• hernia, diaphragmatic
• hernia, hiatal
• thoracic wall
• thorax
• traumatic

• Humans
• Thoracic Diseases/diagnostic imaging
• Hernia/diagnostic imaging
• Tomography, X-Ray Computed/methods
• Magnetic Resonance Imaging/methods

• bedside point-of-care ultrasound
• blunt trauma
• cardiac arrest
• case report
• tension pneumothorax
• tension viscerothorax

• Humans
• Male
• Pneumothorax/diagnosis
• Wounds, Nonpenetrating/complications
• Wounds, Nonpenetrating/diagnosis
• Middle Aged
• Heart Arrest/etiology
• Heart Arrest/diagnosis
• Diagnosis, Differential
• Accidental Falls
• Tomography, X-Ray Computed

• Humans
• Hernia, Diaphragmatic
• Rupture, Spontaneous
• Back Pain/etiology
• Thoracic Injuries
• Rupture
• Hernia, Diaphragmatic, Traumatic/diagnostic imaging
• Hernia, Diaphragmatic, Traumatic/etiology

Blunt traumatic diaphragmatic hernia (TDH) is a complication of blunt diaphragmatic injury. If missed, it could lead to critical presentations, such as incarceration or strangulation of the herniated intra-abdominal organs, and thus, early surgical repair is required. Methods of the operative approach against delayed TDH remain unclear. Even with the spread of the minimally invasive approach, laparotomy has been predominantly selected for cases with hemodynamic or gastrointestinal complaints. Literature on the use of laparoscopy for repair of such cases is limited, and no study has been conducted for those with intrathoracic gastric perforation.

A 55-year-old male patient with a history of multiple traumas presented with shock, followed by left hypochondrium pain and vomiting. The patient was admitted to the emergency department of our institution and diagnosed with delayed TDH complicated by intrathoracic gastric perforation, and tension empyema. Emergency surgery using laparoscopic approach was performed, despite unstable hemodynamics, considering orientation, exposure, and operativity compared with laparotomy. Repair of the diaphragm plus total gastrectomy was successfully performed by minimally invasive management. The patient made an uneventful recovery without recurrence after 8 months.

Unstable hemodynamic conditions and intrathoracic gastric perforation could not be contraindications to laparoscopic repair in treating delayed TDH.

The study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia.

Preoperative and postoperative computed tomography imaging from 373 patients from the International Early Lung Cancer Action Program and the Initiative for Early Lung Cancer Research on Treatment were compared at a median of 31.1 months of follow-up after resection of clinical early-stage non–small cell lung cancer. Incidence of new hiatal hernia or changes to preexisting hernias were recorded and evaluated by patient demographics, surgical approach, extent of resection, and resection site.

New hiatal hernias were seen in 9.6% of patients after lung resection (5.6% after wedge or segmentectomy and 12.4% after lobectomy; P = .047). The median size of new hernias was 21 mm, and the most commonly associated resection site was the left lower lobe (24.2%; P = .04). In patients with preexisting hernias, 53.5% demonstrated a small but significant increase in size from 21 to 22 mm (P < .0001). All hernias persisted through the latest postoperative computed tomography scan. When 110 surgical patients without preexisting hernia were matched by sex, age, and smoking to nonoperative controls, the incidence of new hernia at follow-up was significantly higher among those who underwent surgery (17.3% vs 2.7%, P = .0003).

Both open and minimally invasive lung resection for clinical early-stage lung cancer are associated with new or enlarging postoperative hiatal hernia, especially after resections involving the left lower lobe.

Simultaneous occurrence of pneumothorax and pneumoperitoneum is a rare event, usually related to traumas or surgical procedures involving the diaphragm.

However, clinicians should be aware of the possible onset of these two clinical conditions even in patients without a recent clinical history that can clearly explain them.

Cross-sectional imaging techniques are of great importance, providing crucial information about the patient's clinical status and guiding the following patient management.

This work describes a unique case of a sudden occurrence of simultaneous pneumothorax and pneumoperitoneum in a previous asymptomatic man with a solely clinical history of minor trauma during childhood, evaluated through a multimodality imaging approach and treated with video-assisted thoracoscopy surgery.

• Computed Tomography
• Diaphragmatic injury
• Pneumoperitoneum
• Pneumothorax

•

Spontaneous diaphragmatic rupture has multifactorial etiopathogenesis related to anatomical defect and thoracoabdominal pressure gradient.

Diaphragmatic rupture (DR) is an acquired diaphragmatic defect that can cause herniation of abdominal organs into the chest. It is usually a trauma-related lesion, but rarely it can occur spontaneously. Every DR with abdominal herniation should be considered a surgical emergency.

A 61-year-old male patient, with previous exposure to asbestos, was diagnosed of Stage Ib malignant pleural mesothelioma (MPM). He underwent neo-adjuvant chemotherapy (three cycle of cisplatin-pemetrexed combination) and a cytoreductive surgery with pleurectomy/decortication. Post-operative course was characterized by prolonged air-leakage (PAL). After three months, during a follow-up CT-scan, a spontaneous diaphragmatic rupture (SDR) with gastric herniation was detected and treated by a laparascopic diaphragmatic repair and suture.

Spontaneous diaphragmatic rupture (SDR) is an extremely rare injury of the diaphragm (less than 1% of all DR). In this case, potential predisposing factors for SDR could be: presence of diaphragmatic “locus minoris resistentiae” due to thinning of the diaphragm and increase tissue fragility after neo-adjuvant chemotherapy and diaphragmatic pleural stripping; increased thoraco-abdominal pressure gradient due to PAL and residual pleural space. Thus, we confirmed the feasibility and safety of the laparoscopic approach.

We highlight the multifactor etiopathology, the challenging diagnosis and the importance of a prompt treatment of SDR.

• Case report
• Diaphragmatic herniation
• Malignant pleural mesothelioma
• Spontaneous diaphragmatic rupture

Incarcerated diaphragmatic hernias with intrathoracic perforation of the colon is a very rare but serious surgical emergency. A 78-year-old male patient presented to our emergency department with severe abdominal pain. A computer tomography (CT) scan revealed herniation of the left transverse colon and spleen into the thorax with colon perforation and fecal contents in the thoracic cavity. An emergent laparotomy confirmed the radiological diagnosis and showed a 6 cm dehiscence of the left diaphragm with strangulation of the left transverse colon as well as the spleen. A left-sided hemicolectomy with terminal transversostomy and splenectomy were performed. The diaphragm was closed with interrupted nonabsorbable sutures. We abstained from reinforcement of the suture line with a mesh because of the feculent contamination of the abdominal cavity. After extensive thoracoscopic lavage and insertion of two chest tubes, the patient was transferred to the intensive care unit. Diaphragmatic hernia even after a mild chest trauma can cause fatal complications. Diagnosis and treatment can be challenging and an interdisciplinary approach is recommended. Due to the associated comorbidity and long-lasting sequelae, we believe the awareness of this rare pathology as a differential diagnosis is important; both as an abdominal and thoracic emergency.

A spontaneous diaphragmatic hernia (SDH) occurs when intra-abdominal contents extend into the thoracic cavity through a defect in the diaphragm after a sudden increase in intra-abdominal pressure. SDH is one of the rarest surgical emergencies with less than 30 reported cases in the literature.1,2 In our case a 94-year-old female presented to the emergency department in respiratory distress with unilateral breath sounds and was diagnosed with a SDH. The only treatment option for a SDH is surgical.3,11 However, nasogastric tube decompression of the gastrointestinal tract and supplemental oxygen can be used to alleviate symptoms until definitive operative management is performed.

Blunt diaphragmatic lesions (BDL) are uncommon in trauma patients, but they should be promptly recognized as a delayed diagnosis increases morbidity and mortality. It is well known that BDL are often overlooked at initial imaging, mainly because of distracting injuries to other organs. Sonography may directly depict BDL only in a minor number of cases. Chest X-ray has low sensitivity in detecting BDL and lesions can be reliably suspected only in case of intra-thoracic herniation of abdominal viscera. Thanks to its wide availability, time-effectiveness and spatial resolution, multi-detector computed tomography (CT) is the imaging modality of choice for diagnosing BDL; several direct and indirect CT signs are associated with BDL. Given its high tissue contrast resolution, magnetic resonance imaging can accurately depict BDL, but its use in an emergency setting is limited because of longer acquisition times and need for patient’s collaboration.

• Diaphragm
• Blunt injury
• Trauma
• Imaging
• Computed tomography

• hernia
• thoracoabdominal
• trauma
• diaphragm

• Abdominal Pain/etiology
• Accidents, Traffic
• Aged
• Colonic Diseases/complications
• Colonic Diseases/diagnostic imaging
• Dyspnea/etiology
• Female
• Hernia, Abdominal/complications
• Hernia, Abdominal/diagnostic imaging
• Hernia, Diaphragmatic, Traumatic/diagnostic imaging
• Humans
• Tomography, X-Ray Computed
• Wounds, Nonpenetrating/complications

Diaphragmatic rupture due to blunt or penetrating injury may be a missed diagnosis in an acute setting and can present with a delayed complication with significantly increased morbidity and mortality.

The objective of this study is to better understand why diaphragmatic tears with delayed presentation and diagnosis are so often missed and why traumatic diaphragmatic tears are difficult to diagnose in emergency settings and how they present with grievous complications.

Eleven patients with diaphragmatic hernias with delayed presentation and delayed diagnosis were operated within the last five years. All patients presented with different complications like gut gangrene or respiratory distress.

Out of eleven patients who were operated on for diaphragmatic hernia, three patients (27%) died. Three patients required colonic resection, one patient needed gastrectomy and one patient underwent esophagogastrectomy.

A small diaphragmatic tear due to blunt trauma to the abdomen is difficult to diagnosis in acute settings due to ragged margins and possibly no herniated contents and usually present with a delayed complication. Therefore a careful examination of the entire traumatized area is the best approach in treating delayed presentation of traumatic diaphragmatic hernia prior to development of grievous complications.

• Delayed Diagnosis
• Hernia, Diaphragmatic, Traumatic
• Wounds, Nonpenetrating

Diaphragmatic hernia after blunt trauma is an uncommon and often undiagnosed condition.

We aimed to review patients who presented with delayed blunt traumatic hernia of diaphragm.

In this retrospective study, the medical records of six patients treated for blunt diaphragmatic hernias who were admitted to Kashan Shahid Beheshti hospital between June 2007 and June 2011 were analyzed.

Six patients with mean age of 41 years were included in the study. Male to female ratio was 2:1. Mean duration between trauma and admission to the hospital was 6.5 years (2 – 26 years). Five patients had left-sided diaphragmatic hernia. Chest X-ray was obtained from all patients which was diagnostic in 50 percent of the cases (n = 4). Additional diagnostic imaging with computerized tomography (CT) was used in six patients and upper gastrointestinal (GI) contrast study was performed in one patient. All patients underwent thoracotomy incision. Mesh repair was utilized in one patient. The mean hospitalization time was 14.1 days. There was one postoperative death (16.7%).

Late presentation of blunt diaphragmatic hernia is an uncommon and challenging situation for the surgeon. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and perforation of herniated organ.

• Diaphragm
• Diaphragmatic Hernia
• Trauma

Blunt diaphragmatic rupture is an uncommon injury and even less common is the bilateral form. This entity poses diagnostic and therapeutic challenges to the treating team. Despite the advances in diagnostic modalities, it remains a difficult diagnosis leading to missed or late presentations with increased risk of morbidity and mortality. We report a case of a 12-year-old girl who sustained a blunt abdominal trauma and found to have left hemidiaphragmatic rupture for which she underwent laparotomy and repair. Postoperatively, persistent elevation of the right hemidaiphragm was noticed, and right-side rupture was suspected and confirmed by collar sign on repeated computed tomography scan. The second repair was done successfully through a right posteriolateral thoracotomy. She improved dramatically and was discharged in an optimal state to be followed in the surgical outpatient department.

• Blunt trauma
• diaphragm
• repair

• Delayed presentation
• Diaphragmatic injury
• Laparoscopic assisted mini-thoracotomy
• Laparoscopic repair

Right-sided diaphragmatic rupture is less common and more difficult to diagnose than left-sided lesion. It is rarely combined with the herniation of the abdominal organs into the thorax. High level of suspicion is the key to early diagnosis, and a delay in diagnosis is implicated with a considerable risk of mortality and morbidity. We experienced a case of right-sided diaphragmatic rupture combined with complete avulsion of the right kidney and herniation of the liver into the thoracic cavity.

• Diaphragm
• Diaphragm, trauma
• Kidney
• Liver
• Trauma

• Blunt trauma
• Hepatothorax
• Motor vehicle accidents
• Right-sided diaphragm rupture

• Aged
• Female
• Hernia, Diaphragmatic/complications
• Hernia, Diaphragmatic/diagnosis
• Hernia, Diaphragmatic/surgery
• Humans
• Intestinal Obstruction/etiology
• Magnetic Resonance Imaging
• Male
• Tomography, X-Ray Computed

Rupture of the diaphragm is almost always due to major trauma. Diaphragmatic injuries are rare (5–7%), usually secondary to blunt, or more rarely to penetrating, thoracic or abdominal trauma. No single investigation provides a reliable diagnosis of diaphragmatic rupture when a patient first arrives at hospital. Almost 33% are suspected on initial chest x-ray, but the percentage is lower in patients who are immediately intubated. Mortality in patients with diaphragmatic rupture following blunt abdominal trauma is generally associated with coexistent vascular and visceral injuries that could be rapidly fatal. It's mandatory that the right diagnosis is reached as soon as possible given that mortality is influenced by the time elapsing between trauma and diagnosis.

A 35-year-old worker was hit by a heavy object while working in the factory. He was transferred immediately to our emergency room. Chest x-ray showed massive left hemothorax without any additional signs to suggest diaphragmatic injury. It was decided to perform immediate surgical exploration before further radiological examination. During surgery, the right kidney and liver appeared normal, but the left kidney and spleen were not found in their anatomical position. The left hemidiaphragm had a10-cm oblique posterior tear. The left kidney was found lacerated in the left side of the chest, separated completely from its vascular pedicle and ureter, along with the entire spleen which was also separated from its vascular tree.

The avulsion of both kidney and spleen following abdominal trauma is uncommon and survival depends on prompt diagnosis and treatment.

• Adult
• Diaphragm/injuries
• Female
• Hernia, Diaphragmatic, Traumatic/diagnosis
• Hernia, Diaphragmatic, Traumatic/diagnostic imaging
• Hernia, Diaphragmatic, Traumatic/etiology
• Hernia, Diaphragmatic, Traumatic/mortality
• Hernia, Diaphragmatic, Traumatic/surgery
• Humans
• Laparotomy
• Male
• Middle Aged
• Radiography
• Rupture
• Wounds, Nonpenetrating/complications

• Age Factors
• Aged
• Antibiotic Prophylaxis
• Aorta, Thoracic/injuries
• Chest Tubes
• Diaphragm/injuries
• Heart Injuries/diagnosis
• Heart Injuries/therapy
• Humans
• Pneumothorax/etiology
• Pneumothorax/therapy
• Rib Fractures/therapy
• Rupture
• Thoracic Injuries/diagnosis
• Thoracostomy
• Wounds, Nonpenetrating/diagnosis

• Adult
• Female
• Hernia, Diaphragmatic, Traumatic/complications
• Hernia, Diaphragmatic, Traumatic/diagnosis
• Humans
• Postpartum Period
• Pregnancy
• Pregnancy Complications/diagnosis
• Respiratory Distress Syndrome/diagnosis
• Respiratory Distress Syndrome/etiology
• Time Factors

• Aged, 80 and over
• Diagnosis, Differential
• Fatal Outcome
• Hernia, Diaphragmatic/complications
• Hernia, Diaphragmatic/diagnostic imaging
• Hernia, Diaphragmatic/surgery
• Humans
• Laparotomy/methods
• Male
• Mediastinal Diseases/diagnostic imaging
• Mediastinal Diseases/etiology
• Mediastinal Diseases/surgery
• Radiography, Thoracic