Traumatic diaphragmatic ruptures: clinical presentation, diagnosis and surgical approach in adults

OBJECTIVE Traumatic diaphragmatic injuries are rare, but potentially life-threatening due to herniation of abdominal organs into the pleural cavities. They can be easily overlooked on initial diagnostics and a high index of suspicion is required. The aim of this retrospective study was to analyze the clinical presentation, diagnostic methods and surgical management of patients with diaphragmatic rupture at our institution. METHODS A retrospective study was performed to analyze our experience with patients suffering from traumatic diaphragmatic rupture. Charts were reviewed for sex, age, side-location, concomitant injuries, time-to-diagnosis, diagnostic methods, surgical approach and outcome. RESULTS Fourteen patients (median age: 46 yrs, range 18-71, 9 male, 5 female) with diaphragmatic injuries (left side: 10, right side: 4) were treated between July 2003 and September 2011. Mechanism of injury was a penetrating trauma (14%), blunt trauma (50%) and others (36%). Associated abdominal injuries included spleen rupture (n=3), liver laceration (n=2), abdominal wall laceration (n=2) and gastric perforation (n=1). Computed tomography was the most sensitive diagnostic method. All patients underwent trans-abdominal repair of the diaphragmatic defect (direct suture: 10, prosthetic mesh insertion: 4). Associated abdominal procedures included splenectomy (n=3), liver packing (n=2), abdominal wall reconstruction (n=2) and partial gastric resection (n=1). Morbidity and hospital mortality rate were 36% and 0%, respectively. Median postoperative hospital stay was 17 days (range: 7-40 days). CONCLUSION Morbidity and mortality of diaphragmatic ruptures are mainly determined by associated injuries or complications of diaphragmatic herniation like incarceration of viscera or lung failure. Early diagnosis helps to prevent severe complications. Spiral CT-scan is the most reliable tool for acute diagnosis of diaphragmatic rupture and associated visceral lacerations. Laparotomy is an adequate surgical approach for diaphragmatic repair, especially in cases of associated abdominal organ injury.