John-Paul Bellistri, MD, Edward Kwon, MD, Ajay Chopra, MD. Jacobi Medical Center.
The incidence of diaphragmatic rupture after blunt thoracoabdominal trauma has an incidence ranging from 1% to 3%1. Early identification and diagnosis remains a challenge. Among numerous retrospective studies, increase in Injury Severity Score appears most frequently with statistical significance. Traumatic diaphragmatic hernia may be repaired by thoracotomy, open abdominal, and laparoscopic approaches. Laparoscopic approach is associated with decreased length of stay and decreased number of discharges to skilled nursing facility2. Nothing in the English literature has described diaphragmatic rupture in a patient who had previously undergone lapraroscopic roux-en-y gastric bypass (LRYGB).
A 49 year old woman with a history of LRYGB presented to our institution with a post-traumatic diaphragmatic rupture after blunt thoracoabdominal trauma. One month prior, she had been involved in a motor vehicle accident and presented to an outside institution. She presented to our institution with sympoms of chest pain related to rib fractures and the diaphragmatic hernia was identified on chest imaging. Repair of the diaphragm was postponed to allow for healing of rib fractures. A laparoscopic approach for repair was decided upon with the expectation of reducing length of stay and morbidity that may be associated with open or thoracic approaches to repair.
The patient was placed in split leg position for the procedure. Five trocar sites were used during the procedure. The liver was retracted with a triangular retractor, which was followed by lysis of perihepatic adhesions. The diaphragmatic defect was then exposed. The gastric remanant and omentum had herniated into the pleural space. Harmonic scalpel was utilized to free the omentum from the lateral aspect of the defect. The liver was then freed from the diaphragm and retroperitoneum at the triangular ligament to free the medial border of the diaphragmatic defect. The diaphragmatic defect was repaired primarily using permanent sutures. A polyester mesh with anti-adhesion barrier was used to reinforce the defect. The mesh was anchored in with absorbable tacks laterally. Fibrin gel was utilized to anchor the medial border of the mesh in order to avoid cardiac injury. A left sided chest tube was placed intraoperatively. On post–operative day 2, the chest tube was removed and the patient was discharged home. A post-operative CT scan was obtained after three months demonstrating successful repair.
Diaphragmatic rupture in the setting of blunt thoracoabdominal trauma can be repaired by open abdominal, laparoscopic, or thoracic approaches. Laparoscopic approach to repair is a safe and effective option for these patients. This approach avoids morbidity associated with thoracotomy and open abdominal approaches. Our case describes a successful repair by laparoscopy.
1.) Reiff D et al. Identifying Injuries and Motor Vehicle Collision Characteristics that Together Are Suggestive of Diaphragmatic Rupture. J of Trauma 2002; 53:1139-1145.
2.) Paul S et al. Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database. Arch Surg 2012; 147:607-612.