1/153. Bochdalek hernia in adulthood: a case report and review of recent literature. A 37-year-old Filipino woman presented with a post road-traffic accident fracture of dorsal spine 12. Chest radiograph revealed evidence of loops of small bowel in the left lung field. She admitted to symptoms of respiratory insufficiency since birth and treatment for tuberculosis in childhood. A pre-operative diagnosis of left traumatic diaphragmatic hernia was not confirmed at laparotomy which revealed typical left congenital Bochdalek hernia with smooth edges and herniation of small bowel and spleen into the left pleural cavity. Following reduction and repair of the hernia, the patient made an uneventful recovery. Chest radiograph remains normal till now, eight years post-operatively. ( info) |
2/153. Posttraumatic diaphragmatic hernia and death--etiologic factor or putrefactive artifact? Late-presenting diaphragmatic hernias, whether congenital or acquired, may remain clinically undetected until mediastinal shift with cardiorespiratory compromise or intestinal or gastric infarction with perforation occur. A right-sided diaphragmatic hernia with herniation of small intestine into the adjacent pleural cavity is described in a 72-year-old man who was found dead at home in a putrefactive state. Subsequently, a history of a motor vehicle accident 8 years previously was obtained. Although postmortem herniation due to extensive putrefactive change may have occurred, producing gaseous distention and migration of the intestine, tight twisting of the herniated intestine several times around a pleural fibrous adhesion suggested that the herniation could have been an antemortem event. Unfortunately, marked tissue autolysis prevented assessment of possible ischemic changes in the herniated intestine. Although diaphragmatic hernia may be a contributing factor to death at all ages, it may not be possible to exclude it as an artifact of putrefaction in a predisposed individual. ( info) |
3/153. Thoracoscopic repair of a recurrent diaphragmatic hernia four years after initial trauma, laparotomy, and repair. Traumatic diaphragmatic hernia is not an uncommon problem and has been noted after either penetrating or blunt trauma. A high index of suspicion must be maintained in order to identify patients with this injury, as delay in identification may result in significant morbidity and death. It is essential that a thorough evaluation be performed, and if a diaphragmatic hernia is found, surgical repair is necessary. We present a case of thoracoscopic repair of an incarcerated recurrent diaphragmatic hernia appearing several years after successful open (via laparotomy) repair of an acute blunt traumatic hernia. A brief review of the surgical literature is also presented. With the broadening use of minimally invasive surgical techniques, we feel that their application to the repair of chronic diaphragmatic hernia is safe and effective, reduces morbidity, and results in a faster recovery. ( info) |
4/153. A patient with a traumatic right diaphragmatic hernia occurring 4 years after sustaining injury--statistical observations of a delayed diaphragmatic hernia caused by uncomplicated injury in japan. We describe our experience with a patient in whom a traumatic right diaphragmatic hernia developed 4 years after sustaining injury and review cases of delayed diaphragmatic injury reported in japan. The patient was a 28-year-old man who sustained a severe contusion of the right epigastric region and fractured a right rib in a traffic accident in September 1992. In August 1996, the patient presented with shortness of breath on effort or after meals. A chest roentgenogram revealed intestinal gas in the right side of the thoracic cavity. A right diaphragmatic hernia was diagnosed on the basis of a gastrointestinal series, and the patient was operated on. The hernial orifice extended anteriorly from the central tendon in an 11:00 direction and measured 11 x 6 cm. The small intestine, right side of the colon, and liver were herniated. A total of 297 cases of blunt traumatic diaphragmatic hernia were reported in japan between 1981 and 1996, including 47 cases (left side, 32 cases; right side, 15 cases) of delayed diaphragmatic hernia, defined as occurring one month or more after injury. Diaphragmatic hernia should be considered as a possible diagnosis in patients with abnormal shadows in the thoracic region who have recently sustained injury or who have a past history of injury. ( info) |
5/153. Right diaphragmatic rupture and hepatic hernia: an indirect sign on computed tomography. We report a case of blunt traumatic right diaphragm rupture with hepatic hernia. The diagnosis was first suggested by an abnormal hepatic location depicted on axial CT. This finding can be considered as a potentially new indirect sign of right diaphragm rupture in patients with blunt trauma. The diagnosis was then confirmed by reformatted CT and MR images. ( info) |
| Intrapericardial herniation of abdominal viscera following blunt abdominal trauma is rare. We have been able to find only nine reported cases. Six of these were finally diagnosed after a long delay, ranging from a year to 23 years. Three were diagnosed within three months of the original injury, but in these patients, the investigations were initiated following an abnormal chest skiagram. We wish to report a unique case in which a traumatic intrapericardial hernia presented as an acute cardiac tamponade within 48 hours of injury. ( info) |
7/153. Delayed presentation of traumatic left-sided diaphragmatic avulsion. A case report. We describe the case of a 35-year-old man who had suffered a severe multitrauma with blunt thoracic injury, left scapula and humerus fractures 5 years earlier. At the time of the trauma, a diaphragmatic lesion went unnoticed. Five years later, the patient had a 24-h history of increasingly severe abdominal pain with repeated vomiting. Helical CT showed a portion of the left hemidiaphragm avulsed from its insertions on the ribs with large-bowel loop obstruction herniated in the left hemithorax. The preoperative CT diagnosis was confirmed by surgery: reduction of the hernia and reinsertion of the hemidiaphragm to the lumbocostal arch were performed. ( info) |
8/153. Laparoscopic management of traumatic ruptures of the diaphragm. INTRODUCTION: As a result of the relatively high frequency of high-speed accidents, diaphragmatic rupture is a diagnosis that is increasingly being established. Not all of these, usually multi-traumatized, patients are diagnosed as having diaphragmatic rupture immediately following the traumatic event--rather, an appreciable number of these injuries are not detected until some time later--often after a considerable delay. Most of the cases involve rupture of the left diaphragm, with most defects occurring in the region of the central tendon. methods: During the course of the second half of the year 1998, we operated on three patients with left diaphragmatic rupture. Two of these patients were treated immediately following traumatization, while the third case was a 10-year-old rupture originally misdiagnosed as a para-esophageal hernia. In all three cases, we were able to reduce the hernia and close the diaphragmatic defect laparoscopically. In the case of the two patients with a fresh rupture, the post-operative course was unremarkable, while in the patient with the missed rupture, a serous pleural effusion requiring drainage occurred on the left side. CONCLUSION: overall, it would appear that in the case of an acute traumatic diaphragmatic rupture in particular, laparoscopic management, with its low level of traumatization and excellent access, offers a favorable alternative to conventional surgery. A point to be considered, however, is the fact that probably not every hospital will have the facilities for laparoscopic management available on a 24-h basis. In the case of longstanding ruptures, reduction of herniated bowel and treatment of the rupture will make considerable demands on the surgeon. ( info) |
9/153. pregnancy complicated by traumatic diaphragmatic rupture. A case report. BACKGROUND: Diaphragmatic rupture may be easily overlooked at the time of multiple trauma. Occult diaphragmatic rupture may first manifest during pregnancy as severe dyspnea. CASE: A parous woman who had sustained multiple traumatic injuries prior to pregnancy presented in midtrimester with abdominal pain and dyspnea. Chest roentgenography and computed tomography revealed bowel in the left hemithorax, compatible with a left-sided diaphragmatic rupture. Surgical correction was indicated secondary to the symptomatic nature of the presentation. CONCLUSION: Diaphragmatic rupture may be occult and may first present during a subsequent pregnancy. Surgical therapy is the cornerstone of management when a diaphragmatic defect is symptomatic. The route of delivery may be individualized for patients with diaphragmatic repairs in whom there has been sufficient time for healing. ( info) |
10/153. The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture. BACKGROUND: Diaphragmatic rupture is one of the most commonly missed injuries in trauma cases. Traditionally, laparotomy or thoracotomy has been the treatment of choice for this condition. methods: During the last 2 years, we treated three patients laparoscopically to address neglected diaphragmatic ruptures that caused herniation of the intraabdominal contents. RESULTS: In all three cases, laparoscopy succeeded in identifying the diaphragmatic defect, so that the herniated viscera could be released and the defect repaired primarily or with a prosthesis. The intraoperative and the postoperative courses were uneventful; there were no significant complications. CONCLUSION: laparoscopy has an important role in the surgical treatment of missed diaphragmatic ruptures. ( info) |