S N Zafar, MD, MPH, Adeel A Shamim, MD, Terrance Fullum, MD, Daniel D Tran, MD, FACS. Howard University Hospital
Introduction: Traumatic diaphragmatic hernia (TDH) is a rare sequela of thoraco-abdominal injury, occurring in about 3-5% of patients. Motor vehicle collision (MVC) is the leading etiology of blunt trauma. A high level of suspicion is essential to discover such injuries, as up to 53% of the patients can be asymptomatic. Rapid increase in intra-abdominal pressure causes a change in the trans-diaphragmatic pressure gradient culminating in the herniation of abdominal contents. Left sided TDH is more common. In literature, laparoscopic, trans-thoracic and trans-abdominal interventions have been described for TDH depending on various factors such as chronicity and surgeon experience. We present a video presentation demonstrating a successful laparoscopic reduction and repair of a large acute TDH.
Case Presentation: A twenty-two year old obese female was involved in a severe MVC. She was hemodynamically stable and upon initial work up found to have pelvic fractures. Chest x-ray demonstrated an elevated left hemi-diaphragm and CT scan confirmed the findings of a left sided TDH. After a period of observation in the intensive care unit with serial abdominal examinations the patient successfully underwent a laparoscopic repair of her TDH. The hernia was about 8cm in length and contained the stomach and transverse colon. The diaphragmatic hernia was primarily repaired with running interlocking sutures. No mesh was used. By utilizing the valsalva maneuver with our last stich we were able to evacuate all the intra-thoracic air, thus obviating the need for a chest tube. Post operatively the patient was initiated on clear liquid diet the same day and continued to do well. She underwent pinning for her pelvic fracture the next day and was clear for discharge on post op day 2. At two week follow up, the patient was asymptomatic from a GI and Pulmonary standpoint.
Discussion: The dictum of management for diaphragmatic rupture following trauma is an immediate exploratory laparotomy. This is mainly to rule out associated intraabdominal injuries. However, we demonstrate that in a stable patient with a benign abdominal exam a period of observation in an intensive care unit followed by laparoscopic repair can avoid the need for a large midline laparotomy incision. Patients would have all the advantages of laparoscopic surgery compared to open including post-operative pain, recovery and less complications. It is important to note that this should only be done in highly selected patients in a highly controlled setting.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 78943
Program Number: V103
Presentation Session: Acute Care Surgery
Presentation Type: Video