Management of penetrating traumatic diaphragm injury

Case presentation

A middle-aged patient was transported to our emergency department after sustaining a self-inflicted stab wound to the chest. The patient had a history of schizophrenia and had discontinued psychiatric follow-up approximately 6 months prior to presentation. After an abrupt escalation of suicidal ideation at home, the patient inflicted a stab wound to the left anterior chest using a kitchen knife. The patient subsequently went to sleep, and about 6 hour later, was found by the patient’s father, who then activated emergency medical services.

On arrival, the patient was alert and oriented. Vital signs were as follows: blood pressure, 118/56 mm Hg; heart rate, 110 beats per minute; oxygen saturation, 98% on room air; and temperature 36.0 °C. Physical examination revealed an approximately 6 cm stab wound on the left anterior chest wall (figure 1). Cardiopulmonary auscultation was unremarkable, and the abdomen was soft with mild diffuse tenderness, but no peritoneal signs. Focused assessment with sonography for trauma (FAST) demonstrated no pericardial effusion.

Figure 1. Photographs obtained on arrival showing an approximately 6 cm stab wound on the left anterior chest wall.

Contrast-enhanced CT of the chest and abdomen revealed a moderate left pneumothorax and pulmonary contusion (figure 2A). Low-density areas were observed along the anterior wall of the gastric body and around the spleen (figure 2B). A continuous low-density tract extending from the left thoracic cavity through the diaphragm into the abdominal cavity was identified, suggesting transdiaphragmatic penetration of the knife (figure 2C).

Figure 2. Contrast-enhanced CT demonstrating a moderate left pneumothorax (arrowheads) and pulmonary contusion (arrow) (A). Low-density areas are seen on the anterior gastric body and around the spleen (arrowheads) (B). Sagittal view shows a continuous low-density tract from the left thoracic cavity to the abdomen (circle) (C).

A left chest tube was placed, resulting in immediate resolution of the pneumothorax without persistent air leakage or hemorrhagic drainage. Given the radiological suspicion of diaphragmatic injury and potential intra-abdominal organ damage, further surgical exploration was required.

What would you do next?

1. Diagnostic laparotomy.

2. Diagnostic thoracotomy.

3. Therapeutic laparoscopic surgery.

4. Therapeutic thoracoscopic surgery.

What we did and why

The patient had stable hemodynamic and respiratory status throughout the initial assessment period. The absence of bloody drainage from the chest tube, consistent vital signs, and negative FAST findings for pericardial effusion made major pulmonary and clinically significant cardiac injuries unlikely. However, the CT findings raised concerns regarding traumatic diaphragmatic injury and associated intra-abdominal organ damage, which are often occult and difficult to diagnose noninvasively. Because the patient was hemodynamically stable without evidence of immediately life-threatening thoracic injury, we proceeded with urgent laparoscopy.

Intraoperatively, a hematoma was observed in the left hemidiaphragm. After evacuation, an approximately 5 cm diaphragmatic defect was visualized and repaired using a combination of continuous and interrupted non-absorbable sutures. Additionally, a 5 mm seromuscular injury on the anterior wall of the mid-gastric body near the lesser curvature was repaired using absorbable sutures. No other intra-abdominal injuries were observed (figure 3).

Figure 3. Laparoscopic findings revealing a left diaphragmatic hematoma; evacuation exposing an approximately 5 cm diaphragmatic defect (A–C). The defect was repaired with non-absorbable sutures (D). A 5 mm seromuscular injury of the anterior gastric body near the lesser curvature was repaired with absorbable sutures; no other intra-abdominal injuries were identified (E, F).

Traumatic diaphragmatic injury (TDI), particularly penetrating thoracic trauma, poses a diagnostic challenge in the absence of diaphragmatic herniation. Although CT is widely used in emergency settings, it has limited sensitivity for small diaphragmatic defects. Importantly, TDI is frequently associated with concomitant intra-abdominal injuries, and a delayed diagnosis may lead to significant morbidity. Therefore, early diagnostic and therapeutic interventions are recommended when TDI is suspected.¹ Traditionally, TDIs have been predominantly managed via laparotomy or thoracotomy. However, evolving evidence and recent guidelines from major trauma societies, including the Eastern Association for the Surgery of Trauma and the World Society of Emergency Surgery, have increasingly supported the laparoscopic management of hemodynamically stable patients.^{2 3} Laparoscopy offers superior visualization of the diaphragm and abdominal organs while minimizing surgical invasiveness, postoperative pain, and recovery time.^{2 3} For laparoscopic repair of diaphragmatic injuries, both interrupted and continuous nonabsorbable suturing techniques have been described.³ In the present case, a combination of continuous and interrupted nonabsorbable sutures was used to achieve secure closure of the approximately 5 cm diaphragmatic defect.

The patient’s consistently stable hemodynamic status combined with reassuring chest tube findings allowed us to consider major thoracic injuries unlikely and proceed safely using a minimally invasive approach. Laparoscopy enabled definitive diagnosis and repair of both the diaphragmatic and gastric injuries, resulting in an uneventful postoperative course and discharge on postoperative day 7. This case suggests that, in selected patients with penetrating thoracic trauma, diagnostic and therapeutic laparoscopy is a valuable and minimally invasive option for managing suspected diaphragmatic injuries, providing both diagnostic accuracy and favorable clinical outcomes.

The views expressed in this article are solely those of the authors.