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|Year : 1979 | Volume
| Issue : 1 | Page : 63-65
Traumatic diaphragmatic hernia-late presentation
PLNG Rao, RN Katariya
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
The traumatic diaphragmatic hernia is an established consequence of modern high speed transportation. Late presentation of traumatic diaphragmatic hernia is an uncommon surgical problem. Two cases of latent and obstructive traumatic diaphragmatic hernia have been presented. The clinical presentation, the diagnostic problems and the management of such cases are discussed.
|How to cite this article:|
Rao P, Katariya R N. Traumatic diaphragmatic hernia-late presentation. J Postgrad Med 1979;25:63-5
| :: Introduction|| |
Traumatic diaphragmatic hernia which was initially a medical curiosity, is now an established consequence of civilian warfare and modern high speed transportation.  It can be the result of either direct or indirect trauma. It has got a different clinical presentation in the acute phase which is most common, as compared to the latent and obstructive phases which are rather uncommon. According to recent literature, indirect trauma is responsible in a ratio of 4 : 1 to direct trauma in resulting strangulated traumatic diaphragmatic hernia.  Here we are describing our experience with two cases of traumatic diaphragmatic hernia which presented to us in latent and obstructive phases.
| :: Case reports|| |
Mr. J.S., a known case of bronchial asthma was admitted to our Emergency services on 14-2-1976 with a history of acute intestinal obstruction of 3 days' duration. Three years prior to this he had blunt injury to the chest and abdomen which had resulted in fractures of ribs on the left side and was treated conservatively. Since that time he had been getting colicky abdominal pain off and on and was repeatedly treated for amoebiasis. On examination, in addition to the evidence of intestinal obstruction, there was diminished air entry on the left side of the chest and a shift of the mediastinum to the right.
Blood biochemistry and haematological examinations were within normal limits. X-ray chest showed mediastinal shift and collapse of the left lung (See [Figure 1] on page 62B).
The patient was explored through an abdominal approach, with a provisions diagnosis of obstructed traumatic diaphragmatic hernia. This was confirmed at surgery. The stomach, spleen, parts of small intestine and transverse colon were lying in the thorax. Hernia was reduced and the diaphragmatic defect was repaired. Patient made an uneventful recovery.
A 19 year old female was admitted on 20-71977 with history of recurrent attacks of atypical upper abdominal pain, mainly epigastric, of 5-6 years' duration. There was history of blunt trauma (in the way of collapse of a wall) to the left chest and abdomen 10 years prior to admission. Examination revealed only mild tenderness in the epigastric region. Chest examination revealed absent breath sounds and presence of bowel sounds in left infra-axillary and infra-scapular regions.
Routine haematological examinations were normal. X-ray chest showed elevated diaphragm on the left side (See [Figure 2] on page 62B) and on screening, the left diaphragm could not be located. Barium meal examination revealed organo-axial volvulus of the stomach (See [Figure 3] on page 62B) . A provisional diagnosis of traumatic diaphragmatic hernia and/or eventration of diaphragm with volvulus of stomach was made and the patient was explored through an abdominal incision on 26-7-1977, which revealed a left traumatic diaphragmatic hernia. The abdominal approach was later converted into abdomino-thoracic approach. There was a rent of 3½ size in the diaphragm starting from the oesophagus to the costal margin. A part of liver, stomach and transverse colon had herniated into the left thorax (See [Figure 4] on page 62B). The contents were reduced and repair of the rent was carried out in 2 layers using interrupted silk stitches. Patient's post-operative period was uneventful.
| :: Discussion|| |
Though Sennortus described the laceration of the diaphragm in a post-mortem case as early as 1541, it was Bonditch who published the ante-mortem diagnosis of the traumatic diaphragmatic hernia in 1855.  Though there is a good amount of literature on this subject, it is mainly confined to the acute cases. Childress and Grimes  described about 15 cases of late traumatic diaphragmatic hernia over period of 22 years which is one of the biggest series. Samma  and Schiwidt and Gale  described 4 and 3 cases respectively which presented to them years after blunt injury. Langlay and Innes,  over a period of 20 years, could record 3 such cases indicating the relative rarity of this condition. Both of our patients presented to us very late after 3 years (case 1) and after 10 years (case 2). The maximum time interval described between trauma and presentation has been as long as 45 years. 
Both our cases are left sided ones. This is the most common presentation  and is attributed to the diminished buffering force under the left dome of the diaphragm. 
The fact that these patients are misdiagnosed and treated for peptic ulcer, coronary disease, gall bladder or lung diseases  before the actual diagnosis becomes apparent only shows the difficulty involved in making a correct diagnosis. Both our patients had been misdiagnosed and had received treatment for amoebiasis (Case 1) and for peptic ulcer (Case 2) for a long time before correctly diagnosed.
Often X-ray chest gives a clue to the diagnosis but it is misinterpreted for various diseases like eventration of diaphragm, gastric dilatation and diseases of the lower lung fields. Nevertheless high index of suspicion of this condition in a person presenting with obscure abdominal illness who sustained blunt or penetrating injury to the thorax in the recent and remote past clinches the diagnosis.  This was the basis for a correct pre-operative diagnosis in both our cases. Radiology of the abdomen after pneumoperitoneum has been advised by some authors , for establishing the diagnosis of this disorder.
Abdominal  and thoracic  approaches are described for the repair of this hernia. Abdominal approach was found satisfactory in our first case but needed to be extended to abdomino-thoracic in the second case. Post-operatively and in follow-up both our patients did well indicating a good prognosis of the condition
| :: References|| |
|1.||Child, G. G. III, Harman, G. S., Dotter, T. C. and Steinberg, I.: Liver herniation simulating intra-thoracic tumour. J. Thoracic Surg., 21: 391-393, 1951 |
|2.||Childress, M. E. and Grimes, O. F.: Immediate and remote sequalae in traumatic diaphragmatic hernia. Surg. Gynaecol. & Obstet., 113: 573-584, 1961. |
|3.||Clay, M. G. and Munro, A. I.: Bilateral diaphragmatic hernia from blunt injury causing a Budd-Chiari syndrome (use of liver and spleen scan in demonstrating the defects). Ann. Surg., 173: 321-324, 1971. |
|4.||Clay, R. C. and Hamles, C. R.: Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. J. Thoracic Surg., 21: 57-70, 1951. |
|5.||Griswold, F. W., Warden, H. E. and Cardner, R. J.: Acute diaphragmatic rupture caused by blunt trauma. Amer. J. Surg., 124: 359-362, 1972. |
|6.||Hill, L. D.: Injuries of the diaphragm following blunt trauma. Surg. Clin. North Amer., 52: 611-624, 1972. |
|7.||Langley, J. R. and Innes, B. J.: Traumatic non-penetrating diaphragmatic hernia. Amer. Surg., 41: 409-412, 1975. |
|8.||Orringer, M. B., Kirsh, M. M. and Solan, H.: Congenital and traumatic diaphragmatic hernias exclusive of the hiatus. Curr. Probl. Surg.. March 1975. |
|9.||Samaan, H. A.: Undiagnosed traumatic diaphragmatic hernia. Brit. J. Surg., 58: 257-261, 1971. |
|10.||Schwindt, W. D. and Gale. J. W.: Late recognition and treatment of traumatic diaphragmatic hernias. Arch. Surg., 94: 330-334, 1967. |
|11.||Sullivan, R. E.: Strangulation and obstruction in diaphragmatic hernia due to direct trauma. J. Thorac. Cardiovase. Surg., 52: 725-734, 1966 |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]