Undiagnosed traumatic diaphragmatic hernia

Abstract

In penetrating wounds and crushing injuries involving the chest and the abdomen, rupture of the diaphragm may be difficult to diagnose and is easily missed. Strangulation and obstruction may occur at any time in a previously undiagnosed traumatic diaphragmatic hernia or it may present with acute pain in the chest and collapse due to perforation of a displaced viscus into the chest, a clinical appearance mimicking myocardial infarction. Severe pain in the shoulder and neck may occur due to irritation of the phrenic nerve; anorexia, vomiting, or disabling dyspnoea which may be sudden or of gradual onset over years may also be presenting signs. The dome of the diaphragm may be torn transversely or obliquely. Occasionally complete detachment of the periphery of the diaphragm and rupture of the central tendon and pericadium may occur. Eight cases of complications following undiagnosed traumatic diaphragmatic hernia are discussed. The importance of searching for a previous history of injury to the chest is stressed. The transthoracic approach for treatment in such cases seems the most suitable.

Traumatic diaphragmatic hernia

“…Any upper abdominal organ may herniate through the left hemidiaphragm, whereas on the right side the liver (Samaan, 1971) is usually the only herniated viscus. The stomach (Strug et al, 1974) or colon (Schwindt and Gale, 1967;Mansour et al, 1975) are the commonest organs to herniate.…”

“…The diagnosis is made by clinical suspicion and radiological investigation. Delay in diagnosis increases the mortality (Samaan, 1971 ;Christiansen et al, 1975). The present series was collected prospectively by two of the authors, and because of their interest the surgical staff made the diagnosis early and preoperatively in the majority of cases.…”

“…TRAUMATIC diaphragmatic hernia was first reported by Sennertus in 1591 (Reid, 1840) but only in the past three decades has the condition been commonly recognized, although few published series contain more than 30 cases (Ebert et al, 1967;Pomerantz et al, 1968;Samaan, 1971;Drew et al, 1973;Strug et al, 1974;Mansour et al, 1975). Diaphragmatic hernia is due to blunt (Desforges et al, 1957;Williams, 1969;Struget al, 1974) or penetrating (Mansour et al, 1975) injuries and the incidence of each reflects the socioeconomic status of the population involved (Ebert et al, 1967;Strug et al, 1974).…”