered to be safe and effective procedures. They also provide rapid recovery from the operation, avoid the morbidity of laparotomy, and allow rapid recovery of gastric function.

METHOD

From June 2002 to June 2006, we encountered 4 cases of acquired diaphragmatic hernia with acute gastric volvulus, which were successfully treated with laparoscopic reduction, detorsion, repair of diaphragmatic hernial defect, and percutaneous endoscopic gastropexy.

RESULTS

There were no operative complications. All 4 patients tolerated the procedure well and the patients were discharged 1 to 3 days after the operation. After 1 to 2 years of follow-up, there were no radiologic recurrences of the volvulus and all patients remained asymptomatic.

CONCLUSIONS

Laparoscopic surgery represents a safe and acceptable approach in the treatment of acute gastric volvulus through the abdominal approach with minimal morbidity and good outcome.

Mediastinal shift secondary to a diaphragmatic hernia: a life-threatening combination

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.

Imaging of diaphragmatic rupture after trauma

Traumatic rupture of the diaphragm usually results from blunt or penetrating injuries, or iatrogenic causes. Most cases are initially overlooked in the acute phase because they present with variable clinical and radiological signs. An overlooked diaphragmatic injury presents as a hernia many years later with potentially serious complications, therefore selection of the most appropriate radiological technique and accurate diagnosis of traumatic diaphragmatic hernias (DH) on the first admission is important. Although the diagnosis of diaphragmatic injuries is problematic, various investigations may be used for diagnosis. We describe the imaging findings of 19 traumatic DH cases with various imaging techniques. The patients were acute trauma cases or cases with prior trauma or thoraco-abdominal surgery with clinical suspicion of DH. An evaluation of the imaging techniques used in the diagnosis of DH is presented.

Diaphragmatic hernia: diagnostic approaches with review of the literature

Because surgical repair is indicated for the treatment of diaphragmatic hernia (DH), preoperative imaging of the diaphragmatic defect, hernia content, and associated complications with other organ's pathologies is important. While various techniques can be used on imaging of DHs, selection of the most effective but the least invasive technique will present the most accurate findings about DH, and will facilitate the management of DH. We reviewed the diaphragmatic hernia types associated with our cases, and we discussed the preferred imaging modalities for different DHs with review of the literature. We evaluated the imaging findings of 21 DH cases. They were Morgagni's hernia (n=4), Bochdalek hernia (n=2), iatrogenic DH (n=4), traumatic DH (n=6), and hiatal hernia (n=5). Although its limited findings on DH and indirect findings about the diaphragmatic rupture, plain radiography is firstly preferred technique on DH. We found that ultrasound (US) is a useful tool on DH, on traumatic DH cases especially. Not only it shows diaphragmatic continuity and herniated organs, but also it reveals associated abdominal organ's pathologies. Computed tomography (CT) scan is most effective in many DH cases. It shows the herniated abdominal organs together with complications, such as intestinal strangulation, haemothorax, and rib fractures. We stressed that Multislice CT scan with coronal and sagittal reformatted images is the most effective and useful imaging technique on DH. With high sensitivity for soft tissue, MR imaging may be performed in the selected patients, on the late presenting DH cases or on the cases of the diagnosis still in doubt especially.

[Tension faecopneumothorax as the rare presenting feature of a traumatic diaphragmatic hernia]

A traumatic diaphragmatic hernia is a well-known complication following abdominal trauma. It occurs in approximately 3% of abdominal injuries with a 2/1 ratio of penetrating trauma. These injuries remain undiagnosed in nearly half of the patients in the acute phase. Hence, delayed presentation, days or even years after the onset of the initial trauma, are not uncommon. Indeed, they are often revealed by a complication. It's exactly what happened with our patient who presented with an acute tension fecopneumothorax, resulting from diaphragmatic herniation and perforation of the colon in the pleural cavity. This presentation is rarely reported. In a search of the literature, only 11 cases could be found.

Chronic traumatic diaphragmatic hernia with pericardial rupture and associated gastroesophageal reflux

Major thoracic and abdominal trauma damages the diaphragm 5% of the time. These injuries may be recognized when they occur but often are discovered months later during work up for related symptoms. Typically, the injury is to the left posterolateral aspect of the diaphragm. Rarely, rupture through the central diaphragmatic tendon into the pericardial space occurs and this results in different symptoms than the more common injury. We present the case of a patient who presented with chest pain, near syncopal episodes and refractory gastroesophageal reflux years after he was struck by a car and hospitalized. Radiographic imaging included a chest CT that demonstrated herniation of the transverse colon into the mediastinum. During exploration, a defect in the central diaphragm was found with free communication between the peritoneal and pericardial spaces. In this paper, we review our management of this unusual diaphragmatic hernia and the unique symptoms associated with it.

Delayed traumatic diaphragmatic hernias presenting with strangulation

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.

Incarcerated transdiaphragmatic intercostal hernia preceded by Chilaiditi's syndrome

Transdiaphragmatic hernia most often develops after blunt or penetrating thoracoabdominal trauma. We report on the case of a 73-year-old man who underwent emergency ileocoecal resection for an incarcerated transdiaphragmatic intercostal hernia. The patient's history included both a lumbotomy for right nephrectomy and Chilaiditi's syndrome. The literature regarding both transdiaphragmatic intercostal herniation and Chilaiditi's syndrome is reviewed in relation to the presented case.

Late bilateral diaphragmatic rupture: Challenging diagnostic and surgical repair

A 67-year-old man was referred to our department, after a vehicle accident, with multiple bone fractures and a left blunt diaphragmatic rupture. An emergency laparatomy was performed, and the left diaphragmatic defect directly sutured. Postoperatively, a delayed right diaphragmatic rupture occurred due to progressive inflammation and muscle devitalisation. The diagnosis was challenging because the right rupture became clinically evident later after extubation. Diaphragmatic reconstruction was performed through a right thoracotomy. A high index of suspicion should always be observed for missed or delayed bilateral diaphragmatic ruptures.

Bochdalek diaphragmatic hernia: not only a neonatal disease

AIMS

To characterise the clinical manifestations of late presenting Bochdalek diaphragmatic hernia (DH), the incidence of misdiagnosis, and prognosis; and to explore the sequence of events that leads to this clinical picture.

METHODS

Retrospective chart review. All children with Bochdalek DH were identified. Children 1 month of age and older at the time of diagnosis were included.

RESULTS

Twenty two children with Bochdalek DH met the inclusion criteria. Three clinical presentations could be defined. Fourteen children presented with acute onset of symptoms, predominantly vomiting and respiratory distress. Four had chronic non-specific gastrointestinal or respiratory symptoms, and in four the DH was found incidentally. Although five children were initially misdiagnosed, in 20 children (91%) the correct diagnosis was made on x ray examination. One child experienced a complicated course when the x ray picture was misinterpreted as pneumothorax. All children had favourable outcome. Two children had previously normal chest imaging, suggesting acquired herniation. A large pleural effusion without DH in a 9.5 year old girl with an abdominal infection prior to presenting with herniation suggests a pre-existing defect in the diaphragm.

CONCLUSIONS

Late presenting Bochdalek DH can present with acute or chronic gastrointestinal, or less frequently, respiratory symptoms. It can also be found incidentally. Misdiagnosis can result in significant morbidity. Favourable outcome is expected when the correct diagnosis is made. The sequence of events is probably herniation of abdominal viscera through a pre-existing diaphragmatic defect. Although rare, DH should be considered in any child presenting with respiratory distress or with symptoms suggestive of gastrointestinal obstruction.

Isolated trans-hiatal colonic herniation

Isolated herniation of the colon through congenital or traumatic diaphragmatic defects are well documented. However, trans-hiatal herniation of the colon in the absence of an intrathoracic stomach has been reported only once. A 67-year-old man presented with intragastric abdominal pain and a chest x-ray film documenting a posterior mediastinal air-fluid level. Computed tomography showed gastrointestinal contents within the thorax. The findings on an upper gastrointestinal film with small bowel follow-through were normal. Finally, a barium enema identified transverse colon within the thoracic cavity. At laparoscopy, the entire transverse colon was reduced with the hernia sac. The crural defect was repaired, and a Toupet fundoplication was performed. A gastropexy was also added. The patient was discharged on postoperative day 2 able to tolerate a regular diet, and he has been asymptomatic for 5 months. This defect most likely represents a congenital deformity of the diaphragm with intact posterior gastric attachments, including the posterior phrenoesophageal ligament. An intact gastric mesentery enabled isolated colonic herniation with retention of the stomach its normal anatomic position. An antireflux procedure was performed in addition to the crural repair because of the circumferential dissection of the esophagus. This article is the second report of an isolated trans-hiatal herniation of the colon and the first report of laparoscopic repair of this entity.