Delayed traumatic diaphragmatic hernias presenting with strangulation

Abstract

Traumatic diaphragmatic injuries commonly occur following blunt and penetrating trauma, and that may be missed during a first evaluation, resulting in chronic diaphragmatic hernia and/or strangulation. In this study, we present three cases of delayed traumatic diaphragmatic hernias presenting with strangulation. The type of trauma was blunt in two and penetrating in one patient. In all three cases, the diagnoses of diaphragmatic injuries were missed in acute and chronic settings. While two patients had transverse colonic strangulation, the other one had strangulated stomach and spleen. Transverse colon resection was performed in one patient. Two patients had postoperative complications, and no postoperative mortality was detected. Patients complaining of upper abdominal pain and dyspnea with past history of thoracoabdominal trauma should be evaluated for a missed diaphragmatic injury. A high index of suspicion, physical examination of the chest, and x-ray film are helpful for diagnosis of delayed traumatic diaphragmatic hernias presenting with strangulation.

Delayed presentation of posttraumatic diaphragmatic hernia

“…Three patients with acute abdominal symptoms were reported earlier. [12] Delayed presentation of posttraumatic diaphragmatic hernia was defined as the diaphragmatic hernia not detected during the initial hospitalization after the trauma. The medical records of patients were reviewed for the demographic data, mechanism of injury, clinical presentation, diagnostic modalities, operations, and the outcome.…”

“…[10,11] Recent case reports have reported low mortality rates in the treatment of delayed diaphragmatic hernias. [12,19] However, the presence of strangulation with gangrene and perforation was related with increased morbidity and mortality. [11] In conclusion, the delayed presentation of diaphragmatic hernia necessitates prompt awareness of the surgeon since the symptoms are usually vague and the trauma history is remote.…”

Delayed Traumatic Diaphragmatic Hernia With Bacterial Pleuritis

“…In previous reports, the stomach was the most frequently herniating organ, followed by the spleen, small bowel, and so forth. [6][7][8][9][10][11][12][13] Moreover, a maximum of 1-2 visceral organs were reported in such diaphragmatic hernias; however, in our patient, we noted the unusual herniation of multiple viscera into the left thoracic space. Therefore, we made further incisions in the diaphragm to return the viscera safely into the abdominal cavity without bleeding, especially from the spleen.…”

“…The proposed mechanism for such hernia is an increase in the intraabdominal or intrathoracic pressure at the time of impact, which results in shearing forces on to the stretched diaphragm and avulsion from its points of attachment. [8][9][10][11][12] Traumatic diaphragmatic hernias occur following injury to the musculotendinous membrane and are believed to predominantly occur on the left side because of the anatomically protective location of the liver on the right side. 10 In our case, the cause of the hernia was the weakening of the diaphragm due to rib fractures.…”

“…5 Subsequently, many reports have described this condition, with the stomach being the most frequently herniating organ, followed by the spleen, small bowel, and so forth. [6][7][8][9][10][11][12][13] However, few studies have reported multiple viscera herniating into the chest simultaneously. Further, no reports have described the occurrence of bacterial pleuritis in combination with diaphragmatic hernia without perforation or necrosis.…”