Laparoscopic management of a delayed traumatic diaphragmatic rupture complicated by bowel strangulation

Laparoscopic management of traumatic diaphragmatic rupture with herniation of abdominal contents into left hemithorax

Key Clinical Message

Early traumatic diaphragmatic rupture diagnosis using radiological investigations and early surgical management is critical to avoid complications.

Abstract

Traumatic diaphragmatic rupture (TDR) is a rare presentation reported following blunt trauma due to road traffic accidents. Our case showed the importance of early diagnosis of TDR using radiological investigations. Also, early surgical management is critical to avoid complications.

Laparoscopic repair and total gastrectomy for delayed traumatic diaphragmatic hernia complicated by intrathoracic gastric perforation with tension empyema: a case report

Background

Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury. If missed, it could lead to critical presentations, such as incarceration or strangulation of the herniated intra-abdominal organs, and thus, early surgical repair is required. Methods of the operative approach against delayed TDH remain unclear. Even with the spread of the minimally invasive approach, laparotomy has been predominantly selected for cases with hemodynamic or gastrointestinal complaints. Literature on the use of laparoscopy for repair of such cases is limited, and no study has been conducted for those with intrathoracic gastric perforation.

Case presentation

A 55-year-old male patient with a history of multiple traumas presented with shock, followed by left hypochondrium pain and vomiting. The patient was admitted to the emergency department of our institution and diagnosed with delayed TDH complicated by intrathoracic gastric perforation, and tension empyema. Emergency surgery using laparoscopic approach was performed, despite unstable hemodynamics, considering orientation, exposure, and operativity compared with laparotomy. Repair of the diaphragm plus total gastrectomy was successfully performed by minimally invasive management. The patient made an uneventful recovery without recurrence after 8 months.

Conclusion

Unstable hemodynamic conditions and intrathoracic gastric perforation could not be contraindications to laparoscopic repair in treating delayed TDH.

Resolution of Chronic Shoulder Pain after Repair of a Posttraumatic Diaphragmatic Hernia: A 22-Year Delay in Diagnosis and Treatment

Diagnosing traumatic diaphragmatic rupture (TDR) due to penetrating rib fractures is challenging because the lesions are often too small to be detected and may present years after injury. Patients with delays in diagnosis of TDR rarely present with orthopaedic-related complaints of pain. We report the case of a 52-year-old female who presented with chronic left shoulder pain following a motor vehicle accident (MVA). In addition to left-side lower rib fractures, she also sustained a left-sided splenic laceration, pneumothorax, and two-part upper humerus fracture. Fracture treatment was percutaneous pinning; the other injuries were treated nonoperatively. Her shoulder pain could not be attributed to shoulder or neck pathology. Twenty years after the MVA, she began experiencing episodes of left-sided abdominal pain and nausea. A CT scan obtained two years later revealed a diaphragm hernia, which was repaired laparoscopically. Unique aspects of this case include (1) presentation to an orthopaedic surgeon with a chief complaint of chronic shoulder pain; (2) at 22 years, this is the fourth longest case of a delay in diagnosis of TDR; and (3) the unique symptom of ipsilateral referred shoulder pain, which immediately improved after hernia repair.

Laparoscopic Repair of Diaphragmatic Rupture: A Case Report with Radiological and Surgical Correlation

The leading cause of diaphragmatic rupture is penetrating abdominal trauma, including gunshot- and stab-related wounds; however, diaphragmatic rupture can also result from blunt trauma to the abdomen. The diagnosis can be difficult to make as the physical examination may be unremarkable, and imaging, that is, a conventional chest X-ray and/or CT imaging, may initially fail to reveal the injury. Failure to recognize diaphragmatic rupture can result in a delayed presentation, sometimes years later, with a potential catastrophic outcome. Therefore, prompt and swift diagnosis is critical to avoid this potential harmful scenario. Traditionally, repair is performed through a laparotomy or a thoracotomy incision. Owing to the many advances made in minimally invasive surgery, not only has laparoscopy become the modality of choice to diagnose diaphragmatic rupture due to its high degree of sensitivity and specificity, but it can provide simultaneous therapeutic intervention as well. We report a case of laparoscopic repair of a diaphragmatic rupture in a 22-year-old female who sustained blunt abdominal trauma during a motor vehicle accident.

Laparoscopic Resection of the Diaphragmatic Tumor Nodule for Management of Recurrent Endometrial Cancer

STUDY OBJECTIVE

To show a surgical video in which an isolated hemidiaphragmatic tumor nodule was resected laparoscopically in a patient with isolated recurrence of endometrial cancer.

DESIGN

Case report (Canadian Task Force Classification study design III).

SETTING

Tertiary referral center in New Haven, CT.

INTERVENTIONS

This is a step-by-step illustration of tumor nodule resection from the right hemidiaphragm. The patient was a 55-year-old white woman who was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in June 2011 after surgical debulking. She received adjuvant carboplatin and paclitaxel and vaginal brachytherapy. She was disease free until March 2015 when she presented with right upper abdominal pain. A computed tomographic scan showed a 1-cm implant on the right hepatic dome. The implant was noted to be enlarged to 1.8 cm on a subsequent computed tomographic scan in August 2015. The patient was taken to the operating room for exploratory laparoscopy and resection of the hepatic dome/hemidiaphragmatic tumor nodule. The tumor nodule was noted to involve the full thickness of the right hemidiaphragm. The resection of the entire nodule required perforation of the diaphragm, which was reapproximated after the excision.

MAIN RESULTS

The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged home on postoperative day 1. Pathology revealed metastatic endometrioid endometrial adenocarcinoma with negative resection margins.

CONCLUSION

Laparoscopic resection of the diaphragmatic tumor nodule and the reapproximation of the diaphragm were successfully performed in this patient with isolated disease recurrence. The laparoscopic approach should be considered for management of isolated recurrences in gynecologic cancers by experienced laparoscopic surgeons because it might otherwise be associated with significant morbidity and mortality [1-3].

Laparoscopic correction of experimentally induced diaphragmatic rupture in dogs

PURPOSE

To describe the dog as a model for studying laparoscopic correction of experimental diaphragmatic ruptures.

METHODS

Five male dogs were used in this study. Under laparoscopic approach, a defect of 7 cm was created on the left ventral insertion of the diaphragm. Fourteen days after this procedure, the abdomen was explored using laparoscopic access and the diaphragmatic defect was corrected with intracorporeal suture. The dislocated organs, surgical time, and suturing time were recorded. Analgesia and clinical condition were monitored during the postoperative period.

RESULTS

All animals recovered well from the diaphragmatic rupture creation. After 14 days, abdominal organs (liver, spleen, omentum and/or intestine) were found inside the thoracic cavity in all animals. It was possible to reposition the organs and suture the defect by laparoscopic access in three animals. These animals showed excellent postoperative recovery. It was not possible to reposition the liver safely when it was friable.

CONCLUSIONS

Laparoscopic creation of diaphragmatic rupture in dogs is feasible. Dogs are a good model for training and studying the correction of experimentally created diaphragmatic rupture by the laparoscopic approach. A friable liver is a complicating factor that should be taken into account. Animals submitted to laparoscopic correction showed excellent postoperative recovery.

The feasibility and efficacy of laparoscopic repair for chronic traumatic diaphragmatic herniation: introduction of a novel technique with literature review

PURPOSE

Traumatic diaphragm rupture is a rare trauma that is easily overlooked. A missed diagnosis would result in chronic traumatic diaphragmatic herniation (CTDH). Surgical repair is the standard treatment that is conventionally performed by laparotomy or thoracotomy. Laparoscopic repair has been reported, but its efficacy remains controversial. In this study, we present our novel technique and experience of laparoscopic repair of CTDH and analyze the feasibility and effectiveness of this procedure.

METHODS

We conducted a prospective collection with retrospective review of patients with CTDH treated at Chang Gung Memorial Hospital, Taiwan, from 2000 to 2013. The demographic characteristics, surgical procedure, perioperative results, length of hospital stay (HLOS) and follow-up were record and analyzed.

RESULTS

There were 114 patients with traumatic diaphragm hernia, and 24 of them had CTDH with a mean age of 54.9 ± 13.3 years. The HLOS was 15.08 ± 8.17 days. Regarding the surgical method used, 19 patients had open surgery, and 5 patients underwent laparoscopic surgery. The demographic distribution, trauma mechanism, location and size of CTDH were comparable. In the laparoscopic group, the patients had a shorter median HLOS (6 days) than in the open surgery group (16 days; p = 0.002). There was no mortality or recurrence in both groups.

CONCLUSIONS

In this study and literature review, patients had laparoscopic repair with a smooth recovery. Laparoscopy provides good surgical exposure, allowing easy repositioning of the herniated content and a smooth repair of the defect without the morbidity of laparotomy. For CTDH, with caution, we can apply this technique with an acceptable result.