CASE REPORT

Repair of right sided Traumatic Diaphragmatic Herniawith intrathoracic herniation of liver and a segmentof ruptured jejunum—a case report and review of literature

Kallol Dasbaksi & Ramendra Narayan Hazra &

Plaban Mukherjee & Malay Mondol & Sushil Nayak

Received: 11 March 2010 /Revised: 19 September 2010 /Accepted: 21 November 2010 /Published online: 31 December 2010# Indian Association of Cardiovascular-Thoracic Surgeons 2010

Abstract We present this rare case of a 24 year old malewho was knocked down by a slowly backing truck whenthe rear wheels climbed on to the right side of the abdomenand on hearing the shouts of people rolled forwards causinga partial run over injury. He was resuscitated and treatedconservatively. An X Ray Chest done 24 h later showedright sided chest wall fracture, right basilar opacitysuggesting chest injury with localized haemothorax/pulmo-nary contusion and a chest tube was inserted through Rt.5th intercostal space. Initially some blood came out. But onthe third day bile was seen coming out of the intercostaldrain prompting a diagnosis of traumatic rupture ofdiaphragm with liver injury. A Magnetic ResonanceImaging (MRI) scan was done when the diagnosis ofruptured right dome of diaphragm with Traumatic Dia-phragmatic Hernia (TDH) with herniation of liver into theright hemithorax was made. Surgical exploration on the 4thday through right thoraco- abdominal approach confirmedTDH with herniated liver into the right hemithorax without

any injury to the liver, hepatic blood vessels or the bile ductsbut an unsuspected rupture in a herniated loop of jejunumwedged into the right hemithorax anterior to the liver withbiliary discharge into the right hemithorax but without anyperitoneal soiling. Repair was done by resection anastomosisof the ruptured jejunum, reduction of the liver into theabdomen, suturing of the torn diaphragm effectively obliter-ating the hernia orifice and reinforcing it with a polypropylenemesh anchored to the chest wall. There was a stormy postoperative phase involving burst thorax which was correctedby re-exploration of the thoracic portion of the thoracoabdominal wound, wound toileting and resutured. The woundhealed after 2 months. The patient is doing well after20 months of follow up.

Keywords Magnetic resonance imaging . Anastomosis .

Hernia

Introduction

The diagnosis and management of Traumatic Diaphragmat-ic Hernias (TDH) still presents a problem. This is due tolack of specificity in clinical signs and chest film findings.Clinical incidence of rupture of the right dome ofdiaphragm due to blunt trauma is much less common(10%) compared to the left (90%) [1] as it is usuallyassociated with more grievous injuries with a very high prehospital mortality [2] thus accounting for a relatively lowclinical diagnosis of right TDH. Among the patients withTDH who require emergency surgery, such is the urgencyto treat other associated injuries that initially 20 to 40% ofboth left and right sided TDH can be missed duringemergency laparotomy for these injuries the operativemortality being 21% [3]. On the other hand TDH is present

K. Dasbaksi : R. N. Hazra : P. MukherjeeDepartment of Thoracic and Cardiovascular Surgery (CTVS),Calcutta National Medical College,Gorachand Road,Kolkata 700014, India

M. Mondol : S. NayakDepartment of Anaesthesiology,Calcutta National Medical College,Gorachand Road,Kolkata 700014, India

K. Dasbaksi (*)23, New Santoshpur 1st Lane, PO: East Jadavpur,Kolkata 700075, Indiae-mail: kalloldb@yahoo.com

Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44DOI 10.1007/s12055-010-0064-2

in 5% of the hospitalized patients admitted with trauma [4].Some of these patients present with respiratory insufficien-cy and may require ventilation [2]. Diagnosis is mostdifficult in patients admitted with haemodynamic stabilitywith spontaneous respiration without any indication ofurgent surgery. The left sided TDH can be suspected bysimple Chest X Ray showing coils of intestine or passage ofa nasogastric tube into a herniated stomach on the left chest.But there is no definite radiological findings of a right sidedblunt TDH diagnosed clinically. Serial chest X Ray to notethe progression of an abnormal chest shadow and a strongsuspicion of TDH to carry out an appropriate scan withComputed Tomograpy (CT)/Magnetic Resonance Imaging(MRI) scan are the effective options to confirm diagnosis.

This report describes a right sided TDH in such a patientof blunt trauma to chest and abdomen caused by partial runover by the rear wheels of a slowly backing truck. Rightbasilar opacification seen in the initial chest X Rays causedby herniated liver was diagnosed as localised haemothoraxor pulmonary contusion and was treated with tubethoracostomy. Biliary discharge a day later through thethoracostomy tube prompted MRI scanning of chest andabdomen when the diagnosis of TDH with herniation of theliver into the right hemithorax with collapse of right lungwas made. Exploration revealed additionally an unsuspect-ed laceration in a herniated loop of jejunum alongside theherniated liver without any hepatic injury. The clinicalpresentation, difficulty in diagnosis, planning of operation,operative findings, post operative complications and clini-cal outcome of such a case is depicted here.

Case report

A 24 year old non alcoholic fully conscious male wasknocked down unaware by a slowly backing medium sizetruck whose rear wheels climbed on to right side of hisabdomen and then hearing the shouts of people, rolledforwards causing a partial run over. The patient was in astate of shock and was resuscitated and stabilized in aperipheral hospital and thereafter transferred to our hospitalon the next day. There was severe pain abdomen after 24 hwhich was relieved with a nasogastric tube which yieldedbilious and gaseous discharge. Apart from some bruisesover the anterior abdominal wall and the lower right thorax,there appeared to be no major injury and the patient washaemodyanamically stable. X Ray of chest done almost24 h after the injury showed fracture of right 5th to 7th ribsposteriorly and right basilar opacification. Spine, pelvis andthe limbs were normal. Abdomen was silent without anydistension. Quadrant punctures were negative. Breathsounds were present in the upper portion of right chestbut absent in lower half. A diagnosis of blunt injury of chest

with right sided localized haemothorax/pulmonary contusion(Fig. 1a) was made and a tube thoracostomy was done in theusual way through a small incision and digital explorationwithout trocar over the right 5th intercostal space on the 2ndday. He was treated conservatively with respiratory physio-therapy, naso gastric suction, intravenous fluids and medi-cations since there was no peristaltic sounds. He washaemodynamically stable maintaining an oxygen saturationof 96 to 97% with nasal oxygen but slightly tachypnoicpresumably due to pain of chest trauma. Initial yield was asmall quantity of blood. However on the 3rd day biliarydischarge started coming out of the tube drain (Fig. 1b). Thebreath sounds had considerably diminished by this time inthe upper half of the right hemithorax. So chest injury withatelectasis of the right lung along with liver injury withbilious collection in the thorax coming through the rupturedright dome of diaphragm was clinically suspected. Anultrasonogrgraphic screening of the chest and abdomenshowed the liver occupying the right hemithorax with littlefluid in the hemithorax. Injury to the liver could not beconfirmed. Since the patient was stable haemodynamically,an MRI was done to image the biliary tree when thediagnosis became clear. There was a right sided diaphrag-matic rupture with herniation of liver into the right hemithorax almost to the apex of the chest cavity with a collapsedlung (Fig. 1c) and although there was no haematoma orgross disruption of the hepatic architecture, we suspected aminor injury to the liver not discernable in the MRI slice toaccount for biliary leakage. Clinically breath sounds by thistime were much reduced in the right chest. Exploration wasdecided through a right thoraco abdominal approach keepingthe heart lung machine as a standby with provision ofhypothermia and Total Circulatory Arrest (TCA) to deal withbleeding from an unsuspected occult injury to the hepaticvein- Inferior Vena Caval (IVC) junction which weapprehended could be present due to high migration of liver.

Right thoraco abdominal incision was made under generalanaesthesia and chest entered through the 5th intercostalsspace. The whole of the right lobe of the liver was in the chestcavity along with biliary soiling from a coil of rupturedjejunum which was found adhered to the herniated liver. Theupper surface of the liver was normal with no evidenceof biliary and vascular of injury. The liver was reducedinto the abdomen when the edges of the diaphragm tornantero posteriorly across the muscular dome was found(Fig. 2a as marked by white arrow head while thefalciform ligament is shown by black arrow and the gallbladder and hepato biliary duct is intact). The right lungwas totally collapsed.

A small segment of gut which was ruptured was resectedand repaired by end to end anastomosis (Fig. 2b). The lungexpanded fully on inflation filling up the chest cavity. Thetorn diaphragmatic leaflets were approximated and closed

40 Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44

in 2 layers using continuous suture of # 1 polypropylene(Fig. 3a) and reinforced with a polypropylene mesh(Fig. 3b) on the pleural surface, fixed to the chest walland medially to the central tendon to prevent recurrentdiaphragmatic hernia as we were skeptical about the vitalityof the repaired muscular diaphragm. An expanded lung andproperly sutured diaphragm automatically stabilized theliver down into its abdominal bed. Rest of the abdominalcontents showed no abnormal findings. The chest and theabdominal wound were closed in the usual fashion afterreconstruction of the costal margin with a chest andabdominal drains. The patient was extubated and faredwell on the 1st Post Operative Day (POD). But hedeveloped sepsis and burst thorax on 4th POD for which

re exploration of thoracic portion of the thoraco abdominalwound and wound toileting was done. The abdominalportion of the wound was normal. There was a period ofchronic pleural discharge through intercostal chest drainwhich was treated conservatively and healed completelywith intensive respiratory physiotherapy after almost2 months and the patient was discharged. He is doing wellafter 20 months of follow up.

Discussion

Diaphragmatic hernia was first described in 1541 bySennertus in an autopsy finding, who in a letter to Hildani

Fig. 1 a X Ray Chest taken24 h after the injury showingbasilar opacification with provi-sional diagnosis of localizedhaemothorax/pulmonary contu-sion with expanded upper rightlung. b showing collection ofbile into the chest drain intro-duced into the right hemithorax.c MRI of chest and abdomenshowing massive herniation ofliver into the right hemithoraxwith collapse of right lung. Twoimages in the bottom also showsthe nasogastric tube in the duo-denum. The white lines havebeen explained in the chapter ofdiscussion of intestinalherniation

Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44 41

described herniation of stomach through a rent in thediaphragmatic dome which had occurred 7 years ago by aself inflicted stab wound [5]. Ambroise Pare in 1579described TDH again as an autopsy finding after a gunshotwound sustained 8 months back in a French artillerycaptain [6]. Most injuries reported involve the left domeof the diaphragm. There are a few reported cases involvingthe right diaphragmatic dome [3, 7–12]. The rarity of rightTDH caused by blunt injuries is due to the cushioningeffect of the liver. The blunt injuries causing right dometear are usually fatal because the force required to rupturethe right dome is massive and cause extensive collateraldamage to other intra abdominal organs, spine, pelvis andgreat vessels with high pre hospital mortality [2, 10].

Generally right sided TDH due to injury by speedingvehicles may be due to primary high energy impact over thethoraco abdominal region with resultant momentary devel-opment of high intra abdominal pressure. Sometimes thereis additional secondary impact caused by speeding wheelsrunning over the abdominal region resulting in very highIAP and resultant TDH and direct crush injuries to severalintra abdominal organs with high mortality. The subject indiscussion had a low energy primary impact by the slowly

backing truck sustained in the upper half of the body whenthe patient was erect. This impact was unlikely to raise theIAP. After he fell down supine on the ground, the rearwheels climbed over the right side of the abdomen beforerolling back causing a partial run over injury. Thissecondary impact by the massive weight of the truckresulted in high IAP causing rupture of the diaphragm withherniation of the liver and the gut into the thorax with organinjury limited only in the gut. A complete run over by thewheels over the abdomen would have caused much severecrush injury.

Other mode of right TDH is penetrating trauma. 11 ofthe 16 cases of right TDH treated and reported by K. Ala-Kulju et al. (1986) [12] 11 were due to penetrating traumawhile only 5 were due to blunt injuries.

Diagnosis of TDH is often delayed because intra abdominalorgans take some time from hours to days to reach through therent in diaphragm the intra thoracic cavity with negative intrapleural pressure as reported by Meyers and McCabe [4] fromHarvard Medical School and Massachusetts General Hospitalin 1993. The same authors stated that pre operative diagnosisof TDH was only possible in 31%. It was diagnosed duringsurgery in only 45%, after surgery in 4.5% and 1.5% duringautopsy. Sirbu et al. [2] from Germany discussed an

Fig. 3 a Suturing of the edges of the diaphragm by #1 polypropylenesotures. b Chest cavity after reconstruction of the costal arch, theunderlying diaphragm was sutured and thereafter reinforced with apolypropylene mesh anchored to the chest wall and the central tendonmedially. A portion of fully expanded right lung can be seen above themesh. The abdominal cavity can be seen on the far right

Fig. 2 a Exploration through Right thoraco abdominal approachshows the torn right hemidiaphragm (white arrow), right lobe of theliver reduced into the abdomen with gall bladder, the left lobe lyingintact on the left of the falciform ligament (black arrow). b gut endsbeing anastomosed after the crushed portion of the small gut adheredto the upper surface of liver staining it with bilious luminal outflowwas resected

42 Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44

interesting case of delayed right TDH, of liver throughdevitalized muscles repaired successfully 10 days after aprevious exploration for repairing a left TDH by anexperienced surgeon in the same patient when the rightdiaphragm was reported to be normal. Hiroaki et al. [8] in1974 reported right sided TDH following blunt trauma inabdomen sustained a year back. Herniation of liver into theright chest could be successfully operated a year later.

Those diagnosed late obviously have major injuriesexcluded and are subjected to investigations only when thechronic symptoms of a slowly growing diaphragmatic herniadevelops over days and weeks before being confirmed. Ourpatient falls in an intermediate category where diagnosis wasmade on the 3rd day after injury when leakage of bile throughthe intercostal drain alerted us to the possibility of TDH whenMRI showed the actual diagnosis. Simple innovations with astraight X Ray of chest available allowed Whitely et al. in1993 [7] to show the outlines of herniated liver in the rightchest cavity caused by a sudden deceleration seat belt injuryin a 4 year old child by instilling diluted barium in the righthemithorax . However X Ray chest is often not diagnosticinitially due to slow passage of abdominal contents throughthe diaphragm as discussed in the previous paragraph andfollow up with serial X Rays is often helpful [3]. The initialchest X Ray in our case (done 1 day after injury) was passedoff as localized haemothorax or pulmonary contusion. Theopacity which was actually caused by herniating liver tillthen had considerable expanded right lung filling the rest ofthe chest cavity on the 2nd day (Fig. 1a). But lung volumewas considerably diminished when MRI was done on the 3rdday showing massive collapse when TDH was diagnosed(Fig. 1c). Unfortunately further chest X Ray was not doneafter MRI confirmation of TDH which would have helpedcomparison.

The loop of intestine was pushed up into the thorax throughthe diaphragmatic tear and got wedged in between the liverand chest wall preventing any abdominal soiling from theruptured segment. Hence no signs of peritonitis was presenteven though there was bilious discharge from ruptured gutwhich was drained out through the intercostal chest tube.Biliary leakage with sepsis also explains post operativethoracic wound disruption when abdominal wound wasnormal. The way the loop of intestine was found to becrushed and adhered to the liver, it appeared to have herniatedinto the thorax and wedged between chest wall and liverbefore being ruptured. A close scrutiny of the MRI plateretrospectively pointed out two images formed by the cut endsof gut just below the right lung (Fig. 1c) and pointed by whiteline markers which was not noticed preoperatively the wholeattention being on the herniated liver and the collapsed lung.Herniated intestinal loops through right TDH has beendescribed [11] but were mostly through stab injuries whencompared to blunt right sided TDH.

We had used polypropylene mesh to reinforce thediaphragmatic repair since we were suspicious about thevitality of the ruptured muscle repaired by simple suturing.Late occurrence of TDH after 10 days through devitalizedmuscles has been reported by Sirbu et al. (2004) [2] whichwas repaired successfully by Gore-Tex-Patch.

Since the liver was pushed up almost to the apex of theright lung, we suspected injury albeit contained in thehepatic vein-IVC junction area though the MRI did notshow any obvious clot or haematoma in that region andkept the heart lung machine ready in the operation room forcardio pulmonary bypass (CPB) to deal with any sucheventuality. Ushijima et al. (2007) [13] had reported the useof CPB with total circulatory arrest and Taga et al. [14]reported veno-venous bypass for repairing hepatic vein andcaval trauma. Although there was no such vascular injury,we believe any such injury with TDH involving highmigration of liver need to be dealt in units which hasprovision of CPB.

Conclusion

We present this rare case of right sided TDH to highlightcertain points associated with management of this patientwho remained haemodynamically stable after resuscitationfor the next 4 days

A. Planning of the operation: through thoraco abdominalroute with the added provision of cardio pulmonarybypass with hypothermia as standby to deal with anyoccult hepatic vein avulsion injury as suspected andtamponaded by high up herniation of liver.

B. Findings of the operation: Unsuspected Ruptured loopof intestine herniated through the diaphragmatic rentwedged in between the liver and chest wall preventingany abdominal soiling with bile while there was biliousdischarge through the intercostals drain.

C. The mechanism of injury: A partial run over injury thewheels stopping short of the abdominal midline isdefinitely rare.

D. Timing of diagnosis: The diagnosis was not animmediate one nor it was inordinately delayed butdeduced logically in each step.

Acknowledgement Colleagues in the Departments of General Surgeryand Radiology, Calcutta National Medical College, Kolkata-700014.

References

1. Brooks JW. Blunt traumatic rupture of diaphragm. Ann ThoracSurg. 1978;26:199–203.

Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44 43

2. Sirbu H, Busch T, Spillner J, Schachtrupp A. Late bilateraldiaphragmatic rupture: challenging diagnostic and surgical repair.Hernia. 2005;9:90–2.

3. Thillois JM, Tremblay B, Cerceau E, et al. Traumatic rupture ofright diaphragm. Hernia. 1998;2:119–21.

4. Meyer BF, McCabe CJ. Traumatic diaphragmatic hernia, occultmarker of serious injury. Ann Surg. 1993;218:783–90.

5. Bosanquet D, Farboud A, Luckraz H. A review of diaphragmaticinjuries. Respir Med CME. 2009;2:1–6.

6. Biswas S, Keddington J. Soft chest wall swelling simulatinglipoma following motor vehicle accident: transdiaphragmaticintercostal hernia. A case report and review of literature. Hernia.2008;12:539–43.

7. Jennifer M, Whitely JM, Cohen RC, Steinberg A. Right sidedtraumatic diaphragmatic hernia in a child a simple technique fordiagnosis. Pediatr Surg Int. 1993;8:427–8.

8. Hiroyuki O, Isao I, Kazuo U, Takeshi Y, Isotoshi Y, Sadaki I. Acase of right sided traumatic diaphragmatic hernia resulting in

progressive respiratory failure. J Jpn Assoc Surg Trauma.2006;20:356–9.

9. Yamamoto H, Taki T, Teramatsu T. Traumatic right sideddiaphragmatic hernia—a case report and review of Japanesecases. Bull Chest Dis Res Inst Kyoto Univ. 1974;7:148–54.

10. Christophi C. Traumatic diaphragmatic hernia: analysis of 63cases. World J Surg. 1983;7:277–80.

11. Bhatia S, Kaushik R, Singh R, et al. Traumatic diaphragmatichernia. Indian J Surg. 2008;70:56–61.

12. Ala-Kulju K, Verkkala K, Ketonen P, Harjola PT. Traumaticrupture of the right hemidiaphragm. Scand J Thorac CardiovascSurg. 1986;20:109–14.

13. Ushijima T, Yachi T, Nishida Y. Successful surgical treatment ofchronic inferior vena caval thrombosis following blunt trauma.Gen Thorac Cardiovasc Surg. 2007;55(6):255–8.

14. Taga S, Ezaki T, Yano K, et al. Hepatic venous injury; a casereport of atriocaval shunt by a centrifugal pump. Hepatogastroen-terology. 1997;44:1219–21.

44 Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:39–44

intensive/critical care, for publication in the forthcoming issues. Authors are also

encouraged to submit review articles on any relevant subject for publication

in the Indian Journal of Thoracic and Cardiovascular Surgery.

Call for papers

The Indian Journal of Thoracic and Cardiovascular Surgery invites Original

articles on cardiac, thoracic and vascular surgery, cardiovascular anesthesia,