.. Acute Diaphragmatic Injuries John A. Drews, M.D., Elliott C. Mercer, M.D., and John R. Benfield, M.D. ABSTRACT A 5-year experience with 43 patients with acute diaphragmatic injuries is reviewed. Thirty-three of the patients had penetrating trauma, and 10 suffered blunt trauma. All but 1 of the patients had associated intraabdominal trauma. Fifteen had traumatic diaphragmatic hernia at the time of operation. The operative approach was uniformly through the abdomen. Mortality and morbidity were directly related to the number of associated organs injured. Chest roentgenograms in 26 of the 43 patients were interpreted as suspicious or diagnostic of diaphragmatic injury when presented as unknowns to fully trained radiologists, but only 7 of these were originally so interpreted. Delay in operation was a significant contributing factor to morbidity, particularly in patients with thoracic stab wounds. Guidelines suggested to prevent delay include: ( 1) increased awareness of the possibility of acute diaphragmatic injury, (2) careful evaluation of the plain chest roentgenogram and liberal use of appropriate contrast studies when indicated, (3) prompt repair of recognized diaphragmatic injuries, (4) laparotomy as the operative approach in the acute injury, and (5) appropriate contrast studies after recovery from massive thoracoabdominal trauma and prior to hospital discharge. T he recent focus on diaphragmatic injuries has been on the late sequelae of traumatic hernia [4]. Although the factors that tend to make the diagnosis of diaphragmatic injuries difficult in their early stages have been emphasized [3, 121, it was our impression that prompt recognition of diaphragmatic disruption is not regularly achieved, and we therefore reviewed our recent 5-year experience with acute diaphragmatic injuries. Our purpose is to present guidelines for accurate and prompt diagnosis of acute diaphragmatic disruption in order to prevent suboptimum management of patients with these potentially lethal injuries. Clinical Material and Meth.ods Diaphragmatic injury was defined as all traumatic defects, whether or not herniation of abdominal contents into the chest cavity had occurred. For the 5-year period prior to September, 1972, the records of all our patients in whom diaphragmatic defects were found at operations for trauma were analyzed. In addition to review of the clinical data and compilation of statistics concerning mortality, morbidity, and duration of hospitalization, a From the Departments of Surgery and Radiology, Harbor General Hospital, Torrance, and UCLA School of Medicine, Los Angeles, Calif. Presented at the Ninth Annual Meeting of The Society of Thoracic Surgeons, Houston, Tex., Jan. 22-24, 1973. Address reprint requests to Dr. Benfield, 1000 W. Carson St., Torrance, Calif. 90509. VOL. 16, NO. 1, JULY, 1973 67
DREWS, MERCER, AND BENFIELD critical retrospective review of the preoperative management was conducted. Comparison was made between the original interpretation of the chest roentgenograms and our retrospective interpretation. In addition, current interpretation was made by a group of faculty radiologists from whom knowledge of the history and operative findings was withheld until after their reading of the films. Based on the original reports, the roentgenographic findings were categorized into three preoperative groups. Group 1 patients had reports of normal chest roentgenograms. In Group 2 patients the films had been recognized as abnormal, but diaphragmatic injury had either not been mentioned or was only considered possible. In Group 3 patients the films had been considered diagnostic of diaphragmatic injury. The object of these groupings was to provide a base line for comparison with a current review of the films by faculty radiologists. We wished to learn whether higher diagnostic accuracy than that achieved during the acute management of the patients was possible. More specifically, we sought to conduct a critical retrospective review upon which to base recommendations for the future. Results During the 5-year period of this study, 765 patients whose mean age was 27.9 years were operated upon for trauma. Acute diaphragmatic injuries were found in 43 patients, or 5.8% of the total group. There were 39 men and 4 women who ranged in age from 15 to 87 years, with a mean age of 34.5 years. Of the 43 patients with diaphragmatic disruptions, 10 had suffered blunt trauma and 33 were victims of penetrating injury. The extent of the injuries to the diaphragm ranged from avulsion of two-thirds of the circumference, including the costochondral insertion of the left hemidiaphragm, to a 1 cm. perforation from a gunshot wound. Regardless of the causes of the injuries, the diaphragmatic disruptions were on the left side in 33 of the 43 patients. Forty-two patients had associated intraabdominal trauma, the stomach being the most commonly injured organ (24 patients). In order of frequency, the other organs injured were the liver (20 patients), spleen (19 patients), colon (7 patients), and small intestine (6 patients). Of the 10 victims of blunt trauma, 9 had injuries of intrathoracic abdominal viscera. Three of 11 patients with stab wounds had true diaphragmatic herniation at operation, while only 3 out of 22 patients with gunshot wounds had herniation. In 2 of the 3 patients with herniation following stab wounds, diagnosis and repair were delayed. There were 9 patients whose associated injury was limited to one organ in addition to the diaphragm, and there were 34 patients with multiple associated organ injuries. Mortality and morbidity increased in direct proportion to the number of organs injured (Table 1). Five of the 43 patients died, but 3 of them were among the 10 patients who had sustained blunt trauma. All 3 patients with blunt trauma who died had associated 68 THE ANNALS OF THORACIC SURGERY
Acute Diaphragmatic Injuries TABLE 1. MORTALITY AND MORBIDITY IN ACUTE DIAPHRAGMATIC INJURIES IN 43 PATIENTS, 1967-1972 No. Other No. of No. of Postop. Organs Injured Patients Complications No. of Deaths 1 9 3 0 2 12 7 0 3 14 10 0 4 5 5 2 5 or more 3 3 3 Total 43 28 5 injury to five or more organs. One of the 22 patients with a gunshot wound died, and 1 of the 11 patients with a stab wound died. The 2 patients with penetrating trauma who died were both over 65 years of age and had sustained multiple organ injuries. Postoperative complications occurred in 18 of the 31 survivors of penetrating trauma and in 5 of the 7 survivors of blunt trauma. The most common complications were atelectasis, pneumonia, shock lung syndrome, and recurrent pleural effusion. Other complications included posttraumatic pancreatitis in 4 patients, upper gastrointestinal bleeding in 3 patients, urinary tract infection in 3 patients, and unexplained, prolonged ileus in 1 patient which resolved spontaneously. The length of hospitalization varied from an average of 7.5 (4 to 15) days among patients with stab wounds to 31.3 (9 to 53) days in the blunt trauma group. The gunshot victims remained in the hospital 21 (6 to 65) days. In general, the length of hospitalization was directly proportional to the number of organs injured and to the number and severity of the postoperative complications. The most prominent symptom in these patients was abdominal pain. Chest pain was the second most common complaint, and shortness of breath was the third most common symptom. Four patients were completely asymptomatic. The two most common physical findings were absent breath sounds on the side of injury and the unequivocal presence of an acute abdomen. Almost all the patients presented with at least one of these two findings. Thirty-five patients were operated upon soon after admission. Eight patients had either no signs and symptoms whatever or signs and symptoms that were not judged sufficient to warrant immediate operation. Of these 8 patients, 7 with penetrating thoracic wounds developed peritoneal irritation within 24 hours. The other patient suffered increasing abdominal pain and postprandial vomiting from diaphragmatic herniation of the stomach 10 days after admission. In all, 3 of the 8 patients in this delayed diagnosis group had true diaphragmatic herniation at operation. In retrospect, all 8 patients had abnormal chest roentgenograms on admission, the significance of which was VOL. 16, NO. 1, JULY, 1973 69
DREWS, MERCER, AND BENFIELD not recognized, and all had significant diaphragmatic injuries repaired at operation. Of the 43 patients, 36 were operated upon through abdominal incisions and 7 through thoracoabdominal approaches. The abdominal incisions were uniformly correct. The combined incisions were used in 2 patients with continuous bleeding from chest tubes, in 2 patients after severe blast injuries, in 1 patient with suspected aortic injury, and in 1 patient with an intrapericardial hernia. One patient had a thoracotomy following cardiac arrest in the operating room. The choice of incisions proved suboptimum in only 1 patient, in whom the abdominal incision was not adequate to handle an associated aortic injury that was not recognized until some weeks later when an aortogram was done. Roentgenographic Review. The records (Table 2) showed that 12 of the 43 patients had normal preoperative chest roentgenograms (Group 1). Group 2 consisted of the 30 patients who had plain chest films that were considered abnormal but not diagnostic of diaphragmatic injury. Twentyfour of these patients were recognized as having abnormal chest roentgenograms on admission, but no mention of diaphragmatic injury was made (Group 2A). The possibility of diaphragmatic injury was mentioned in the remaining 6 patients (Group 2B). Four of these 6 patients had barium contrast studies that confirmed the presence of diaphragmatic disruptions. Only 1 patient was in Group 3, in which the original chest film interpretation was diagnostic for diaphragmatic injury. Retrospective review showed that of the 43 patients, 10 had normal chest roentgenograms (Group l), 4 had films diagnostic for diaphragmatic trauma (Group 3), and the remaining 29 had films suspicious for diaphragmatic injury (Group 2B). These 29 roentgenograms were presented as unknowns to TABLE 2. ACUTE DIAPHRAGMATIC INJURIES IN 43 PATIENTS, 1967-1972: RETROSPECTIVE RADIOLOGICAL REVIEW Roentgen. Finding of DI Group 2 Group 1 (A) (B) Group 3 Total Original 12 24 6 1 43 interpretation Others' 10 7 22 4 43 retrospective review" Authors' 10 0 29 4 43 retrospective review LPlain films of chest reviewed without clinical data by various faculty radiologists. DI = diaphragmatic injury; Group 1 = normal chest roentgenograms; Group 2A = abnormal chest roentgenograms (diaphragmatic injury not considered) ; Group 2B = abnormal chest roentgenograms (diaphragmatic injury considered) ; Group 3 = chest roentgenograms diagnostic of diaphragmatic injury. 70 THE ANNALS OF THORACIC SURGERY
Acute Diaphragmatic Injuries fully trained radiologists. None of the films were described as classic for diaphragmatic trauma. In 22 the possibility of diaphragmatic injury was initially entertained, but in each case additional studies (or operation) were deemed necessary for diagnosis. The remaining 7 were considered unlikely for diaphragmatic injury, even when the history was supplied. It is apparent that the diagnosis of diaphragmatic injury, even with an abnormal posttraumatic chest roentgenogram, was not entertained in most cases. However, trained radiologists considered diaphragmatic disruption a possibility in most of these same patients without knowing their history of trauma. Clinical Histories PATIENT 1 A 43-year-old man jumped in front of a speeding car. On initial examination a 4 cm. left-sided chest wall laceration was seen at the level of the seventh intercostal space laterally. Protruding through this defect were omentum and colon wall. He had also suffered multiple lower extremity fractures. He was in shock and had an acute abdomen. A chest roentgenogram revealed an obvious diaphragmatic herniation on the left (Fig. 1). At laparotomy the stomach, spleen, and colon were reduced through a 6 cm. tear in the left hemidiaphragm. Following removal of the ruptured spleen the diaphragm was repaired, a chest tube was placed, and the chest wall laceration was closed. He had an uneventful postoperative recovery but was kept in the hospital for 37 days for psychiatric reasons. Comment. This patient survived abdominal visceral herniation through the diaphragm and chest wall. To our knowledge, only 1 similar FIG. 1. Anteroposterior view of the chest in Patient 1 showing posttraumatic air-filled viscus above the left hemidiaphragm as a consequence of diaphragmatic rupture. VOL. 16, NO. 1, JULY, 1973 71
DREWS, MERCER, AND BENFIELD FIG. 2. Upright posteroanterior view of the chest in Patient 2 showing free intraperitoneal air under the right hemidiaphragm. The stab wound in the left anterior fourth intercostal space traversed the chest and penetrated subdiaphragmatic organs. Nevertheless, the chest roentgenogram remained normal. patient has previously been reported [ll]. Although not required for diagnosis in this patient, the chest roentgenogram was diagnostic of diaphragmatic disruption. PATIENT 2 A 21-year-old man was stabbed once just above the left nipple. He was asymptomatic, and his chest was clear. Chest roentgenogram was within normal limits, but free air was present under the diaphragm (Fig. 2). At laparotomy his perforated stomach was repaired and a 2 cm. perforation of the left hemidiaphragm was closed. The postoperative course was complicated by recurrent pleural effusions that were managed successfully with thoracocenteses. He was discharged on the twelfth postoperative day. Comment. This patient s history illustrates that diaphragmatic penetration with a wound of entrance as high as the fourth intercostal space can A FIG. 3. (A) Up-ight posteroanterior and (B) left lateral views of the chest in Patient 3, originally interpreted as questionably high left hemidiaphragm. B 72 THE ANNALS OF THORACIC SURGERY
Acute Diaphragmatic Injuries reach to an intraabdominal viscus and yet not show intrathoracic roentgenographic abnormalities. PATIENT 3 A 37-year-old man was stabbed twice in the anterior left chest in the fourth and seventh intercostal spaces. He was asymptomatic on admission but had decreased breath sounds on the left. A questionably high left hemidiaphragm was noted on chest roentgenogram (Fig. 3). Physical examination of the abdomen on admission was normal, but signs of peritoneal irritation developed during the next 24 hours. Gastroduodenal roentgenograms showed the stomach to be above the diaphragm (Fig. 4). At laparotomy the stomach was returned to the abdomen through a 7 cm. tear in the dome of the left hemidiaphragm, and the diaphragm was repaired. No visceral injury was present. The patient was discharged after eight days in the hospital. Comment. This patient s history illustrates that delay in diagnosis of diaphragmatic injury is apt to occur after thoracic stab wounds. In retrospect, the questionably high left hemidiaphragm noted in the records should have led to an immediate gastroduodenal contrast study and prompt operation. PATIENT 4 A 16-year-old boy was struck by a car. He presented with flaccid paraplegia, decreased breath sounds over the left chest, and moderate abdominal tenderness. Roentgenographic studies showed a fracture and dislocation involving the first and second lumbar vertebrae. A chest roentgenogram showed an elevated left hemidiaphragm and a small right hemothorax. Ten days after decompressive laminectomy the patient suffered from increasing dyspnea and postprandial vomiting. The chest roentgenogram was misinterpreted, and in addition to a nasogastric tube, a chest tube FIG. 4. Gastrointestinal series 24 hours later in Patient 3 showing portion of stomach herniated through left hemidiaphragm. Earlier contrast study could have made definitive diagnosis of diaphragmatic rupture more promptly. VOL. 16, NO. 1, JULY, 1973 73
DREWS, MERCER, AND BENFIELD FIG. 5. Supine anteroposterior view of the chest demonstrating important differential diagnostic point. Original diagnosis was loculated pteumothorax, for which a tube was placed in the left pleural space. The nasogastric tube at the level of the chest tube is above the normal level of the left hemidiaphragm. Patient had gastric herniation through ruptured diaphragm. was inserted to treat the pneumothorax. Repeat films showed the nasogastric tube in the stomach above the diaphragm and the adjacent chest tube (Fig. 5). After correct interpretation of the roentgenograms, the patient had immediate operation and repair of the diaphragmatic hernia. Following a protracted hospitalization as a result of his paraplegia, he was transferred to an extended care facility. Comment. This patient s history illustrates that the question of diaphragmatic injury can easily assume low priority in the face of massive trauma. It also shows that the differential diagnosis of ruptured diaphragm includes loculated pneumothorax. The air collection about the left hemidiaphragm is diagnostic for neither and suggestive of both. SUMMARY Acute diaphragmatic disruption waj almost invariably accompanied by intraabdominal injury. Inordinate delay in operation was associated with penetrating thoracic wounds, particularly stab wounds. Penetrating thoracic wounds as high as the fourth intercostal space lacerated subdiaphragmatic organs. Retrospective clinical and radiological review showed that little consideration was given to diaphragmatic injury in patients with abnormal chest roentgenograms following trauma. Comment Ambrose Pard s first description of diaphragmatic hernia concerned a patient in whom the splenic flexure had belatedly herniated through a thumb-sized gunshot wound OL the diaphragm [7]. The patient died from an unrecognized large bowel obstruction. We have focused upon the diagnostic features of acute diaphragmatic injuries. Whether or not herniation is present and whether or not there is associated injury of organs, the potential danger of delayed or missed diagnosis is great. 74 THE ANNALS OF THORACIC SURGERY
Acute Diaphragmatic Injuries Only exceptional patients have physical findings diagnostic of diaphragmatic disruption, but many other patients are too critically injured to undergo any but the most basic diagnostic studies. Therefore, plain chest films are of great importance. Overlooking the possibility of diaphragmatic injury in evaluating an abnormal chest roentgenogram after trauma has been indicted as the chief reason for missing the diagnosis [lo]. We have confirmed this by our retrospective and faculty radiological review. There was a 37% increase in consideration of diaphragmatic disruption in abnormal chest roentgenograms by the faculty radiologists in comparison with the admission evaluation, even in the absence of a history of trauma. The roentgenographic signs suggestive or diagnostic of diaphragmatic injury are acute diaphragmatic elevation (with or without pleural effusion), atelectasis with silhouetting of the ipsilateral diaphragm, and evidence of an air-filled or solid viscus above the diaphragm [5, 6, 81. No additional roentgenographic signs were found to be of diagnostic value in our series. The histories of the 8 patients whose operation was delayed warrant close retrospective analysis. The 7 patients with penetrating trauma had progressive intraabdominal bleeding or increasing abdominal tenderness which led to operation. In retrospect, all their chest roentgenograms were abnormal on admission, and all had significant diaphragmatic injuries repaired at operation. The 1 patient with blunt trauma had multiple severe associated injuries. Diaphragmatic injury was not considered until the patient s condition was stable and increasing abdominal tenderness and postprandial vomiting were noted. It is likely that immediate diagnosis and operation would have reduced the postoperative morbidity in these patients. In fact, 3 of the 8 patients had true diaphragmatic herniation at the time of operation, and all of them had prolonged hospital stays because of postoperative complications. Most authors agree that small diaphragmatic tears, if not detected and repaired, will expand to become full-blown diaphragmatic hernias. Small diaphragmatic tears have a greater tendency to strangulate tissue than do large defects [l, 21. The fact that an anterior thoracic stab wound as high as the fourth intercostal space can perforate the diaphragm and enter the peritoneal cavity is not fully appreciated. Under conditions of stress and during forced expiration this is possible-particularly if the thrust of the knife is downward. Conversely, a stab wound high in the flank can also penetrate the diaphragm. The operative approach in these patients in the acute situation was uniformly through the abdomen or through a combined thoracoabdominal approach. Objection to a thoracoabdominal incision is based on the surgical creation of a diaphragmatic defect that may break down with time [lo]. This can be avoided by using separate thoracic and abdominal incisions. Of the 43 patients, 42 had associated intraabdominal trauma, and an adequate exploration of the peritoneal cavity can only be done with a formal VOL. 16, NO. 1, JULY, 1973 75
DREWS, MERCER, AND BENFIELD laparotomy. Adequate exploration includes careful examination of the diaphragm so as not to miss the potentially lethal small diaphragmatic perforation. Based on our experience, we suggest the following guidelines for the management of acute diaphragmatic injuries. Any injury involving the area from the fourth intercostal space to the level of the umbilicus should be considered as potentially involving the diaphragm. Careful evaluation of the plain chest roentgenogram is crucial. If it is abnormal and operation is not immediately contemplated for other reasons, an appropriate contrast study should be done to help determine if the diaphragm is intact. Even in the absence of other operative indications, acute diaphragmatic disruptions should be promptly repaired using interrupted nonabsorbable sutures. Abdominal exploration is mandatory in the acute injury, and careful examination of the entire diaphragm must be part of any abdominal exploration following trauma. Following recovery from massive thoracoabdominal trauma involving the diaphragm, upper gastrointestinal contrast studies should always be done prior to hospital discharge. Occasionally a barium enema roentgenographic study is also indicated. The data we have presented confirmed our concern that our index of suspicion and diagnostic acuity regarding diaphragmatic injuries had been suboptimum. We believe that our experience in this regard likely is general and not unique, and we hope these data will bring about increased accuracy of diagnosis and more prompt operative repair of this serious injury. References 1. Blades, B. Ruptured diaphragm. Am. J. Surg. 105:501, 1963. 2. Carter, R., and Brewer, L. A., 111. Strangulating diaphragmatic hernia. Ann. Thorac. Surg. 12:281, 1971. 3. Ebert, P. A., Gaertner, R. A., and Zuidema, G. D. Traumatic diaphragmatic hernia. Surg. Gynecol. Obstet. 125:59, 1967. 4. Graivier, L., and Freeark, R. J. Traumatic diaphragmatic hernia. Arch. Surg. 86:363, 1963. 5. Kiok, P. A. Diaphragmatic rupture following indirect trauma. Scand. J. Thorac. Cardiovasc. Surg. 1:212, 1967. 6. Lavender, J. P., and Potts, D. G. Differential diagnosis of elevated right diaphragmatic dome. Br. J. Radiol. 32:56, 1959. 7. Park, A. Oeuvres Complttes (J. F. Malaigne, Ed.). Paris: Balli&re, 1840. Vol. 11, Chap. 32. 8. Pomerantz, M., Rodgers, B. M., and Sabiston, D. C. Traumatic diaphragmatic hernia. Surgery 64: 529, 1968. 76 THE ANNALS OF THORACIC SURGERY
Acute Diaphragmatic Injuries 9. Samaan, H. A. Undiagnosed traumatic diaphragmatic hernia. Br. J. Surg. 58:257, 1971. 10. Sutton, J. P., Carlisle, R. B., and Stephenson, S. E., Jr. Traumatic diaphragmatic hernia: A review of 25 cases. Ann. Thorac. Surg. 3:136, 1967. 11. Thiese, J. K., and Milson, B. Hernia of the diaphragm and chest wall. Wis. Med. J. 64251, 1965. 12. Waldhausen, J. A., Kilman, J. W., Helman, C. H., and Battersby, J. S. The diagnosis and management of traumatic injuries of the diaphragm including the use of Marlex prostheses. J. Trauma 6:332, 1966. D iscussi o n DR. KOBERT F. WILSON (Detroit, Mich.): A couple of weeks before we came down here, we decided to see if our statistics at Detroit General Hospital agreed with those of the authors. We reviewed the records of 353 patients with diaphragmatic injuries from the 5-year period 1968 through 1972, and we still have about 50 to 100 more to review. We have seen somewhat more penetrating injuries. Ninety-eight percent of our patients had penetrating injuries, with 269 gunshot wounds of the diaphragm, 65 stab wounds, and 13 shotgun wounds. Our mortality rates generally agree; however, our mortality rate with gunshot wounds was 18% as opposed to the authors' single death among 22 patients. The greater incidence of injuries on the left side, even with the penetrating wounds, is interesting; about 58y0 of our series involved the left side. As far as coincident abdominal injuries, about two-thirds of our patients had liver injuries, whereas Dr. Benfield noted somewhat more stomach injuries. It was interesting that only about 1% of our patients with penetrating wounds actually had herniation of viscera into the chest. The incidence of postoperative complications in our patients with diaphragmatic injuries was extremely high. Seventy-nine percent in our series had postoperative complications. About half of these complications were related to atelectasis with a fever for more than 48 hours. Symptoms have not been of great value in diagnosing the diaphragmatic injuries in our patients because most of them were bleeding and hypotensive or had acute abdomen. It is surprising how reliably the findings of decreased breath sounds at the time of the initial examination correlated with the incidence of damage above the diaphragm. It is easy to suspect a diaphragmatic injury if the penetrating wound involves the lower chest, but if the entrance wound is in the abdomen the chest involvement is much easier to miss. Speed in treating these patients is essential because many of them are in shock when they arrive. Any delay results in a poor prognosis. About 1 out of every 8 of our patients had to have massive transfusions of more than 10 units of blood before and during operation. Dr. Benfield stressed the importance of an abdominal incision when a patient has a diaphragmatic injury. I would like to emphasize considering the chest for the initial incision if there is a lot of blood coming out through the chest tube or if there is a possibility of a penetrating cardiac injury. Obviously, if the patient has a cardiac arrest and a penetrating injury he should have open cardiac massage. If the abdomen is distended with blood and there is persistent shock in spite of massive blood and fluid replacement, we recommend opening the chest and clamping the aorta above the diaphragm before entering the abdomen and releasing the peritoneal tamponade. One should always try to get chest and abdominal roentgenograms preoperatively for any patient with an injury to the chest or abdomen. Upright films are far more valuable than those obtained when the patient is lying flat and should be obtained whenever possible. If the patient is in severe, persistent shock, however, one may not have time to get roentgenograms. VOL. 16, NO. 1, JULY, 1973 77
DREWS, MERCER, AND BENFIELD Of our patients with diaphragmatic injuries, 28% had a persistently norrnal chest film and 12% had films that were considered normal initially but then showed an abnormality later. A roentgenographic abnormality anywhere near the diaphragm is considered to be a diaphragmatic injury until proved otherwise, especially if the mediastinum is pushed to the other side. DR. KAMAL A. MANSOUR (Atlanta, Ga.): I wish to cite a recent example of a chronic diaphragmatic rupture to show its grave nature and possibly fatal complications and the urgency of surgical repair as soon as the diagnosis is made. The case is that of a paraplegic 28-year-old woman who was involved in an automobile accident in 1963. She underwent a series of surgical procedures, including laminectomy for fracture of the twelfth thoracic through first lumbar vertebrae, colostomy in 1970, and ileal conduit in 1971. In the meantime, and in a wheelchair, she finished college and got a degree in sociology. A left diaphragmatic rupture, however, was overlooked until 1972, when she was hospitalized for grafting of decubital ulcers. An operation for the diaphragmatic herniation was advised but refused. Three days later the patient had an episode of acute respiratory distress, and she became cyanotic, hypotensive, and almost moribund. Chest roentgenograms showed markedly dilated intestinal loops in the left chest with an acute mediastinal shift to the right. Emergency thoracotomy was performed, and this revealed massive traumatic diaphragmatic herniation of the transverse colon, great omentum, spleen, tail of the pancreas, and some six feet of small bowel that showed acute obstruction and early gangrene. Due to an adhesive band forming at the diaphragmatic opening, release of the obstruction was performed with resection of some six inches of small bowel as well as splenectomy. Reduction of the hernia with repair of the diaphragmatic defect was accomplished, and recovery was complete. DR. BENFIELD: I was going to make the same point that Dr. Mansour has just made. Instead, I want simply to indicate that we also have made a clear distinction between the acute problem stressed in this paper and the delayed consequences of not recognizing the acute problem. Our review has addressed itself to the management of the acute situation only. Certainly the consequences of not recognizing the acute situation can be grave. In 1 patient we know of the acute manifestations did not appear until 15 years after the initial injury. So, Dr. Mansour, we agree with your comments and your approach. In our opinion, for delayed management of the complications that these diaphragmatic injuries cause, the thoracic approach is almost always preferable. The adhesions which are often present and the nature of the operation required are better handled through the chest than through the abdomen. Dr. Wilson, we are happy to see that your experience has been similar to ours, and I agree with your suggestion that there are some patients who should be operated upon through the chest. In our opinion, operating through the chest for diaphragmatic injuries in the acute situation is indicated if there are other clear indications for doing a thoracotomy, such as continued blood loss or large, continuing air leaks. Under these circumstances we, too, would go through the chest rather than through the abdomen. However, when there are no clear signs indicating that one should operate through the chest, we believe the abdomen is preferable because of the possible need for colostomies and other procedures upon the gastrointestinal tract. 78 THE ANNALS OF THORACIC SURGERY