Case Reports

TRAUMATIC DIAPHRAGMATIC HERNIA

Arcot Rekha a, Ananthakrishnan Vikrama
ABSTRACT
Traumatic diaphragmatic hernias are uncommon, yet
associated with high mortality. The colon very rarely
herniates through the diaphragmatic defect. This case is
submitted as the diagnosis was delayed due to an initial

asymptomatic state. Patients are often seen initially by the

physician for respiratory symptoms.
Key words : trauma, diaphragm, hernia
SRJM 2010;3:23-25

INTRODUCTION
Diaphragmatic rupture occurs due to blunt or
penetrating injury, either as an acute presentation or delayed
as respiratory distress or obstruction [1], can be managed
through a laparotomy or a thoracotomy[2] and in the present
day with minimal access surgery. Given the number of
variables a review of this condition is interesting and
thought provoking.
HISTORICAL VIGNETTE
Traumatic diaphragmatic hernia apparently was
described by Sennertus, who in 1541 reported an instance
of delayed herniation of viscera through an injured
diaphragm [3]. Ambroise Par, in 1579, described the first
case of diaphragmatic rupture diagnosed at autopsy. The
patient was a French artillery captain who initially survived
a gunshot wound of the abdomen, but died 8 months later
of a strangulated gangrenous colon, herniating through a
small diaphragmatic defect that would admit only the tip
of the small finger. It was not until 1853 that ante mortem
diagnosis of traumatic rupture of diaphragm was made by
Bowditch.The first successful diaphragmatic repair was
reported by Riolfi in 1886 in a patient with omental
prolapse, and Naumann in 1888 repaired the defect with
herniated stomach. The largest and the most comprehensive
collective review was published by Hood in 1971, whereas
the earliest review on this subject was by Carter and
associates in 1951.[4]

Fig 1 : Chest X-ray & CT showing the diaphragm hernia

A plain X Ray taken in the ER showed bowel loop
shadows in the chest (Fig 1 left inset).She was stabilised in
ER and then shifted for a CT thorax and abdomen which
showed herniation of the bowel loops through the left
hemi diaphragm. There was mediastinal shift to the right
and there was little lung field visualized on the left chest
(Fig 1-right inset).
A diagnosis of diaphragmatic hernia was made. On
questioning there was a history of fall 10 days prior to the
admission (apparently minor injury when patient slipped
and fell while crossing the road). She had sustained no
external injuries and had not been treated.

CASE REPORT
A 65 year old lady presented to the emergency room(ER)
with complaints of dyspnea at rest and orthopnoea. She
had been referred to our tertiary care centre as a case of
bronchopneumonia. The lady also complained of abdominal
distension and of having difficulty in defaecation over the
last one week. Examination showed decreased breath sounds
on the left hemithorax and the presence of bowel sounds
over the left thorax and normal bowel sounds in the
abdomen. She had severe respiratory acidosis on analysis of
the blood gas.
CORRESPONDING AUTHOR :
Dr. Arcot Rekha
Associate Professor
Department of General Surgery
Sri Ramachandra Medical College & Research Institute
Sri Ramachandra University, Porur, Chennai - 600 116.
Email : [email protected]
a
Department of General Surgery

Fig 2 : Shows the rent in the diaphragm

Fig 3 : Shows the rent repaired with a prolene mesh

Sri Ramachandra Journal of Medicine, July - Dec. 2010, Vol. 3, Issue 2

23

Case Reports

Patient was shifted for surgery after informed high risk

consent.
A diagnostic laparoscope inserted showed a large defect
on the left side and colonic loops herniating through this.
Attempts to reduce this laparoscopically failed and
laparotomy was done. At laparotomy dense adhesions were
found between the loops of transverse colon. The incision
was extended as a left thoracotomy and the contents were
reduced. There was a large defect about 15 cm 13 cms in
the left hemi diaphragm (Fig 2) which was repaired using a
prolene mesh (Fig 3). There was compressed lung tissue
that did not expand significantly even after reduction of the
hernia. A left thoracic drain was placed and wounds (thoracic
and abdominal) were closed.
DISCUSSION
Incidence
Diaphragmatic injury accounts for 0.8-1.6% of blunt
trauma abdomen. Approximately 4-6% of patients who
undergo surgery for trauma have a diaphragmatic injury.[5]
Aetiology
Diaphragmatic injuries are caused either by penetrating
or blunt injuries to the abdomen. They are diagnosed
immediately as part of multi-organ injury, or present later
either with respiratory distress or as intestinal obstruction[4].
The mechanism in blunt injury is explained by shearing of
a stretched membrane, avulsion at the point of diaphragmatic
attachment, and the sudden force transmission through
viscera acting as viscous fluid1.Left sided injuries are more
often seen. Left-sided rupture occurred in 68.5% of the
patients, 24.2% had right-sided rupture5, 1.5% had bilateral
rupture, 0.9% had pericardial rupture, and 4.9% were
unclassified in the present collective review. Increased
strength of the right hemi-diaphragm, hepatic protection of
the right side, under diagnosis of right-sided ruptures, and
weakness of the left hemi-diaphragm at points of embryonic
fusion all have been proposed to explain the predominance
of left sided diaphragmatic injuries.[5] Autopsy studies reveals
that the incidence of rupture is almost equal on both sides
but the greater force needed for the right rupture is associated
with more grave injuries that, these are seen more by the
forensic examiner than the trauma surgeon! A positive
pressure gradient of 7-20 cms of H2O between the intraperitoneal and the intra pleural cavities forces the contents
into the thorax. With severe blunt trauma the pressures may
rise to as high as 100cms of water.
Pathophysiology:
The pathophysiologic effects of ruptured diaphragm are
on circulation and respiration. This is due to the impaired
function of the diaphragm, compression of the lungs, and
displacement of the mediastinum with impairment of the
venous return to the heart. In cases of pericardial tear, the
heart is compressed by the herniating viscera, and a clinical
picture of cardiac tamponade may follow. Diaphragmatic
action accounts for two thirds of the tidal volume when
supine. Functional loss of one hemi-diaphragm results in
25% to 50% decrease in pulmonary function.
24

Clinical features and grading

The patient with a diaphragmatic rupture often presents
with breathlessness and is mistaken for bronchopneumonia,
especially when a history of injury is not forthcoming.
Abdominal signs due to obstruction may be another mode
of presentation.
The grading of severity has been proposed by Grimes.[6]
who discussed diaphragmatic rupture in phases- acute, latent
and the obstructive phase. The acute presentation is in the
patient with poly trauma associated with multiple intra
abdominal and chest injuries. The latent phase is when
herniation occurs through undetected diaphragmatic ruptures
and rents. The obstructive phase is when the loop herniating
obstructs and the patient develops distension and
strangulation.
Investigations : An X-ray is diagnostic when the nasogastric
tube is seen in the chest. The collar sign is seen when
abdominal contents are seen in the thorax with/without focal
constriction. Elevation and distortion of the hemi diaphragm
are corroborative signs.[7,8].
A CT thorax has a sensitivity of 14-82% and a
specificity of 87% and permits direct visualization of the
contents and the rupture.Focussed abdominal sonography
for trauma(FAST) is now a good aid in diagnosing
diaphragmatic hernia.[9]
MANAGEMENT
When a diagnosis of diaphragmatic rupture is suspected
in a patient with poly trauma, military anti shock trousers
are contra-indicated as it could cause severe cardiopulmonary deterioration. The patient is stabilized and taken
up for emergent surgery. While controversies exist between
laparotomy and thoracacotomy-laparotomy is preferred as
this is often associated with other abdominal injuries.[10] In
a series of 15 patients who underwent intial thoracotomy,
7 required laparotomy for associated injuries as against 1 in
65 that required thoracotomy after laparotomy.Minimally
invasive procedures(abdominal and thoracic)are now a days
preferred in small defects detected early. Laparotomy remains
the gold standard in large defects. While simple suture is
sufficient in the former, larger defects need a synthetic
mesh.[10]
CONCLUSION
A knowledge of diaphragmatic hernia is essential for
both the physician and the surgeon in atypical abdominal
and respiratory discomfort, especially when there is history
of trauma.This hernia is amenable to correction by minimal
access surgery and requires a prompt diagnosis aided by a
high index of suspicion.
ACKNOWLEDGEMENT
The authors wish to acknowledge the cardiothoracic
team, Dr. Sivamuthukumar and Dr. Naveen Alexander for
their assistance.

Sri Ramachandra Journal of Medicine, July - Dec. 2010, Vol. 3, Issue 2

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