Diaphragmatic Hernias in Trauma · 2015. 8. 28. · Diaphragmatic Hernias . . Hernia: Derived from latin word for rupture . . Defined as an abnormal protrusion of an organ or tissue
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ONAONA GURNEY, PGY4 SUNY DOWNSTATE DEPARTMENT OF SURGERY AUGUST 28 TH 2015 Diaphragmatic Hernias in Trauma www.downstatesurgery.org
61M restrained driver in MVA, transferred from Brookdale Hospital
Airbag deployment, prolonged extrication
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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,
CT C/A/P: stomach & splenic flexure herniating through diaphragmatic defect. Fx of L iliac crest, ileum, anterior column of L acetabulum and L superior/inferior pubic rami fx. Small L pelvic & lateral abdominal wall hematoma. No free air or fluid.
Operation Performed
Laparoscopic repair of traumatic left sided diaphragmatic hernia with placement of L sided chest tube
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Presenter
Presentation Notes
5mm optiview port LUQ, additional 5mm port Lateral LUQ, additional 5mm port supra-umbilical just off the midline. One additional 10mm port in the LUQ which was used to assist in laparoscopic suturing. Approximate 10cm defect in L diaphragm, lateral to crura just inferior to pericardium. Interrupted 0 ethibond was used to primarily repair the defect.
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!
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QUESTIONS????
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Diaphragmatic Hernias
Hernia: Derived from latin word for rupture
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Presenter
Presentation Notes
Defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls In that respect then diaphragmatic hernias are a protrusion of abdominal contents into the chest through a weakness in the daiphragm. DH are classified into congential, including Bochdelach & Morgagni, and acquired, including hiatal and traumatic. For this discussion we will only be covering acute traumatic diaphragmatic hernias.
History
First described in 1541 by Sennertus1
Pare described first organ strangulation as consequence of TDH
First successful repair by Riolfi in 18862
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Presenter
Presentation Notes
Over 450 years ago when sennertus first described a TDH during an autopsy on pt with delayed herniation of the stomach through the diaphragm after a self-inflicted stab wound. 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
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
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Presenter
Presentation Notes
When we discuss TDHs the mechanism we are describing is Diaphragmatic rupture. This can be caused by either blunt or penetrating forces. Penetrating trauma is self-explantory. However in blunt trauma we are dealing with a significant force which contributes not only to an abrupt increase in intra-abdominal pressure but also the transmission of this force to the muscle itself, causing a shearing, tearing or avulsion of the diaphragm. This combination leads to Sudden increase in the transdiaphragmatic pleuroperitoneal pressure gradient, resulting in herniation of abdominal contents Of trauma admissions with Dx incidence is 3-5%. Likely under-reported numbers given that many times dx is missed initially if hernia not present. Most commonly 2/2 to blunt trauma and approx 70% of the time on the Left, because of the protective effect of the liver as well as a congential weakness seen on the left part of the diaphragm 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
Anatomy
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Presentation Notes
3mm domed muscle responsible for respiration. Blood supply from aorta/internal thoracic (sup/inf phrenic)/(musculophrenic/pericardiophrenic) Innervated by the phrenic (C3/4/5 keep the diaphragm alive) T8: IVC T10: esophagus T12: Aorta
Characteristics
Majority present on the left
Organs most commonly herniated2 Stomach Spleen Small/large bowel, mesentery
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Presenter
Presentation Notes
2/2 to the cushioning effect of the liver on the right and the congenital inherent weakness of the L diaphragm Most commonly associated with multiple other injuries, TBI is the only associated injury which has any predictive value of M&M 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
Presentation
Physical Exam Decreased breath sounds & SOB Chest & abdominal pain Bowel sounds auscultated in chest Scaphoid abdomen Shoulder pain
BASED ON MECHANISM OF INJURY physician requires high IOS Thoracoabominal penetrating trauma must require investigation into possibility of diaphragm injury DPL: >1000 RBC to dx injury, however not useful for this dx, more of a historical point
Chest X-Ray
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Presentation Notes
The obvious diagnosis can be made on initial CXR, and the classic NGT coiling in the chest is rarely ever seen in the acute trauma setting. However, subtle signs on the radiograph, such as an obscured diaphragmatic shadow, elevated hemidiaphragm, irregular diaphragmatic contour, or pleural effusion, can suggest injury to the diaphragm5. However, up to50% or more of the time CXR will be normal 5: Carter B.N., Guiseffi J., and Felson B.: Traumatic diaphragmatic hernia. Am J Roentgenol Radium Ther 1951; 65: pp. 56
CT Scan
Sensitivity close to 95%6
Without herniation
sensitivity poor
Aides w/Dx of other injuries
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Presenter
Presentation Notes
In the presence of herniation of abdominal organs into the thoracic cavity, the sensitivity of oral contrast-enhanced CT scan is close to 95-100%. Without herniation, what it does offer is the identification of other injuries. 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
Operative Exploration
Exploratory Laparotomy
Laparoscopy/Thoracoscopy
Thoracotomy
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Presenter
Presentation Notes
Exlap: most commonly other injuries necessitating exploration, result in dx of diaphragm injury as 2/2 Laparoscopy/thoracoscopy: Advocated when there is a high index of suspicion in an otherwise HDS pt who otherwise does not require operative exploration For penetrating trauma to the LL chest or LUQ, these modalities are advocated7, without associated hemothorax, usually laparscopy Thoracotomy: used most commonly when chest injury necessitates exploration 7: Ochsner M.G., Rozycki G.S., Lucente F., et al: Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoraco-abdominal trauma: a preliminary report. J Trauma 1993; 34: pp. 704-710
Treatment
ABC’s, identify, stabilize and treat other life threatening injuries
OR for definitive repair recommended approach to diaphragmatic injury: midline
laparotomy3
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Presenter
Presentation Notes
Given the high rate of associated injuries to intraabdominal organs, it is generally recommended to approach the diaphragmatic injury through a midline laparotomy. This is still considered to be the gold standard, however the increasing use and improved laparoscopic skills of surgeons are really changing this idea. So while for the boards you would still say ex-lap, the reality of the world is that in a HDS pt without other operative injuries the approach should really be laparoscopy.
Surgical Goals
Complete reduction of hernia contents
Repair of diaphragmatic injury, preventing recurrence
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Presentation Notes
Control sources of hemorrhage and GI spillage, identify and repair any other injuries. Identify extent of diaphragm injury. Reduce hernia, inspect, washout/debride thorax and repair. In acute setting almost always able to completely reduce contents. If not phrenotomy can be made to facilitate reduction. In cases with concomitant perforation of abdominal viscera, it is necessary to irrigate the chest to reduce occurrence of an empyema.
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
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Port Placement
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Presenter
Presentation Notes
Camera port is supra-umbilical, usually just off midline. 2 Left sided working ports, lateral and approximately mid clavicular. Possible liver retraction port, if deemed necessary.
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Presenter
Presentation Notes
Note that even though there is a large amount of abdominal contents in the chest, the actual defect size is quite small and more than ammenable to primary repair.
Technical Repair
Non-absorbable suture
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Presenter
Presentation Notes
Small diaphragmatic defects may be repaired using interrupted nonabsorbable sutures. Larger defects will require interrupted figure-of-eight or mattress sutures, in either a single layer or a double layer configuration.
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
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Presenter
Presentation Notes
Now we come to the idea of mesh use. For chronic diaphragmatic hernias, the current recommendations are to close primarily and when this is not feasible the use of synthetic mesh is the advocated standard of care. In the acute setting, the indications for mesh use are the same as that for chronic DH, however the decision to use synthetic vs biological is a decision that one may be faced with. Case series of 5 patients, mixed chronic and acute DH, clean and clean contaminated cases, standard use of biologic mesh. They saw no recurrences, infections, or re-operations and feel that the use of biologics is a feasible option. There are no RCT, mostly just case reports, this was one of the larger series of traumatic hernias using biologics. I present this mainly for thought provocation as to an option available to the surgeon when encountering a DH unable to be closed primarily.
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
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Thank You
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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
