Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma

Non-operative Management of a Diaphragmatic Hematoma: A Case Report

Diaphragmatic hematomas are a rare complication of blunt trauma that are often overlooked due to the presence of high-acuity injuries. However, this injury can result in significant long-term complications if not managed appropriately. We present a 59-year-old female who developed a diaphragmatic crural hematoma following a motor vehicle accident. The patient arrived at the trauma bay unresponsive, hypertensive, requiring bag-valve mask ventilation, and with a Glasgow Coma Scale score of 3/15. On physical examination, the patient was found to have bilateral diminished breath sounds and was promptly intubated. Initial CT imaging of the patient demonstrated active contrast extravasation that was thought to be an adrenal hemorrhage but was actually a diaphragmatic hematoma upon re-examination. Although surgical intervention is a common approach for managing diaphragmatic injuries, non-operative management was chosen in this case due to the patient's stable condition and minimal evidence of active bleeding. This case highlights the possibility of non-operative management of diaphragmatic hematomas when used with accurate radiologic and clinical findings. When appropriate, non-operative management can reduce morbidity and mortality but requires careful radiologic follow-up to detect potential complications.

Characteristics, outcomes, and prognostic factors in patients with penetrating and blunt traumatic diaphragmatic injury: a nationwide retrospective cohort study in Japan

BACKGROUND

Traumatic diaphragmatic injury (TDI) is well-known worldwide as rare and life-threatening. However, because no nationwide cohort study of penetrating and blunt TDI has been conducted in Japan and other countries where penetrating trauma is relatively uncommon, the clinical characteristics of all TDI are unknown. We aimed to describe the characteristics of TDI patients, compare penetrating TDI with blunt TDI, and identify mortality risk factors in Japan.

METHODS

We retrospectively identified TDI patients between 2004 and 2019 using data from the Japan Trauma Data Bank. We extracted data on patient demographics, type of trauma, cause of trauma, physiological parameters, region of concomitant injury, associated injury, and management. We compared penetrating and blunt TDI for each variable. The primary outcome was mortality. Multivariable logistic regression was performed to identify mortality risk factors.

RESULTS

Of the 338,744 patients, 1,147 (0.3%) had TDI, of which 771 were eligible for analysis (excluding 308 in cardiac arrest on arrival). Penetrating TDI represented 29.8% and blunt TDI 70.2%, and comparing penetrating and blunt TDI, the most common cause was self-inflicted (48.7%) vs. accident (85.6%), males were 68.7% vs. 66.0% of the patients (P = 0.50), and the mortality rate was 8.3% vs. 26.4% (P < 0.001). Multivariable analysis found that age (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.04), Injury Severity Score (OR 1.03, 95%CI 1.006-1.06), Revised Trauma Score (OR 0.55, 95%CI 0.45-0.67), severe concomitant abdominal injury (OR 2.45, 95%CI 1.32-4.56), severe concomitant upper extremity injury (OR 3.38, 95%CI 1.24-9.17) were independent predictors of mortality, and computed tomography (CT) (OR 0.32, 95%CI 0.15-0.69) and diaphragm repair (OR 0.44, 95%CI 0.25-0.78) were protective factors.

CONCLUSIONS

In Japan, we found that penetrating TDI was mainly caused by self-injury and the male-female ratio was the same as for blunt TDI, although blunt TDI was much more frequent. TDI was considered highly lethal, with over 25% of patients in cardiac arrest on arrival. Our unique independent predictors were CT, severe concomitant abdominal injury, and severe concomitant upper extremity injury. These findings may help in the management of TDI in countries with less common penetrating trauma.

Robotic Repair of a Missed Traumatic Diaphragmatic Injury in a Prior Gastric Bypass Patient With Herniation of the Gastric Remnant

Traumatic diaphragmatic injuries following blunt or penetrating trauma have a low incidence rate. Symptoms can be obscured by distracting injuries or, in some cases, patients can be asymptomatic, making diagnosis difficult. A 57-year-old female who underwent a robotic Roux-en-Y gastric bypass with a hiatal hernia repair in 2021, presented as an alerted trauma in February 2024 following a motor vehicle accident (MVA). She was an unrestrained driver traveling 35 mph with airbag deployment. During an assessment, it was noted that she had extensive left breast and chest ecchymosis; however, trauma scans were negative. She was admitted for observation and was discharged the next day. Three weeks following the accident, she presented with dull epigastric pain and early satiety, which progressed to dysphagia to solids and significant reflux. Her initial CT scan was concerning a recurrent hiatal hernia. A nasogastric tube was placed and repeat imaging with oral contrast revealed that her gastric remnant had herniated into her chest. Given her recent trauma, there was concern for a missed diaphragmatic injury. The patient was admitted, and the decision was made to perform a robotic reduction and repair of the diaphragmatic hernia on hospital day 3. Intraoperatively, it was noted that her previous hiatal hernia repair was intact and there was a large traumatic defect in the 3 o'clock position of the left hiatus. The excluded gastric remnant and omentum were reduced back into the abdomen and the diaphragmatic defect was repaired primarily. The gastric remnant had multiple areas concerning for devascularization and a subtotal gastric resection was performed. The patient did well after surgery and was discharged home the next day. She regularly follows up with the bariatric clinic and reported doing well with no complaints at her six-month follow-up. This case shows the significance of missed diaphragmatic injuries in trauma, the value of having a high clinical suspicion for injury, and the added complexity of this being a bariatric patient with a previous gastric bypass. It also highlights the successful outcome of a robotic repair.

Diaphragm injuries in a mature trauma system: still a diagnostic challenge

Background

A traumatic diaphragm defect is a rare injury. A missed diaphragm injury may cause serious morbidity and mortality. Detection rate during the first assessment of trauma patients is notoriously low. However, important improvements in imaging modalities were developed. The aim of this study was to analyze traumatic diaphragm injuries in relation to diagnostic tools, therapeutic interventions and outcome over the past two decades.

Methods

A retrospective analysis was performed of all trauma patients with traumatic diaphragm injuries between 2000 and 2018 at a level I trauma center. Data collected were baseline characteristics, diagnostics that were performed, treatment given and follow-up.

Results

A total of 47 patients with traumatic diaphragm injuries were evaluated. The majority of injuries was seen following blunt trauma (72%). Mortality was 21%, mainly due to concomitant injuries. One patient died due to the consequences of an unrecognized diaphragm injury. In 29 cases (62%) the injury was diagnosed pre-operatively through imaging, with the remaining being diagnosed during laparotomy. In 11 patients (35%) the diaphragmatic injury was not seen on a pre-operative CT-scan. Postoperative complications occurred in 19 patients, mostly of pulmonary origin (i.e., pneumonia). No recurrences were reported.

Conclusion

This study confirms diaphragm injuries are infrequent injuries, with high mortality. Even more, despite major improvement in diagnostic modalities over the past 2 decades, the algorithm for detection of diaphragmatic injuries has not changed nor has its outcome. Although the incidence is low, since consequences are severe, it is important to have a high index of suspicion in abdominal trauma, even in a non-conclusive CT-scan.

Role of laparoscopic surgery in managing hemodynamically stable abdominal trauma patients: a single level I trauma center, propensity score matching study

BACKGROUND

The role of laparoscopy in the treatment and diagnosis of penetrating thoraco-abdominal injury has been established. However, there is no clear consensus on the role of laparoscopy in blunt injury due to numerous reasons, such as concerns of missed injury and technical problems in treating various abdominal organs. This study aimed to determine the feasibility of laparoscopy and evaluate its safety in managing blunt and penetrating abdominal trauma.

METHODS

The medical records and Korean Trauma Data Base (KTDB) of patients who underwent abdominal surgery from January 2018 to December 2022 at a single level I center were collected. Patients were classified into a laparoscopy group and a laparotomy group. The laparoscopy groups were matched 1:1 with the laparotomy group by using propensity score matching (PSM). Patient demographics, injured organ and its grade, operative procedure, and postoperative outcomes were evaluated and compared between the two groups.

RESULTS

After propensity score matching, 128 patients were included. There was no significant imbalance in demographics between the two groups except sex. Injured organ and its grade showed no significant differences between the two groups except for the incidence of omentum. Small bowel and mesenteric repair were performed most often in both groups. Splenectomy, pancreatic surgery, duodenectomy, and liver resection were performed exclusively in the laparotomy group. Severe postoperative complication rate (3% vs. 20%: p = 0.004), length of stay in ICU (3.3 ± 3.2 days vs. 4.6 ± 3.7; p = 0.046), and operation time (93.9 ± 47.7 min vs. 112.8 ± 57.7; p = 0.046) were significantly lower in the laparoscopy group. The conversion rate was about 16%. There was no missed injury.

CONCLUSIONS

In hemodynamically stable abdominal trauma patients who sustained penetrating or blunt injury, laparoscopy is feasible and safe as a diagnostic and therapeutic modality in selected cohort of abdominal trauma.

Robotic Repair of Acute Traumatic Diaphragmatic Injury From an Abdominal Approach: A Case Report

Traumatic diaphragmatic injury is a rare condition with a significant mortality risk and may cause a herniation of an intraperitoneal organ into the pleural space. In the acute phase, traumatic diaphragmatic hernia (TDH) may be repaired with laparotomy or thoracotomy and is often associated with multiple concurrent injuries. This case report highlights a rare clinical scenario of blunt traumatic DH in a 62-year-old male with approximately seven centimeters of stomach herniating into the left pleural space, repaired with minimally invasive surgery. This was done via a transabdominal approach with robotic-assisted laparoscopic hernia repair and institution of biologic mesh and represents an important opportunity that potentially reduces the morbidity risk involved with open surgeries.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Management of Traumatic Diaphragmatic Injuries

Diaphragm injuries are rarely seen injuries in trauma patients and are difficult to diagnose. With improving technology, computed tomography has become more reliable, but with increasing rates of non-operative management of both penetrating and blunt trauma, the rate of missed diaphragmatic injury has increased. The long-term complications of missed injury include bowel obstruction and perforation, which can carry a mortality rate as high as 85%. When diagnosed, injuries should be repaired to reduce the risk of future complications.

The Role of Minimally Invasive Surgeries in Trauma

This article delves into the role of minimally invasive surgeries in trauma, specifically laparoscopy and video-assisted thoracic surgery (VATS). It discusses the benefits of laparoscopy over traditional laparotomy, including its accuracy in detecting peritoneal violation and intraperitoneal injuries caused by penetrating trauma. The article also explores the use of laparoscopy as an adjunct to nonoperative management of abdominal injuries and in cases of blunt trauma with unclear abdominal injuries. Furthermore, it highlights the benefits of VATS in diagnosing and treating thoracic injuries, such as traumatic diaphragmatic injuries, retained hematomas, and persistent pneumothorax.

Management of Blunt Chest Trauma

Common mechanisms of blunt thoracic injury include motor vehicle collisions and falls. Chest wall injuries include rib fractures and sternal fractures; treatment involves supportive care, multimodal analgesia, and pulmonary toilet. Pneumothorax, hemothorax, and pulmonary contusions are also common and may be managed expectantly or with tube thoracostomy as indicated. Surgical treatment may be considered in select cases. Less common injury patterns include blunt trauma to the tracheobronchial tree, esophagus, diaphragm, heart, or aorta. Operative intervention is more often required to address these injuries.

Laparoscopic Repair Following a Delayed Presentation of Traumatic Diaphragmatic Hernia: A Case Report

Traumatic diaphragmatic hernia is a rare condition that occurs after trauma, and some patients have a delayed presentation. A laparoscopic approach is rarely used to repair traumatic diaphragmatic hernias. We encountered a case of asymptomatic diaphragmatic hernia diagnosed after a comprehensive medical examination. A 71-year-old woman was diagnosed with a delayed presentation of traumatic diaphragmatic hernia with prolapse of the greater omentum owing to a traffic injury 20 years ago. Surgery was performed laparoscopically using three ports, and intraoperative respiratory management was performed using a double-lumen tube. The 2.5-cm-diameter hernial orifice was sutured under contralateral one-lung ventilation after the greater omentum was returned to the abdominal cavity. The patient's postoperative course was uneventful, and she was discharged on the third day. Intraoperative strategies such as respiratory management and the laparoscopic approach play a crucial role in ensuring favorable postoperative outcomes. The last follow-up was at six months post-operation, and the patient was doing well.

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.

An Unusual Presentation of Diaphragmatic Rupture

Representing less than 1% of all traumatic injuries, diaphragmatic injuries are uncommon and are usually associated with injuries in other thoracic and abdominal organs. We report a case of a diaphragmatic injury in a 38-year-old man who presented to the Emergency Department due to a pedestrian-vehicle accident. He had a massive hemothorax on the left due to a ruptured spleen. An exploratory laparotomy was done to manage the bleeding, restore the diaphragmatic hernia contents in their right anatomical position, conduct a splenectomy, and repair the diaphragmatic defect. Although the majority of diaphragmatic ruptures are diagnosed acutely, late presentations are usually reported in blunt trauma; therefore, a high clinical suspicion with imaging is essential for the diagnosis.

Concordance of CT imaging and surgical lesions in penetrating abdominal trauma

OBJECTIVE

The management of penetrating abdominal wounds has greatly benefited from the development of computed tomography (CT), particularly in stable patients. In this setting, the scanner is the reference examination. Our study aims to evaluate the performance of preoperative CT in the assessment of penetrating abdominal lesions.

MATERIAL AND METHODS

Between January 1, 2015 and January 1, 2022, 81 patients were hospitalized following penetrating abdominal trauma at the Army Training Hospitals of Sainte-Anne and Laveran. Fifty-one stable patients who had an abdominopelvic CT scan and thereafter underwent abdominal surgery (laparotomy or laparoscopy) were included. Radiological and surgical data were collected from the electronic record and compared by a descriptive analysis (calculation of the sensitivity, specificity, positive and negative predictive value of the CT for the detection of lesions of the various organs) and by a correlation of the CT findings with surgical findings using Kripendorff's alpha coefficient.

RESULTS

The cohort was largely male (n=45; 88%), with injuries by knife wound in 62.7% of cases (n=32) and gunshot in 35.3% (n=18) of cases. The median age was 36years (25-47). The median index of severity score (ISS) was 17 (10-26). Excellent agreement between predicted and actual findings was obtained for solid organs (α=0.801) with high sensitivity and specificity (81.8% and 96.6%, respectively). The largest discrepancies were observed for the hollow organs (α=26.2%, sensitivity of 53.3% and specificity of 76.2%) and the diaphragm (α=67.3%, sensitivity 75%, specificity 92.3%). Surgical exploration was non-therapeutic for five patients (9.8%). The failure rate for non-operative treatment was 10% (n=1).

CONCLUSION

CT detection of solid organ lesions in patients with penetrating abdominal wounds is excellent. However, the detection of hollow organ and diaphragmatic wounds remains a challenge with a risk of over- and underdiagnosis. Laparoscopic exploration should be able to fill in the gaps in the CT findings.

Assessment of Outcomes in Laparotomy vs Laparoscopy: A Propensity Score Matched Analysis of Patients Sustaining Single Penetrating Left Upper Quadrant Injury

BACKGROUND

We aim to compare outcomes between laparotomy and laparoscopy in trauma patients with single penetrating left upper quadrant injuries.

METHODS

Using a 1:1 propensity score match, a retrospective study was conducted utilizing data from the ACS-TQP-PUF between 2016 and 2019. Adults sustaining a single penetrating left upper quadrant injury who received either a laparotomy or laparoscopy were included for analysis. The primary outcome was inpatient mortality. Secondary outcomes included ICU-LOS, H-LOS, and complication rates. Multivariable regression and reliability adjustments were performed to control for confounding.

RESULTS

486 patients receiving laparotomy were matched to 486 patients receiving laparoscopy. No differences in inpatient mortality (1.2% vs 2.9%, aOR: 2.92, 95% CI: .32, 26.31); however, patients undergoing laparotomy experienced higher complication rates (7.0% vs 1.2%, aOR: 9.61, 95% CI: 1.94, 47.48), pRBC transfusions (21.8% vs 6.4%, aOR: 3.19, 95% CI: 1.66, 6.13), and H-LOS (Mean ± SD: 8.1 ± 9.8 vs 3.9 ± 4.0, P = .0002). Lower ISS (1 - 15) undergoing laparotomy had more complications (4.3% vs .7%, aOR: 13.52, 95% CI: 1.39, 131.69), pRBC transfusions (13.9% vs 4.9%, aOR: 3.21, 95% CI: 1.53, 6.75), and H-LOS (Mean ± SD: 6.7 ± 7.1 vs 3.6 ± 3.2, P < .0001). There were no differences in mortality among patients with a lower ISS (1.5% vs .4%, aOR: 77.2, 95% CI: (<.001, >999).

CONCLUSIONS

Laparotomy is associated with increased rates of complications for single penetrating LUQ trauma. For patients with low ISS, laparoscopy is associated with better outcomes without increase in mortality.

Theophylline for the management of respiratory disorders in adults in the 21st century: A scoping review from the American College of Clinical Pharmacy Pulmonary Practice and Research Network

Theophylline is an oral methylxanthine bronchodilator recommended as alternate therapy for the treatment of asthma and chronic obstructive pulmonary disease (COPD). However, it is not generally recommended for the treatment of other respiratory disorders such as obstructive sleep apnea (OSA) or hypoxia. Most clinical practice guidelines rely on evidence published prior to the year 2000 to make these recommendations. This scoping review aimed to gather and characterize evidence describing theophylline for the management of respiratory disorders in adults between January 1, 2000 and December 31, 2020. Databases searched included Ovid MEDLINE, Embase, CINAHL Complete, Scopus, and International Pharmaceutical Abstracts. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. Studies were included if they were published in English, theophylline was used for any respiratory disorder, and the study outcomes were disease- or patient-oriented. After removal of duplicates, 841 studies were screened and 55 studies were included. Results aligned with current clinical guideline recommendations relegating theophylline as an alternative therapy for the treatment of respiratory disorders, in favor of inhaled corticosteroids and inhaled bronchodilators. This scoping review identified the need for future research including: theophylline versus other medications deemed alternative therapies for asthma and COPD, meta-analyses of low-dose theophylline, and studies evaluating evidence-based patient-oriented outcomes for OSA, hypoxia, ventilator-induced diaphragmatic dysfunction, and spinal cord injury-related pulmonary function.

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.

Blunt Trauma and Right Diaphragmatic Rupture: Unveiling the Impact

Traumatic diaphragmatic ruptures are rare, yet blunt injuries tend to be more easily overlooked compared to penetrating trauma. The minimal evidence of external injuries makes a high index of suspicion key for diagnosis. We report the case of a right-sided thoracoabdominal blunt trauma that resulted in a diaphragmatic rupture and fractured rib. Although often approached through a midline laparotomy, a definitive right thoracotomy repair was exceptionally performed since the adjacent peritoneum remained uninjured.

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.

Current trends in the diagnosis and management of traumatic diaphragmatic injuries: A systematic review and a diagnostic accuracy meta-analysis of blunt trauma

BACKGROUND

Traumatic diaphragmatic injuries (TDI) are wounds or ruptures of the diaphragm due to thoraco-abdominal trauma. Nowadays, CT-scan is considered the gold standard for TDI diagnosis. The aim of this study was to assess the current diagnostic accuracy of CT-scan in the diagnosis of TDI and describe the management of this type of injury.

METHODS

A systematic review was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers searched the literature in a systematic fashion using online databases, including Medline, Scopus, Embase, and Google Scholar. Human studies investigating the diagnosis and the following management of TDI were included. Pooled estimates of sensitivity, specificity, and positive/negative likelihood (with corresponding 95% confidence intervals) were analyzed based on the bivariate model for blunt TDI. The Newcastle-Ottawa scale for cohort studies was used for the quality assessment of selected articles. The PROSPERO registration number was as follows: CRD42022301282.

RESULTS

Fifteen studies published between 2001 and 2019 were included. All included studies reported a contrast-enhanced computed tomography as the preferred method to obtain diagnostic imaging. Left-sided TDI was the type of injury most frequently found. False negative TDI at CT-scan were more frequent than false positive TDI (11.13 ± 23.24 vs. 2.66 ± 6.65). Six studies on blunt TDI were included in the meta-analysis, showing a high sensitivity [0.80 (95%CI 0.65-0.90)] and specificity [0.98 (95%CI 0.89-1.00)] of the CT-scan in detecting TDI. Overall, 7 articles reported laparotomy as the method of choice to repair TDI. Only 3 studies reported a laparoscopic and/or thoracoscopic approach to TDI repair.

CONCLUSION

CT-scan has a good sensitivity and specificity for blunt TDI diagnosis. However, TDI diagnosis and management are often delayed. The use of water-soluble contrast in CT-scan should be considered when the diagnosis of TDI is not defined after the first scan, and clinical suspicion is still high. In this context, a highly trained trauma team is essential for trauma management and correct imaging interpretation.

Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients With Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset

BACKGROUND

We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients.

METHODS

Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed.

RESULTS

Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001).

CONCLUSIONS

Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.

Contralateral diaphragmatic injury sustained from transhumeral amputation: an unusual case and brief literature review

Right-sided diaphragmatic injury is an uncommon sequelae from blunt trauma and may be associated with other severe thoracoabdominal injuries. This injury can be easily missed on initial assessment and a high index of suspicion and clinical judgment is required. Recently, we treated a 25-year-old male inflicted with a right-sided diaphragmatic injury after a left-sided transhumeral amputation sustained from an overturned motor vehicle collision with thoracoscopic exploration and reapproximation.

Laparoscopic approach in chronic posttraumatic diaphragmatic hernia

Chronic posttraumatic diaphragmatic hernia is an unusual disease with challenging diagnosis and treatment. Surgery represents the treatment of choice which can be transabdominal, transthoracic, or combined approach. The principles of surgery consist of herniated visceral organs reduction and diaphragmatic defect closure. This video demonstrates the steps of chronic posttraumatic diaphragmatic hernia repair via a laparoscopic approach and concerning points during the operation.

Life threatening rupture of the diaphragm after Covid 19 pneumonia: a case report

Background

The incidence of diaphragmatic rupture is low; however, it may be life threatening. Normally caused by blunt trauma, some cases are reported after pulmonary infections with extensive coughing. Covid 19 causes pulmonary infections and pneumonia and has been associated with weakening of the diaphragm after prolonged ventilation. We present a patient who suffered from diaphragmatic rupture 2 months after recovering from a severe Covid 19 pneumonia.

Case

A 71 years old male patient presented with massive thoraco-abdominal pain and severe dyspnea. At the time of admission, the patient was diagnosed with rupture of the diaphragm and developed cardiogenic shock. Intraoperatively there was a 4 cm diameter large rupture of the diaphragm with enterothorax (transverse colon, stomach, spleen, parts of the jejunum). Avulsion of the mesenteric arteries made a segmental resection of the jejunum together with the spleen necessary. A jejuno-jejunostomy was performed and organs were replaced into the abdomen. The rupture of the diaphragm underwent primary closure with non-resorbable suture material. The patient has shown an uneventful post-operative course, fully recovered and was discharged on day 11 after surgery.

Conclusion

Covid 19 is a disease that is known to have various effects on different organs. The diaphragm is only paid heed in case of dysfunction. Also in the setting of Covid 19 it is not known as prominent effector organ. Nevertheless its affection by coughing caused by Covid 19 can lead to life threatening complications.

Traumatic diaphragmatic injury along with ruptured gastrothorax: case report

Accidental fall was the 11th leading cause of death in Australia in 2020. It is essential to promptly diagnose traumatic diaphragmatic injury as a complication of thoracoabdominal blunt trauma and make a decision about an urgent surgical intervention, especially if there is a suspected herniation of internal organs into the thoracic cavity. This case report describes the clinical, intraoperative and computed tomography findings of traumatic diaphragmatic injury and ruptured gastrothorax.

Management of traumatic diaphragmatic injury—A peep into bowel repair via thoracotomy

Background:

Materials and Methods:

Results:

Conclusion:

Open versus laparoscopic repair of traumatic diaphragmatic injury: A nationwide propensity-matched analysis

INTRODUCTION

Minimally invasive surgical techniques have become routinely applied in the evaluation and treatment of patients with isolated traumatic diaphragmatic injuries (TDI). However, there remains a paucity of data that compares the laparoscopic repair to the open repair approach. The aim of our study is to examine patient outcomes between TDI patients managed laparoscopically versus those managed using open repair.

METHODS

Adult (age ≥18 years) trauma patients presenting with TDI that required surgical repair were identified in the Trauma Quality Improvement Program database 2017. Patients were excluded if they underwent any other surgical procedure of the abdomen or chest. Patients were then stratified into 2 groups based on the surgical approach: laparoscopic repair of the diaphragm versus open repair. Propensity-score matching in a 1:2 ratio was performed. Primary outcome measures were in-hospital major complications and length of stay (LOS). Secondary outcome measure was in-hospital mortality.

RESULTS

A total of 177 adult trauma patients who had a laparoscopic repair of their isolated diaphragmatic injury were matched to 354 patients who had an open repair. Mean age was 35 ± 16 years, 78% were male, and mean BMI was 27 ± 7 kg/m². 67 percent of the patients had penetrating injuries, and the median ISS was 17 [9-21]. CT imaging was done in 67% of the patients, with 71% presenting with left-sided injury and 21% having visceral herniation. Conversion from laparoscopic to open was reported in 7.3% of the cases. Patients with a laparoscopic repair had significantly lower rates of major complications (5.6 versus 14.4%; P<0.001), shorter hospital LOS (6 [3-9] versus 9 [5-13] days; P<0.001) and ICU LOS (3 [2-7] versus 5 [2-10] days; P<0.001). No difference was found in rates of in-hospital mortality (0.6 versuss 2.0%; P = 0.129) between the 2 groups.

CONCLUSION

Laparoscopic repair of traumatic diaphragmatic injury was associated with decreased morbidity and a shorter hospital course, with a low conversion rate to open repair. Future studies remain necessary to further explore the long-term outcomes of patients with such injury.

LEVEL OF EVIDENCE

Level III STUDY TYPE: Therapeutic.

Case Report of a Laparoscopic Primary Diaphragmatic Repair in Acute Penetrating Trauma: Is It Within the Realm of an Acute Care Surgeon?

The laparoscopic repair of traumatic diaphragmatic injuries in the acute phase has not been well established. The current consensus view is an elective repair by a surgeon with an advanced laparoscopic skill set. This case report illustrates the position that with judicious patient selection an acute repair is not only possible but well within the realm of an acute care surgeon. Anterior diaphragmatic injuries with penetrating trauma can even be repaired primarily without the need for prosthetic reinforcement. It is hoped that this case report will add to the surgical armamentarium of the acute care surgeon.

When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review

BACKGROUND

Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair.

METHODS

A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH.

RESULTS

Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected.

CONCLUSIONS

DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries.

Penetrating Thoracoabdominal Trauma With a Cryptic Diaphragmatic Injury in a 23-Year-Old Male

Traumatic diaphragmatic injuries are a rare entity and can occur in relation to penetrating thoracic and abdominal trauma. The most common clinical features of diaphragm rupture include chest or abdominal bruising, decreased breath sounds, and signs of bowel obstruction. However, the classic signs and symptoms of diaphragmatic injury are not always present and can be obscured even in the highest resolution imaging. This highlights the importance for maintaining a high index of suspicion to make the diagnosis and properly manage these patients. Here, we present a rare case of a 23-year-old male who experienced a laceration to his left thorax and was later discovered to have concurrent diaphragmatic injury despite an initially noncontributory physical exam and imaging findings. The patient subsequently underwent robotic repair of the injury and reduction of herniated contents.

Spleen in the thorax: A case report on traumatic diaphragmatic rupture

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Diaphragmatic rupture is a rare complication of abdominal trauma.

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Herniation of abdominal contents can occur following diaphragmatic rupture.

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Spleen was present in the thorax in a case following blunt abdominal trauma.

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Care should be taken when inserting a chest tube in suspected cases.

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Treatment is surgical via Laparotomy or Thoracotomy.

Introduction

Most of the cases of diaphragmatic rupture occur following abdominal trauma and herniation of abdominal organs into the thorax can occur.

Presentation of case

Twenty three years old male presented after a blunt abdominal trauma following a road traffic accident. Investigations revealed a left sided diaphragmatic rupture with herniation of spleen and stomach into the left hemithorax. Surgical repair of the defect was done and splenectomy had to be done due to extensive splenic laceration. Two third of the spleen was found in the left hemithorax.

Discussion

Diagnosis of diaphragmatic rupture can be missed in cases of polytrauma. High clinical suspicion with aids from imaging modalities help in the diagnosis. In suspicion of herniation of abdominal contents into the thorax, one should be careful in insertion of chest tube in view of damaging the herniated organs. Treatment is surgical repair and reduction of herniated contents.

Conclusion

Although a rare entity, diaphragmatic rupture can occur in cases of abdominal trauma. High clinical suspicion with imaging helps in the diagnosis.

Minimally invasive repair of right-sided blunt traumatic diaphragmatic injury

Right-sided blunt traumatic diaphragmatic injury (TDI) is a rare injury that is rarely repaired by the minimally invasive approach in the acute setting. Laparoscopic repair of right-sided TDI is challenging because the liver often obstructs access to the injury site. Herein, we report a case wherein acute right-sided blunt TDI was successfully repaired using a combined laparoscopic and thoracoscopic approach. A 30-year-old man presented with shortness of breath after falling on his back while jumping on a snowboard. CT revealed a right-sided TDI. As the patient was haemodynamically stable, laparoscopic repair was planned. Laparoscopy revealed a right-sided diaphragmatic rupture. As the posterior portion was covered by the liver and difficult to access, we added trocars in the chest cavity and closed the diaphragmatic defect with a thoracic approach. A combined laparoscopic and thoracoscopic approach can repair right-sided diaphragmatic injury by a minimally invasive approach even in the acute setting.

Diagnostic value of CT contrast extravasation for major arterial injury after pelvic fracture: A meta-analysis

PURPOSE

We conducted a meta-analysis to determine diagnostic performance of CT intravenous contrast extravasation (CE) as a sign of angiographic bleeding and need for angioembolization after pelvic fractures.

MATERIALS AND METHODS

A systematic literature search combining the concepts of contrast extravasation, pelvic trauma, and CT yielded 206 potentially eligible studies. 23 studies provided accuracy data or sufficient descriptive data to allow 2x2 contingency table construction and provided 3855 patients for meta-analysis. Methodologic quality was assessed using the QUADAS-2 tool. Sensitivity and specificity were synthesized using bivariate mixed-effects logistic regression. Heterogeneity was assessed using the I2-statistic. Sources of heterogeneity explored included generation of scanner (64 row CT versus lower detector row) and use of multiphasic versus single phase scanning protocols.

RESULTS

Overall sensitivity and specificity were 80% (95% CI: 66-90%, I2 = 92.65%) and 93% (CI: 90-96, I2 = 89.34%), respectively. Subgroup analysis showed pooled sensitivity and specificity of 94% and 89% for 64- row CT compared to 69% and 95% with older generation scanners. CE had pooled sensitivity and specificity of 95% and 92% with the use of multiphasic protocols, compared to 74% and 94% with single-phase protocols.

CONCLUSION

The pooled sensitivity and specificity of 64-row CT was 94 and 89%. 64 row CT improves sensitivity of CE, which was 69% using lower detector row scanners. High specificity (92%) can be maintained by incorporating multiphasic scan protocols.

Awake Emergency Department Thoracoscopic Investigation of Penetrating Diaphragmatic Injuries: A Novel Minimally Invasive Technique of Diagnosis

Background: The diagnosis of occult penetrating diaphragmatic trauma remains challenging, with conventional imaging offering inadequate accuracy for diagnosis. Minimally invasive surgical options for evaluating the diaphragm conventionally require general anesthesia. We propose a technique for evaluating the diaphragm via awake thoracoscopy in the emergency department. Methods: A prospective interventional study was conducted to investigate the safety and accuracy of emergency department awake thoracoscopy for diagnosing diaphragmatic injuries in penetrating thoracoabdominal trauma. All adult patients who presented to the trauma unit with penetrating thoracoabdominal trauma who were hemodynamically stable were enrolled. The patients underwent emergency department awake thoracoscopy with a rigid endoscope through a previously inserted intercostal drain. Only local anesthesia and conscious sedation were provided. Results: Forty patients were enrolled. All 40 (100%) were men, and the median age was 34 years. Thirty-four had stab wounds (85%), 5 had gunshot wounds (12.5%), and 1 had a suspected iatrogenic diaphragm injury during intercostal drain insertion (2.5%). In 32 (80%), the diaphragm was well visualized, of whom 7 (17.5%) had diaphragm injuries. In the remaining 8 patients in whom the diaphragm was not well visualized, only 1 (2.5%) had a diaphragmatic injury. The diaphragmatic injuries that were identified were confirmed and repaired during a subsequent explorative laparoscopy. There were no procedure-related complications in any of the patients during short-term follow-up. Conclusions: Awake thoracoscopy is safe, feasible, and accurate for the diagnosis of occult diaphragm injuries and may offer a modality for assessment that does not require general anesthesia.

Selective nonoperative management of penetrating abdominal trauma at a level 1 Canadian trauma centre: a quest for perfection

Background

Many patients who sustain penetrating abdominal trauma can be managed nonoperatively. The Eastern Association for the Surgery of Trauma (EAST) has published guidelines on selective nonoperative management (SNOM), and this approach is well established. The purpose of this study is to assess the management of penetrating abdominal trauma, including the selection of patients for SNOM and the use of this approach, at a Canadian level 1 trauma centre.

Methods

We used the Hamilton Health Sciences trauma registry to compile data on patients aged 16 years and older who sustained penetrating abdominal trauma from Jan. 1, 2011, to Dec. 31, 2017. Hemodynamically stable, nonperitonitic patients without evisceration or impalement were considered potentially eligible for SNOM. We compared the SNOM group of patients with the immediate operative (IOR) group. Our primary outcome was SNOM failure; secondary outcomes included length of stay, repeat imaging, computed tomography (CT) protocol, laparoscopy in left thoracoabdominal trauma, and nontherapeutic and negative laparotomies.

Results

We included 191 patients with penetrating abdominal trauma; 123 underwent SNOM and 68 underwent IOR. Of the 68 patients in the IOR group, 4 underwent nontherapeutic laparotomies. Of the 123 patients in the SNOM group, this approach failed in 7 (5.7%). Patients who were successfully managed with SNOM had an average length of stay of 25.4 hours (7.9–43.0 h), with no repeat imaging in 34/35 (97.1%). Only 5 of the 47 patients with flank/back wounds had a CT scan that included luminal contrast. Only 3 of the 58 patients with left thoracoabdominal wounds underwent same-admission laparoscopy, all demonstrating diaphragmatic defects.

Conclusion

Our study demonstrates a high rate of compliance with the EAST SNOM guidelines, including minimal failure rate of SNOM and an efficient use of resources as demonstrated by reduced length of stay and minimal use of reimaging. We identified 2 opportunities for improvement: improved use of luminal contrast CT in patients with flank/back wounds and improved use of diagnostic laparoscopy in patients with left thoracoabdominal wounds.

Traumatic Diaphragmatic Rupture with Transthoracic Organ Herniation: A Case Report and Review of Literature

Patient: Female, 59-year-old

Final Diagnosis: Axillo-subclavian vessel injuries

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Surgery

Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration

Background

Missed injury of the diaphragm may result in hernia formation, enteric strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and difficult to diagnose with standard imaging. As such, for patients with high suspicion of injury, operative exploration remains the gold standard for diagnosis. As no current data currently exist, we sought to perform a pragmatic evaluation of the diagnostic ability of 256-slice multidetector CT scanners for diagnosing diaphragmatic injuries after trauma.

Methods

A retrospective review of trauma patients from 2011 to 2018 was performed at an American College of Surgeons-verified level 1 trauma center to identify the diagnostic accuracy of CT scan for acute diaphragm injury. All patients undergoing abdominal operation were eligible for inclusion. Two separate levels of CT scan technology, 64-slice and 256-slice, were used during this time period. The prospective imaging reports were reviewed for the diagnosis of diaphragm injury and the results confirmed with the operative record. Injuries were graded using operative description per the American Association for the Surgery of Trauma guidelines.

Results

One thousand and sixty-eight patients underwent operation after preoperative CT scan. Acute diaphragm injury was identified intraoperatively in 14.7%. Most with diaphragmatic injury underwent 64-slice CT (134 of 157, 85.4%). Comparing patients receiving 64-slice or 256-slice CT scan, there was no difference in the side of injury (left side 57.5% vs. 69.6%, p=0.43) or median injury grade (3 (3, 3) vs. 3 (2, 3), p=0.65). Overall sensitivity, specificity, and diagnostic accuracy of the 256-slice CT were similar to the 64-slice CT (56.5% vs. 45.5%, 93.7% vs. 98.1%, and 89.0% vs. 90.2%).

Discussion

The new 256-slice multidetector CT scanner fails to sufficiently improve diagnostic accuracy over the previous technology. Patients with suspicion of diaphragm injury should undergo operative intervention.

Level of evidence

I, diagnostic test or criteria.

Spontaneous Diaphragmatic Hernia

A spontaneous diaphragmatic hernia (SDH) occurs when intra-abdominal contents extend into the thoracic cavity through a defect in the diaphragm after a sudden increase in intra-abdominal pressure. SDH is one of the rarest surgical emergencies with less than 30 reported cases in the literature.1,2 In our case a 94-year-old female presented to the emergency department in respiratory distress with unilateral breath sounds and was diagnosed with a SDH. The only treatment option for a SDH is surgical.3,11 However, nasogastric tube decompression of the gastrointestinal tract and supplemental oxygen can be used to alleviate symptoms until definitive operative management is performed.