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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
- Extensive diaphragmatic-pericardial rupture from blunt trauma.J Thorac Cardiovasc Surg. 1972; 63: 275
Article info
Footnotes
Presented at the Forty-Fifth Annual Meeting of the Pacific Coast Surgical Association, Kaanapali, Maui, Hawaii, February 17–21, 1974.
Identification
Copyright
© 1974 Published by Elsevier Inc.
