Intraoperative tension pneumothorax during laparoscopic cholecystectomy as a presentation of delayed traumatic diaphragmatic hernia: a case report

Abstract

Background

Traumatic diaphragmatic hernia (TDH) may present months to years after blunt injury and can mimic biliary or pulmonary disease. Right-sided TDH is particularly prone to delayed recognition because partial hepatic herniation may be overlooked unless the diaphragm is specifically reviewed.

Case presentation

A 45-year-old woman with a remote motor-vehicle collision developed right-sided tension pneumothorax with hemodynamic collapse at the start of laparoscopic cholecystectomy at another hospital; a chest tube and cardiopulmonary resuscitation were required and the operation was aborted. Fourteen months later, she presented to our institution with recurrent right-upper-quadrant pain. A targeted re-review of serial prior CT images demonstrated a hepatic collar sign along the right hemidiaphragm, consistent with hepatic herniation through a traumatic diaphragmatic defect. Cholecystectomy was deferred and urgent thoracoscopic repair was performed the same day. The patient recovered uneventfully and remained asymptomatic at 7-year follow-up.

Conclusions

Unexplained tension pneumothorax during laparoscopy may be a sentinel event of delayed TDH. Targeted CT re-review with attention to diaphragm-specific signs may help avoid inappropriate abdominal surgery and enable timely definitive repair.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-026-04363-8.

Background

Traumatic diaphragmatic injury is uncommon and can be overlooked at the time of initial blunt thoracoabdominal trauma. A missed tear may enlarge over time and present later as a traumatic diaphragmatic hernia, sometimes months to years after the inciting event [1–3]. Delayed right-sided herniation is particularly challenging because the liver can temporarily buttress the defect and herniation may be intermittent, leading to nonspecific abdominal symptoms and diagnostic delay [1, 4].

Computed tomography (CT) is the key diagnostic test. Reported CT signs include diaphragmatic discontinuity, organ herniation with a collar (constriction) sign, and the dependent viscera sign [5, 6]. On the right, hepatic herniation may produce additional findings such as the hump and band signs, which can improve recognition when specifically sought [7, 8].

We report a patient in whom tension pneumothorax during an attempted laparoscopic cholecystectomy at another hospital preceded the diagnosis of delayed right-sided TDH. Focused re-review of prior and current imaging revealed a hepatic collar sign and prompted immediate definitive thoracoscopic repair.

This case report was prepared in accordance with the SCARE 2025 checklist [9].

Case presentation

A 45-year-old woman was referred for evaluation of recurrent right-upper-quadrant pain and perioperative risk after a previous episode of intraoperative tension pneumothorax during attempted laparoscopic cholecystectomy.

Three years earlier, she had been involved in a motor-vehicle collision and underwent whole-body trauma CT at a tertiary trauma center. Multiple rib fractures, hemothorax, liver injury, and lower-extremity injury were documented, consistent with substantial blunt thoracoabdominal trauma. No diaphragmatic injury was recognized at that time.

Fourteen months before presentation to our institution, she was subsequently evaluated at other institutions for right-upper-quadrant pain and was diagnosed with presumed acute cholecystitis based on abdominal CT and ERCP. Laparoscopic cholecystectomy was attempted. At the beginning of the procedure, she developed right-sided tension pneumothorax with hemodynamic collapse. A chest tube was placed, cardiopulmonary resuscitation was performed, and the operation was aborted. Subsequent evaluation for pneumothorax did not identify a diaphragmatic injury, and she remained clinically stable after discharge.

After discharge, she sought evaluation at a tertiary university hospital, where no immediate surgical indication was identified, and she remained clinically stable. Over the following months, however, she continued to experience intermittent abdominal pain and subsequently presented to our institution. Abdominal CT and ERCP were again performed as part of the evaluation for presumed biliary disease. Because of the prior intraoperative pneumothorax, thoracic surgery consultation was requested during preoperative assessment. Review of all available chest radiographs and CT scans, including those from the initial trauma evaluation and subsequent hepatobiliary episodes, demonstrated persistent right hemidiaphragmatic abnormality. On serial CT images, hepatic indentation/herniation compatible with a hepatic collar sign was identifiable from the initial trauma evaluation through the later hepatobiliary evaluations (Fig. 1).

Fig. 1.

Chronologic imaging findings.(A) Whole body Trauma CT obtained after the initial motor-vehicle collision shows subtle abnormal contour along the right hemidiaphragm and hepatic dome, retrospectively suggestive of occult right diaphragmatic injury. (B) Coronal abdominal CT obtained during the first hepatobiliary evaluation for presumed acute cholecystitis shows a more conspicuous abnormal right diaphragmatic/hepatic contour with focal hepatic indentation, suspicious for a hepatic collar sign. (C) Chest radiograph obtained during attempted laparoscopic cholecystectomy at an outside hospital demonstrates marked right-sided tension pneumothorax with surgical instruments visible. Retrospectively, a curvilinear lucency was noted adjacent to the abnormal right hemidiaphragmatic/hepatic contour. (D) Coronal CT reviewed during thoracic surgical consultation demonstrates hepatic herniation through the right hemidiaphragm with a hepatic collar sign, leading to the diagnosis of delayed right-sided traumatic diaphragmatic hernia

The chronological clinical course is summarized in Table 1.

Table 1.

Chronological clinical course and delayed recognition of traumatic diaphragmatic hernia

Time point	Clinical event and interpretation
October 2014	Major blunt trauma from a motor vehicle accident; whole-body CT performed. Right diaphragmatic/hepatic contour abnormality was not recognized at the time
January 2016	First hepatobiliary episode: RUQ pain evaluated as presumed acute cholecystitis at outside institutions. Abdominal CT and ERCP were performed
February 2016	Laparoscopic cholecystectomy attempted; tension pneumothorax with hemodynamic collapse occurred. Chest tube placement, CPR, and abortion of the operation were required
After February 2016	Evaluation for pneumothorax did not identify a diaphragmatic defect, and the patient remained clinically stable
March-April 2017	Recurrent right-upper-quadrant pain led to a second hepatobiliary evaluation, including abdominal CT and ERCP Subsequent preoperative consultation led to focused re-review of prior and current images
April 2017	Focused re-review of available imaging identified delayed right-sided TDH with hepatic herniation; cholecystectomy was deferred, and thoracoscopic repair was performed
Postoperative follow-up	Serial clinical and radiologic follow-up showed no recurrence At 7-year follow-up, the patient remained asymptomatic

Based on these findings, cholecystectomy was deferred, and definitive thoracoscopic repair of the diaphragmatic defect was performed the same day.

A thoracoscopic approach was chosen because this was a delayed right-sided presentation with suspected intrathoracic adhesions and hepatic herniation. Video-assisted thoracoscopy confirmed herniation of the right hepatic lobe through an approximately 6-cm defect in the right hemidiaphragm (Fig. 2). After reduction of the herniated liver, the defect margins were soft, pliable, and viable, without significant tissue loss, friability, or contamination. Mesh reinforcement had been prepared preoperatively and was considered intraoperatively; however, it was not used because the lesion was considered a traumatic diaphragmatic tear rather than a tissue-loss defect, and tension-free primary closure was achievable. The defect was repaired using interrupted nonabsorbable sutures (Video 1).

Fig. 2.

Thoracoscopic views. (A) Hepatic herniation through an approximately 6-cm right diaphragmatic defect in the central tendon. (B) After reduction, the defect was closed primarily with interrupted sutures. Video 1 shows the operative sequence

The postoperative course was uneventful, and she was discharged without respiratory complications. Follow-up chest CT at approximately 3 months showed no recurrence, and subsequent clinical and radiologic follow-up showed no evidence of recurrent diaphragmatic hernia. At 7-year follow-up, she remained asymptomatic.

Discussion and conclusions

Delayed traumatic diaphragmatic hernia can manifest with nonspecific gastrointestinal or respiratory symptoms and may remain unrecognized for months to years after the initial injury [1–4]. Right-sided defects are particularly prone to delayed recognition because hepatic herniation may be intermittent and early imaging findings can be subtle [4].

The present case demonstrates that right-sided traumatic diaphragmatic injury may remain unrecognized despite repeated imaging evaluations. In retrospect, a hepatic collar sign was identifiable on the initial trauma CT and on CT scans obtained during both hepatobiliary episodes that were treated as presumed acute cholecystitis. The diagnostic delay was likely related to the right-sided location, partial hepatic herniation, and the presence of an alternative hepatobiliary diagnosis that directed clinical attention away from the diaphragm.

The episode of intraoperative tension pneumothorax during the attempted laparoscopic cholecystectomy was a critical warning sign. Pneumothorax is an uncommon but potentially life-threatening complication of laparoscopic procedures, and several reports describe tension pneumothorax occurring during laparoscopic cholecystectomy [10–13]. Retrospectively, the combination of prior substantial blunt thoracoabdominal trauma, serial imaging abnormalities along the right diaphragmatic/hepatic contour, and unexplained pneumothorax during laparoscopy represented an opportunity for earlier recognition of occult diaphragmatic injury. Thoracic surgical evaluation should be considered when a diaphragmatic defect is suspected.

In our patient, the most plausible mechanism is that pneumoperitoneum during laparoscopy increased intra-abdominal pressure, allowing insufflated CO₂ to traverse the pre-existing diaphragmatic defect into the pleural space. The resulting rapid accumulation of intrapleural gas likely led to tension pneumothorax. On retrospective review, the intraoperative chest radiograph showed right-sided tension pneumothorax with a curvilinear lucency adjacent to the abnormal right hemidiaphragmatic/hepatic contour (Fig. 1). Although nonspecific, this finding may be interpreted as a supportive radiographic clue in the context of the intraoperative event. Because the acute event occurred at another hospital and no intraoperative images were available from the attempted laparoscopic cholecystectomy, the proposed mechanism should be interpreted as a clinicoradiologic inference.

A key turning point was focused re-review of available prior and current imaging with attention to the right hemidiaphragm. CT remains the key diagnostic modality, but this case emphasizes that delayed right-sided TDH may be overlooked unless the diaphragm is specifically reviewed in the appropriate clinical context, particularly when serial right diaphragmatic or hepatic contour abnormalities are present.

In this delayed right-sided case, a thoracoscopic approach was selected because the herniated organ was the right hepatic lobe and chronic intrathoracic adhesions were anticipated. This route allowed direct visualization of the pleural cavity, adhesiolysis, and safe reduction of the herniated liver under thoracoscopic view. After reduction, the diaphragmatic defect was clearly exposed, and the margins were viable and pliable. The repair strategy was determined not by defect size alone but also by tissue quality, tissue loss, contamination, and the feasibility of tension-free approximation [14, 15]. Although the defect measured approximately 6 cm, there was no tissue loss or contamination, and tension-free approximation was achievable; therefore, primary repair with interrupted nonabsorbable sutures was performed without mesh reinforcement.

When patients present with biliary-type symptoms, prior thoracoabdominal trauma, or unexplained intraoperative pneumothorax during laparoscopy, delayed TDH should remain in the differential diagnosis. Targeted re-review of prior imaging studies with attention to diaphragm-specific signs may help avoid inappropriate abdominal surgery and enable timely definitive repair.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CT

computed tomography

TDH

traumatic diaphragmatic hernia

Author contributions

JY conceived the report and performed the surgery. SR and CY revised the manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable for this single-patient case report.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.