نقش توراکوسکوپی در تشخیص آسیب مخفی دیافراگم در ترومای نافذ توراکو-ابدومینال

Background: Penetrating thoracoabdominal stab wounds may cause diaphragmatic and abdominal organ laceration. However, 15-20% of these cases who are stable and managed by conservative treatment might have hidden diaphragmatic injuries, which could ultimately lead to chronic diaphragmatic hernia. Therefore, a safe and exact diagnostic method for the detection of occult diaphragmatic injuries is very valuable. In this study we have assessed the diagnostic value of thoracoscopy in occult diaphragmatic injuries resulting from penetrating thoracoabdominal stab wounds. Methods: From March 2005 to October 2007, 30 hemodynamically stable patients with penetrating thoracoabdominal injuries, not requiring emergent exploration, were enrolled in this study. All subjects underwent thoracoscopy to evaluate probable diaphragmatic injury. Diaphragmatic injuries were repaired via thoracoscopy or laparatomy. All patients were evaluated for chronic diaphragmatic hernia by CT-scan six months later. Results: The mean patient age was 26.2 years, with a male/female ratio of 5:1. Using thoracoscopic exploration, we observed five (16.7%) hidden diaphragmatic injuries, three (9.9%) of which were repaired using the thoracoscopic approach and two (6.6%) by laparatomy. Lung parenchymal laceration was seen in two patients (6.6%), for whom the repair was performed using thoracoscopy. Intra-abdominal injury was seen in one patient (3.3%), which was repaired by laparatomy. After thoracoscopy, there were no complications or evidence of chronic diaphragmatic hernia in the chest and abdominal CT-scans performed six months later. Therefore, the diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries in our study was 100%. Conclusion: With its high degree of diagnostic accuracy, low degree of invasiveness, as well as its utility in treatment, we recommend thoracoscopy for all clinically stable patients with penetrating thoracoabdominal stab wounds.