Title : Treatment of traumatic diaphragmatic hernia without prosthesis study of three cases
Abstract:
Introduction: Traumatic diaphragmatic hernia is characterized by the passage of part of the abdominal contents into the thoracic cavity through a diaphragmatic injury resulting from trauma at the thoracoabdominal transition. Diaphragmatic rupture occurs in 0.8% of patients involved in automobile accidents and in approximately 3% to 5% of cases of blunt abdominal trauma. It also occurs in 13% to 19% of penetrating injuries to the thoracoabdominal transition. The natural history of diaphragmatic hernias is described in three phases: the acute phase, when the patient presents with the injury; the intermediate or latent phase, in which abdominal viscera become incarcerated in the thorax; and the chronic phase, where complications such as obstruction and intestinal strangulation may occur.
CASE 1: Patient, CND, 49 years old, female, post-operative bariatric surgery six months prior. Underwent elective surgery for the correction of a left-sided traumatic diaphragmatic hernia, measuring 5 cm, with the presence of the gastric fundus and splenic flexure of the colon identified on computed tomography (CT)
CASE 2: Patient, DCS, 36 years old, male, victim of a gunshot wound, underwent emergency surgery for the correction of a left-sided traumatic diaphragmatic hernia one year after the trauma, with a 5 cm defect, with the presence of the gastric body and fundus identified on CT.
CASE 3: Patient, EC, 57 years old, male, victim of a high-altitude fall, underwent elective surgery for the correction of a right-sided traumatic diaphragmatic hernia, with an 11 cm defect, with the presence of the liver, gallbladder, and transverse colon.
Discussion: Despite advancements in imaging accuracy, between 10% and 30% of diaphragmatic injuries still go undiagnosed, even with the use of thoracic computed tomography. In thoracoabdominal injuries caused by stab wounds or gunshot wounds, the severity often lies in the multiplicity of injured viscera, particularly abdominal, in contrast to blunt trauma. The treatment of traumatic diaphragmatic hernia is essentially surgical, and diaphragmatic repair should be performed using non-absorbable sutures.The thoracic approach can be more complex in certain situations due to the difficulty of dissecting and releasing abdominal viscera adhered to the parietal peritoneum and pleura. The risk of visceral injuries is significant due to adhesions in chronic hernias. Injuries to these viscera during dissection within the abdominal cavity are more easily corrected and have a more favorable outcome regarding contamination and infection compared to thoracic or mediastinal infections.
Surgical treatment is mandatory whenever a traumatic diaphragmatic hernia is diagnosed and is generally performed via an abdominal approach due to the high frequency of injuries to other organs. Thoracoscopy is an option for joint or isolated access in chronic cases. Recently, the laparoscopic approach has been successfully used in cases of diagnosed diaphragmatic injuries.
