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Traumatic injuries of the diaphragm

Diaphragmatic hernia
  • Author Footnotes
    1 From the Department of Surgery, University of California Medical Center, San Francisco, California.
    Orville F. Grimes
    Correspondence
    Reprint requests should be addressed to Dr Orville F. Grimes, Department of Surgery, University of California Medical Center, San Francisco, California 94143.
    Footnotes
    1 From the Department of Surgery, University of California Medical Center, San Francisco, California.
    Affiliations
    San Francisco, California USA
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  • Author Footnotes
    1 From the Department of Surgery, University of California Medical Center, San Francisco, California.
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      Abstract

      Trauma to the diaphragm may be direct or indirect, and herniation may be obscured by concomitant injuries and may remain occult for many years.
      The early physical signs and symptoms are meager before the abdominal organs have penetrated deeply into the thorax. The progress of injury can be divided into three phases: (1) initial, (2) latent, and (3) obstructive.
      Most traumatic hernias occur on the left side because of the diminished buffering force on the undersurface of the left hemidiaphragm. Roentgenograms are most often misinterpreted as indicating eventration of the diaphragm, gastric dilatation, or lesions in the lower lung fields or pleura. A dilated stomach in the left pleural cavity may simulate a pneumothorax. Diaphragmatic injury should always be considered in conjunction with trauma to the liver, kidneys, and spleen. Intestinal obstruction may occur with few significant abdominal findings, when most of the involved viscera are in the thorax. The thoracic approach to surgery provides excellent exposure. The herniated viscera which may be adherent to the lung or pericardium can be released conveniently, there is easy access to the diaphragmatic rent, and lacerations near the heart and esophagus can be repaired without fear of further injury. Extensions or separate abdominal incisions may be necessary to manage concomitant injuries, especially in the initial phase.
      Wounds of the diaphragm are not likely to heal spontaneously; often the omentum or other viscera plug the laceration, thereby preventing acute herniation. However, this same mechanism separates the muscle edges, preventing their union. Traumatic ruptures of the diaphragm are twelve times more common on the left side due to the protection afforded by the liver. Diaphragmatic tears are most common in the dome and the posterior half which are the areas of embryonic weakness. When strangulation of bowel occurs in the thorax, approximately 90 per cent of the cases are due to traumatic hernia of the diaphragm, and when strangulation occurs, the mortality varies from 25 to 66 per cent.
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      Reference

        • Coats RR
        • Sakai K
        • Lam CR
        Extensive diaphragmatic-pericardial rupture from blunt trauma.
        J Thorac Cardiovasc Surg. 1972; 63: 275