Descriptive Analysis of Right and Left-sided Traumatic Diaphragmatic Injuries; Case Series from a Single Institution

Abstract

Objective: To investigate the presentation, management and outcomes of left and right-sided traumatic diaphragmatic injury (TDI) in a single level I trauma center. Methods: This cross-sectional study was conducted during a 7-year period from 2008 to 2015 in a level I trauma center in Qatar. We included all the patients who presented with TDIs during the study period. Data included demographics, mechanism of injury, associated injuries, initial vitals, emergency department disposition, length of ICU and hospital stay, ventilator days, management, and outcomes. The variables were analyzed and compared for patients with left (LTDI) and right (RTDI). Results: A total of 52 TDI cases (79% LTDI and 21% RTDI) were identified with a mean age of 31±11. LTDI patients were more likely to have higher Injury severity scores (p=0.50) and greater AAST organ injury scoring (p=0.661 for all) than RTDI patients. Surgical repair was performed for 85% LTDI vs. 73% RTDI (p= 0.342). Recurrent DIs was reported only in LTDI (5.1% vs. 0.0%; p=0.911). Twelve patients died (9 LTDI and 3 RTDI), of them 5 had associated head injury. Conclusion: This single-institution study confirms that LTDI are more commonly diagnosed than RTDI. Exploratory laparotomy is the most frequent procedure considered for the management of diaphragmatic injuries in the emergency settings. To improve outcomes in patients presenting with TDI, large prospective multicenter studies are needed to standardize the TDI management protocols including the diagnostic workup, timing of surgical intervention, and the most appropriate approach of treatment.

Traumatic Diaphragmatic Rupture, Incidence, Presentation, and Outcome

“…For the rest of the patients associated thoracic injuries were treated only by chest tube. This was consistent with other previously reported studies were the majority of the cases managed by exploratory laparotomy (2)(21) (25) .Minimally invasive surgery not applied in our patients, also all operation in our study done in the night duty by doctors on duty. In the present study The routine surgical repair of the defect is accomplished by interrupted or continuous direct suture using a double layer of nonabsorbable suture without a mesh and evacuation of the involved pleural cavity with a chest tube, this finding is in similar to study done by (21) .…”

“…A thoracoabdominal pressure gradient develops, resulting in a rupture at the left diaphragm, usually after high-impact blunt trauma such as motor vehicle crash or fall from height The right diaphragm is stronger than the left side, and is partially protected by the liver (2)(4) (6) . (2) & Al-Thani H, et al (25) In the present study, the majority of patients presented to hospital post trauma in acute phase 33 patient 92.1% the majority of patients presented to emergency department post trauma <12hrs 25 patients(75.8%), and eight patient presented between 18-48hrs, with no specific signs and symptoms in acute phase, most signs and symptoms of them related to associated injuries, most of the patients suffering from dyspnea, chest pain and pain in the upper abdomen. as seen in previous study (6)(27) patients presented with diaphragmatic hernia in delayed phase, 3 patients post blunt trauma complaining of dyspnea on flat position, and 2 patients post penetrating trauma.…”

“…Traumatic diaphragm rupture incidence was 0.46% (7) . The incidence of traumatic diaphragm rupture ranges from 0.8-7% in patients presented with blunt trauma and 10-15% for penetrating injuries (16) , also reported an incidence of 4% of penetrating trauma and 0.5% of thoracoabdominal blunt trauma (25) . the incidence of diaphragmatic rupture was 0.2% in thoracoabdominal contusions and 2.1% in penetrating wounds (5) .…”

Robotic Transthoracic Repair of a Right-Sided Traumatic Diaphragmatic Rupture

“…4 Surgical approaches through laparotomy, thoracotomy, or thoracoabdominal incisions are often offered to repair traumatic diaphragm ruptures; however, these open operations are associated with a 20% pulmonary complication rate postoperatively. 1,5 While it is prudent to perform open surgery in unstable patients or in patients with associated organ injuries that require urgent repair, minimally invasive surgery (MIS) in a delayed setting is feasible in selected patients. 1,[4][5][6][7] As MIS has been shown to reduce respiratory complications, pain, and faster recovery compared with open surgery, incorporating MIS in selected trauma patients may spare them from the morbidities of open operations.…”

“…1,5 While it is prudent to perform open surgery in unstable patients or in patients with associated organ injuries that require urgent repair, minimally invasive surgery (MIS) in a delayed setting is feasible in selected patients. 1,[4][5][6][7] As MIS has been shown to reduce respiratory complications, pain, and faster recovery compared with open surgery, incorporating MIS in selected trauma patients may spare them from the morbidities of open operations. 8 Several centers have published case reports of thoracoscopic or laparoscopic repair of traumatic diaphragm ruptures in delayed settings with either primary repair with nonabsorbable sutures or patch closure of the diaphragm with mesh.…”