Diaphragmatic herniation after 3 years of penetrating trauma managed through laparotomy: A case report

Highlights

• •Diaphragmatic rupture is an uncommon trauma complication and it is most associated with blunt trauma.
• •Left diaphragmatic herniations are more common, once the liver is not susceptible to herniate through small perforation right-sided.
• •Chronic diaphragmatic herniation is associated with a higher morbimortality rate.
• •Chronic diaphragmatic herniation may take years to manifest any symptoms, which are not associated with herniated content.

Abstract

Introduction

Diaphragmatic rupture is an uncommon trauma complication and it is associated with chronic diaphragmatic herniation, especially in the left side. Chronic diaphragmatic herniation is usually due to white weapon injury and as consequence of low suspicious and absence of proper investigation.

Case report

We report a chronic diaphragmatic herniation after three years of a stab in the left thoracoabdominal transition, managed through laparotomy.

Discussion

Traumatic diaphragmatic rupture is a rare trauma consequence, most common in the left side. The herniation occurs gradually because of negative pressure of the thoracic cavity that works as a suction of the abdominal organs.

Conclusion

Traumatic diaphragmatic ruptures diagnosis is difficult and might go unnoticed without high suspicious and proper investigation. Chronic herniation is associated with higher morbimortality.

1. Introduction

Diaphragmatic rupture is an uncommon trauma complication. Its evolution to diaphragmatic herniation can be acute or chronic. Blunt trauma is responsible for 75% of the cases, meanwhile the rest is due to penetrating trauma [1,2]. The left side is more commonly involved (80%), once the liver is not susceptible to herniate through small perforations in the right side [3,4]. Diaphragmatic ruptures not initially identified can lead months to years before presenting clinical manifestations of herniation. We report a case of delayed diaphragmatic herniation diagnosis after three years of a cold weapon injury in thoracoabdominal transition, managed through laparotomy by the General Surgery service of a public hospital in the Amazon.

2. Case presentation

A 23-year-old indigenous Brazilian man was admitted at our emergency department brought by local indigenous care group with chief complaint of progressive farts and feces elimination stop, associated to nauseas and postprandial vomiting for two years. He reported a penetrating trauma by a stab in left hemithorax three years earlier evolving in the following months with vomiting, constipation, early satiety, heartburn and halitosis. In the admission, the patient also complained productive cough, hemoptysis and dyspnea. Drug or psychosocial history was not possible to collect once the patient did not speak portuguese fluently, only local dialect.

On examination, the patient was afebrile, acyanotic, anicteric, with sinusal heart beating and pulse of 100 beats per minute, blood pressure of 114/84 mmHg and oxygen saturation of 97%. He was evidently malnourished due to weight loss of 37% of his previous weight (63 Kg to 39 Kg), complaining about abdominal pain in left hypochondrium, left flank and left thoracoabdominal transition. No breathe sounds were detected in the lower third of left chest area. He was also diagnosed with SARS-CoV-2 infection, however there was no manifestation of respiratory symptoms.

Laboratory tests of the admission day revealed normal white blood cells counting, low levels of hemoglobin (6.7 g/dL) and hematocrit of 23.8%. The patient had already realized an Upper Gastrointestinal Endoscopy (EGD) with biopsy which identified erosive esophagitis, antrum and body diaphragmatic herniation and Cameron’s ulcer. It was performed a computed tomography (CT) scan of his thorax, abdomen and pelvis that revealed diaphragmatic herniation of stomach and transverse colon (Fig. 1, Fig. 2).

Fig. 1.

CT topogram showing diaphragmatic herniation in the left side.

Fig. 2.

Axial view of CT showing presence of stomach and transverse colon into the left hemithorax.

He was submitted to exploratory laparotomy with single median incision, under general anesthesia. During the procedure, a six centimeters rupture was identified in the left diaphragmatic dome with irreducible herniation of the gastric body and antrum and also transverse colon (Fig. 3, Fig. 4). A frenotomy was performed to help the reduction of the herniated content, followed by closed chest drainage in the left side under direct view. The diaphragmatic defect was repaired in one layer with prolene 2–0 and U suture. The surgery was performed by Digestive Tract surgeons and General surgeons. After the surgery, he was placed in the post-anesthesia recovery room for one day then moved to the male infirmary.

Fig. 3.

Diaphragmatic rupture in the left side of diaphragm dome.

Fig. 4.

Transverse colon inside the diaphragmatic herniation.

In the post-operative recovery, the patient evolved with improvement of the intestinal obstruction symptoms, reporting no vomiting or abdominal pain. The oral diet was well-accepted and there was no longer early satiety. According to the thorax radiography, thoracic drain was well-positioned (Fig. 5), with 50 mL drainage of serous discharge in the first post-operative day. Laboratory tests done in this period revealed an upgrade of hemoglobin values. The patient was discharged four days after surgery, accepting oral diet and in the absence of all previous symptoms.

Fig. 5.

Thorax radiography showing thoracic drain well-positioned in the left side.

This patient follow-up was difficult due to distance from the capital to his birth town. The isolation and not cooperation of the patient were limiting factors.

3. Discussion

Traumatic diaphragmatic rupture is a rare trauma consequence, frequently unnoticed due to low suspect and proper investigation. The diaphragmatic herniation is defined as abdominal organs displacement to thoracic cavity through the pathological slit originated by the trauma. This condition etiology is more related with blunt trauma than penetrating trauma, associated with only 25% of the cases [2]. In white weapon traumas, the left side is injured 66%–77% of the times, once most of aggressors are right-handed, meanwhile there is an equivalent distribution in firearms traumas [1].

Late presentations and right side herniation is associated with a higher morbimortality [1,5]. Patients with unnoticed diaphragmatic rupture might take months to years to present symptoms of visceral herniation, incarceration, strangulation, obstruction or perforation [2]. The extension of the herniated content in diaphragmatic hernias is not directly related with the symptoms manifested by the patient [6].

The herniation occurs gradually because of negative pressure of the thoracic cavity that works as a suction of the abdominal organs. Long-term diaphragmatic herniation may have a complicated surgical repair due to adhesions between thoracic and abdominal cavity components [4]. Diaphragmatic ruptures originated by penetrating trauma is the leading cause of unnoticed diaphragmatic lesions. The stomach, omentum, colons and liver are the most common abdominal organs herniated [1]. Radiography and CT scan are essential in diagnostic investigation, especially in chronic cases [7]. In this case, a thoracic, abdominal and pelvic CT scan was performed and part of the stomach and transverse colon herniation was identified.

The evolution of diaphragmatic herniation is described in three phases: acute, latent and chronic. According to the American Association for the Surgery of Trauma’s Organ Injury Scaling, classification and description of diaphragmatic lesions goes from contusions to lacerations bigger than 25 cm with tissue loss [8].

The tendency to most cases of diaphragmatic herniation is surgical approach through thoracotomy due to possible adherences of chronic cases. In our case, however, the patient was submitted to laparotomy with supra and infraumbilical incision and there was no difficult dissecting the adhesions. The literature does not show any difference about the closing of the lesions with continuous sutures or separated stitches, although it is recommended the use of unabsorbable thread [1].

Most common complications related to this trauma are bowel obstruction and gastric or intestinal strangulation with ischemia [9]. Pneumonia has been a complication descript in the post-operative, nonetheless our patient evolved without intercurrences. The follow-up of these patients is difficult, especially this one for being an indigenous patient and from a distant city of the Amazonas’ capital.

This case report is being reported in line with the SCARE 2020 criteria [10].

4. Conclusion

Traumatic diaphragmatic ruptures diagnosis is difficult and might evolve to diaphragmatic herniation when unnoticed initially. Chronic herniation symptoms manifestation may take years and it is associated with a higher morbidity and mortality. The high suspicious and proper diagnostic investigation are necessary for the management of traumatic diaphragmatic rupture cases.

Declaration of Competing Interest

Each named author has no conflict of interest, financial or otherwise.

Funding

This paper did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

This study was exempt from ethnical approval.

Consent

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

Author contribution

Carolina Augusta Dorgam Maués: study concept and data collection.

Renato da Silva Galvão: study concept, data collection and data analysis.

Enny Luana Carmo de Vasconcelos: data analysis.

Juan Eduardo Rios Rodriguez: data collection and writing the paper.

Alejandro Luis Bastos Voronaya: study concept.

Gustavo Lopes de Castro: writing the paper and design.

Registration of research studies

Not Applicable.

Guarantor

Renato da Silva Galvão.

Provenance and peer review

Not commissioned, externally peer-reviewed.