Laparoscopic Repair of a Ruptured Diaphragm: Avoiding a Trauma Laparotomy

Background: A traumatic diaphragm rupture presents a unique obstacle to a minimally invasive surgical approach; most repairs are performed during an emergency laparotomy. Diaphragm injuries are diagnosed in the acute phase of blunt-force trauma in only 10% of cases, and a high index of suspicion must be maintained to avoid strangulation of the abdominal organs that have herniated into the thoracic cavity. A laparoscopic evaluation and repair of an acute blunt-force rupture of the diaphragm can be diagnostic and curative, mimicking the outcome of an open procedure. Case Description: A 23-year-old woman had a left-side blunt-force rupture of the diaphragm sustained in a high-impact motor vehicle collision. The focused assessment with sonography for trauma (FAST) was negative. The survey chest radiograph identified only streaky opacities that were read as atelectasis. Computed tomography of the abdomen revealed the presence of a congenital abnormality versus a ruptured diaphragm. A diagnostic trauma laparoscopy was performed to evaluate for the possibility of a left-side rupture, and at that point, the spleen and the stomach were found to be located in the left chest, herniating through a rupture in the left diaphragm. A grade I splenic laceration was present. The abdominal structures were reduced and the traumatic rupture was successfully repaired laparoscopically. Discussion: Traumatic rupture of the left diaphragm can occur as an occult injury after blunt-force trauma to the torso. The liver lends protection to the diaphragm and a right-side rupture is far less common than one on the left side. The initial diagnostic plain chest x-ray may not reveal the tear in the diaphragm and the herniation of abdominal viscera into the thoracic cavity. Laparoscopy has been used to evaluate the possibility of a rent in the diaphragm when the patient is hemodynamically stable and the diagnosis is uncertain. Although initial laparoscopic or thorascopic evaluation of a potential rupture of the diaphragm is the standard of care in the trauma literature, laparoscopic repair is not widely accepted. However, laparoscopic evaluation of acute torso trauma with reduction of abdominal viscera and subsequent laparoscopic repair of the diaphragm can be successful.