Laparoscopic-Assisted Repair of a Traumatic Ruptured Diaphragm

Abstract

aparoscopic-assisted surgery has found many applications in the treatment of intraabdominal L and gynecologic pathology. Traumatic diaphragmatic rupture is a difficult clinical diagnosis, and diagnostic laparoscopy has been advocated in the management of this condition (1 ). However, insufflation of carbon dioxide to create a pneunoperitoneum when the diaphragm may not be intact is controversial. We report a case of laparoscopic-assisted repair of traumatic diaphragmatic rupture and the potential respiratory complications. Case ReportA 43-yr-old, 60-kg, previously healthy woman was admitted to our neurosurgical intensive care unit after being involved in a motor vehicle accident. Physical examination on admission revealed a comatose state (Glasgow coma scale 31, a heart rate of 64 bpm, and a supine arterial blood pressure (ABP) of 125/65 mm Hg. Chest radiograph showed blunting of the left costophrenic angle. Pao, and Paco, were 80 and 34 mm Hg, respectively, with a fractional inspired oxygen concentration (FIo,) of 0.4. Management included tracheal intubation and intermittent positive pressure ventilation (IPPV) with a minute volume of 12 L, a respiratory rate of 14 breaths/min, and an inspiratory to expiratory (IE) ratio of 1:2 (Siemens Elema Servo 900 C; Stockholm, Sweden). Minute ventilation was adjusted to maintain a Paco, in the range 34-40 mm Hg. Intracranial pressure was monitored with a subdural catheter, and values ranged from 3 to 14 mm Hg during the intensive care course. Midazolam 2-5 mg/h was administered intravenously (IV) for sedation.A chest radiograph obtained 5 days after admission showed the gastric fundus occupying the left hemithorax. The tip of the nasogastric tube was visible above the diaphragm. Nasogastric tube aspiration of 0.5 L of gastric contents resulted in the return of the chest radiograph to its appearance on admission. No pneumothorax or rib fractures were apparent. A presumptive diagnosis of traumatic ruptured diaphragm was made. The patient remained in a comatose state (Glasgow coma scale 5).The patient was scheduled to undergo a diagnostic laparoscopy to evaluate the integrity of the left hemidiaphragm.Preoperative laboratory investigation revealed hemoglobin 8.2 g/dL and hematocrit 0.26. Pao, and Paco, were 125 and 34 mm Hg, respectively, with a FIO, of 0.4. The preoperative electrocardiogram revealed sinus rhythm, normal ST segments, and T waves. The remainder of the hematologic assessment, coagulation screen, renal and liver function tests, and serum electrolytes were within normal limits. A decision was made not to insert a chest drain preoperatively because of the risk of perforation of the gastric fundal hernia and because there was no evidence of visceral pleural injury.In the operating room, routine monitors were placed. A 16-gauge, 70-cm, central venous catheter was placed via the left basilic vein, and a 14-gauge IV catheter was also inserted for intraoperative fluid administration. A 20-gauge catheter was in situ in the right radial artery. A heart rate of 86 bpm, A...

Laparoscopic repair of traumatic diaphragmatic hernias

“…Transdiaphragmatic exploration of thoracic organs through the laparoscopic approach was easily performed in all three of our patients; therefore, we believe that the risk of missing injuries to thoracic organs is very small. In contrast to the results reported by Power et al [16], we did not experience a significant reduction in insufflatory pressure, and we never observed a tension pneumothorax during any of our procedures. Other investigators have confirmed our experience.…”

Laparoscopic repair of missed blunt diaphragmatic rupture using a prosthesis

“…The surgical procedure should be discussed regarding its safety, the best approach (laparoscopic or thoracoscopic), and the technical aspects of the diaphragmatic repair (suture or prosthesis). Contrary to one reported case [18], this case demonstrates that laparoscopy has been achieved without tension pneumothorax or intraoperative hypoxemia or increased peak airway pressures. This was probably due to intrathoracic adhesions that avoided a communicating pneumoperitoneum and pneumothorax.…”

“…One paper [12] reported a 8-cm rupture that was diagnosed early and repaired by a thoracoscopic approach. In another report [18] the authors stated that the defect was large without specifying its exact size. To our knowledge, the only reported case of diaphragmatic hernia requiring a laparoscopic prosthetic repair concerned an iatrogenic defect with a diameter of 7.5 × 3 cm.…”

“…But few papers reported a minimally invasive repair of missed diaphragmatic rupture [11,18]. In these reports, diaphragmatic lacerations were diagnosed with a relatively short delay (1 and 5 days) or did not exceed 3 cm in length [11].…”

The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture

“…With the development of laparoscopic surgery during the last decade, laparoscopy can now be used in the treatment as well as the diagnosis of the injury. However, this approach has been described in only a few papers that focused on single cases [6,8]. The aim of this paper is to summarize our experience with the laparoscopic diagnosis and treatment of missed diaphragmatic injuries.…”