Diaphragmatic Hernias in Trauma ONAONA GURNEY, PGY4 SUNY DOWNSTATE DEPARTMENT OF SURGERY AUGUST 28 TH 2015
Case Presentation 61M restrained driver in MVA, transferred from Brookdale Hospital Airbag deployment, prolonged extrication
Physical Survey ABC intact, GCS 15 Afebrile 91 120/61 22 92%RA A&Ox3 s1s2 present, no mrg Decreased BS on L s/nt/nd Decreased motor strength on LLE 2/2 pain, sensation intact, femoral/dp 2+ BL, no gross deformities FAST negative
Brief History PMH: DM, CAD s/p stents x2 (7yrs prior) MEDS: Metformin, ASA (stopped 7d prior) NKDA PSH: Lap appendectomy & prostatectomy SH: social EtOH, denies tobacco/ivda FH: non-contributory
Labs & Imaging 10.5>14.5/45<164 139/4.1/100/25/15/1.03<146 6.8/4.2/109/60/0.7 11.3/24.5<1.1
CT Chest
Operation Performed Laparoscopic repair of traumatic left sided diaphragmatic hernia with placement of L sided chest tube
Hospital Course POD 1: Chest tube removed POD 2: Episode of a. fib w/rvr, elevated trop POD 12: Orthopedic repair of pelvic fx POD 1/13: Extubated in SICU, NSTEMI POD 5/17: Downgraded to floor Currently in acute rehab recovering!
QUESTIONS????
Diaphragmatic Hernias Hernia: Derived from latin word for rupture
First described in 1541 by Sennertus 1 Pare described first organ strangulation as consequence of TDH www.downstatesurgery.org History First successful repair by Riolfi in 1886 2
Diaphragmatic Rupture Tear of musculature secondary to trauma Resultant herniation of abdominal contents into thoracic cavity Incidence 0.8-5% 3 75% secondary to blunt trauma
Anatomy
Characteristics Majority present on the left Organs most commonly herniated 2 Stomach Spleen Small/large bowel, mesentery
Presentation Physical Exam Decreased breath sounds & SOB Chest & abdominal pain Bowel sounds auscultated in chest Scaphoid abdomen Shoulder pain
Diagnosis HIGH INDEX OF SUSPICION!! Physical Exam findings CXR CT Scan FAST UGIS, Barium enema, MRI Operative exploration
Chest X-Ray
CT Scan Sensitivity close to 95% 6 Without herniation sensitivity poor Aides w/dx of other injuries
Operative Exploration Exploratory Laparotomy Laparoscopy/Thoracoscopy Thoracotomy
Treatment ABC s, identify, stabilize and treat other life threatening injuries OR for definitive repair recommended approach to diaphragmatic injury: midline laparotomy 3
Surgical Goals Complete reduction of hernia contents Repair of diaphragmatic injury, preventing recurrence
Laparoscopic Repair Position in reverse Trendelenburg with R side down Prepare for possibility of emergent chest tube Use of 30 degree scope Port placement Reduction of hernia Irrigation of chest Non-absorbable suture repair
Port Placement
Non-absorbable suture www.downstatesurgery.org Technical Repair
Mesh Use Not advocated for acute injury If defect cannot be closed primarily, in the setting of bowel contamination, biologic mesh is a feasible option
Summary Diagnosis requires high index of suspicion CXR/CT scan are most common modality of diagnosis Diagnostic/therapeutic laparoscopy in hemodynamically patient becoming standard Exploratory laparotomy still considered standard of care Primary repair with non-absorbable suture Use of biologic mesh in acute setting feasible option when primary repair not possible and bowel contamination is present
Thank You
References 1: Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram K. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. 2004 Nov. 22(7):601-4. 2: Meyers BF, McCabe CJ Traumatic diaphragmatic hernia. Ann Surg 1993;218:783 90 3: Turhan K, Makay O, Cakan A, Samancilar O, Firat O, Icoz G, et al. Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg. 2008 Jun. 33(6):1082-5 4: Hanna W.C., Ferri L.E., Fata P., et al: The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg 2008; 85: pp. 1044-1048 5: Carter B.N., Guiseffi J., and Felson B.: Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther 1951; 65: pp. 56 6: Marts B., Durham R., Shapiro M., et al: Computed tomography in the diagnosis of blunt thoracic injury. Am J Surg 1994; 168: pp. 688-692