62 - Thoracoplasty: Indications and Surgical Considerations

Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.

Title: General Thoracic Surgery, 6th Edition

Copyright 2005 Lippincott Williams & Wilkins

> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section XII - Thoracic Trauma > Chapter 74 - Diaphragmatic Injuries

Chapter 74

Diaphragmatic Injuries

Panagiotis N. Symbas

Diaphragmatic lacerations may result from penetrating or blunt trauma to this musculotendinous structure that separates the thoracic and abdominal cavities. If the laceration is unrecognized and not promptly repaired, one or more of the abdominal viscera will herniate into the thoracic cavity, with resulting early or late compromise of ventilatory or gastrointestinal function. Immediate herniation is most often associated with a large tear in one of the diaphragmatic leaves, but the symptoms of the herniation usually are obscured by the symptoms of other associated injured organs or structures. Small rents such as those caused by stab wounds rarely are symptomatic early, but if they are not repaired, progressive abdominal visceral herniation occurs because of the pressure gradient between the thoracic and peritoneal cavities. As the herniation of abdominal viscera progresses, the likelihood of ventilatory compromise or of mechanical obstruction, with or without strangulation, of a portion of the contained gastrointestinal tract increases.

Diaphragmatic injuries usually are caused by penetrating or blunt trauma, and rarely they may be due to iatrogenic injury, to spontaneous rupture during pregnancy, or to unexplained spontaneous rupture. They can be separated into two categories: those recognized at the time of initial hospitalization for the evaluation of an episode of trauma and those missed initially and recognized at some time remote from the first hospitalization.

RECOGNITION DURING INITIAL HOSPITALIZATION

The mechanism, symptoms, and other features of blunt and penetrating injuries are dissimilar. Therefore, the initial recognition and management of these two types of injury are best discussed separately.

Blunt Diaphragmatic Trauma

Rupture of a portion of the diaphragm usually results from decelerating injuries suffered in motor vehicle accidents or from falls from great heights. Other crushing injuries to the lower chest or upper abdomen also may result in laceration of the diaphragm. Beal and McKennan (1988) and Simpson and associates (2000) reported incidences of 3% and 3.3%, respectively, of ruptured diaphragm in those patients experiencing severe blunt trauma who survived long enough to be admitted to the hospital.

This rupture most commonly occurs in the left leaf. Contrary to common belief, the right hemidiaphragm is not immune from injury. The ratio of rupture of the left versus the right hemidiaphragm in our experience (1986) was 5:1. Estrera and colleagues (1985) reported a 34% incidence of right-sided rupture. Shah and colleagues (1995), in a collective review of the literature, found rupture of the left diaphragm in 68.5% of cases, the right in 24.2%, bilateral in 1.5%, pericardial in 0.9%, and unclassified in 4.9%. Injuries on the right side are usually posterolateral to the central tendon. The pericardial or central portion of the diaphragm also may be ruptured, and avulsion of the diaphragm from the rib cage infrequently occurs.

Pathology

On the left side, the organs most commonly herniated into the chest are the stomach, spleen, large bowel, liver, small intestine, and omentum. On the right, when herniation occurs, the liver is always present and the colon is occasionally herniated, as Brown and Richardson (1985) reported. Vascular injuries (tears of the juxtahepatic vena cava and hepatic vein injuries) as well as lacerations of the liver frequently are associated with rupture of the right hemidiaphragm.

Symptomatology

Symptoms and signs of diaphragmatic rupture (i.e., respiratory distress, cardiac disturbances, deviated trachea, and bowel sounds in the chest) are present in the minority of patients initially seen after the blunt injury. Most symptoms

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that are present are related to other organ system injuries, such as those to the heart, lungs, or spleen, or are due to the presence of hypovolemic shock.

Radiographic Examinations

Routine radiography of the chest is the most efficient study when the patient is stable enough to have the procedure done. It is abnormal in almost all cases and is diagnostic of rupture in over one-half of the patients. Abnormal radiography results of the chest show an elevated, obscured, or irregular diaphragmatic dome on the side of the visceral herniation. The costophrenic angle is almost always blunted because of contained fluid. With lacerations on the left, one or more air fluid levels and radiolucency in the lower lung field, with or without shifting of the mediastinum away from the side of the hernia, appear (Fig. 74-1). Occasionally, the nasogastric tube can be seen to turn upward into the chest (Fig. 74-2). With right-sided injuries, the right leaf is markedly elevated with or without an associated fluid collection; air fluid levels are less frequently observed. Occasionally, a rounded shadow protruding above the leaf appears on the lateral film, which is highly diagnostic for right-sided rupture (Fig. 74-3). Nondiagnostic findings of a pneumothorax, hydrothorax (hemothorax), or both are also frequently present.

Fig. 74-1. Radiographs of a 30-year-old man after a vehicular accident. A. Frontal view of the chest shows abnormal diaphragmatic silhouette. B. Plain radiograph of the abdomen reveals upward displacement of the transverse colon. From Symbas PN, Vlasis SE, Hatcher C Jr: Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 42:158, 1986. With permission.

Diagnosis

Radiography of the chest may be diagnostic, as noted. In those patients too ill to be moved, Ammann and colleagues (1983) suggested using bedside real-time sonographic examination. In patients not requiring emergency operation, the diagnosis may be confirmed with barium contrast studies of either the upper or lower gastrointestinal tract. Computed tomography, as Heiberg (1980) and Toombs (1981) and their associates reported, can likewise be used to demonstrate the herniation. However, helical computed tomography appears to have greater diagnostic specificity and sensitivity, as reported by Killeen and co-workers (1999). For left diaphragmatic rupture the sensitivity was 78% and specificity 100%, and for the right side sensitivity was 50% and specificity 100%. When right-sided injury is suspected and conditions permit, fluoroscopic examination and radionuclide liver scan, as well as ultrasonography and computed tomography, can be done to delineate the herniated portion of the liver. The use of diagnostic pneumoperitoneum is rarely indicated. In patients requiring emergency operation for control of bleeding or correction of other life-threatening injuries, the diagnosis must be made at operation. Both leaves of the diaphragm, therefore, must be adequately inspected in all patients who are operated on with severe blunt chest and upper abdominal injuries.

Fig. 74-2. A. Radiograph of chest made 12 hours after severe trauma, showing multiple rib fractures and a large gas bubble in the lower portion of the left side of the chest. B. Barium study revealed the large gas shadow to be the stomach, which had herniated through the ruptured diaphragm.

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On rare occasions when the diagnosis cannot be established by the previously mentioned tests and the patient is stable, magnetic resonance (MR) imaging, as reported by E. A. Carter and associates (1996), or video-assisted thoracoscopy, as recorded by Spann (1995) and Lindsey (1997) and their colleagues, establishes the diagnosis.

Role of Thoracoscopy

Thoracoscopy as a tool for the evaluation of chest injuries was first reported by Jackson and Ferreira in 1976. They used a rigid-tube scope in 11 patients, finding two diaphragmatic disruptions. In 1981, Jones and colleagues reported their series of 36 patients. They examined their patients with a rigid tube under local anesthesia. They found that examination in this manner saved 44% of their patients an open procedure. They confirmed no diaphragmatic injury in 4 patients. Ochsner and associates in 1993 reported the first series using a video scope, noting the better visualization and diagnostic capability. Since that time, several authors have confirmed the usefulness of this diagnostic procedure, including Smith (1993), Spann (1995) and Mineo (1999) and their associates.

Fig. 74-3. Chest radiographs of a patient with ruptured right hemidiaphragm and partial herniation of the liver. A. Posteroanterior view suggested only minimal elevation of the right hemidiaphragm. B. Lateral view was fairly impressive. From Estrera A, et al: Blunt traumatic rupture of the right hemidiaphragm: experience in 12 patients. Ann Thorac Surg 39:525, 1985. With permission.

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Treatment

Because of the danger of development of respiratory and even circulatory embarrassment or visceral obstruction, with incarceration or strangulation of the involved portion of the gastrointestinal tract, diaphragmatic injury should be repaired surgically as soon as possible after the diagnosis is established and when the patient's clinical condition permits. Although a diaphragmatic leaf may be best exposed through the chest, the approach chosen should be based on the clinical findings in each patient. Because the major source of massive bleeding is usually a lacerated abdominal viscus, Beal and McKennan (1988) prefer the abdominal approach. During the acute postinjury period, the diaphragmatic injury should be repaired through the incision required for the emergency repair of other organ injuries. In all the patients who were operated on by the author and associates (1986) shortly after the injury, laparotomy was the incision used.

Tears of the left hemidiaphragm are most often repaired through the abdomen because of frequently associated injuries to intraabdominal organs, although in the absence of any symptoms suggesting such injury, a left thoracotomy is adequate. Tears of the right hemidiaphragm, when recognized preoperatively, are best repaired through a right thoracotomy, as Estrera and associates described in 1979. In 1985, however, these authors recommended that the approach be individualized, depending primarily on which cavity (thorax or abdomen) shows continued evidence of bleeding. When injury to the retrohepatic vena cava or hepatic veins is encountered during an abdominal approach, Estrera and associates (1985) recommend extending the incision by a median sternotomy to place a temporary vena cava shunt to control the bleeding.

After control and repair of other associated visceral injuries, the diaphragmatic tear is closed with interrupted figure-of-eight No. 0 nonabsorbable sutures. Prosthetic material is rarely needed in acute blunt trauma injuries. Disruption of the repaired diaphragmatic leaf is rare.

Laparoscopic repair has been successful in selected cases. Martin and colleagues (1998) were able to diagnose both left- and right-sided diaphragmatic injuries but could only repair the left-sided injuries from the abdominal side and suggested thoracoscopy for repair of the right-sided injuries. Goudet and associates (2001) described the use of laparoscopic repair in the lateral position. They limited repair to those patients who did not have an associated splenic injury.

Mortality

The mortality rate may be high in these patients, not as the result of the diaphragmatic injury per se but as the consequence of other severe visceral trauma. The author and associates (1986) reported a 22% mortality in this group of patients. Brooks (1978) and Brown and Richardson (1985) reported rates of 14% and 17%, respectively. Beal and McKennan (1988) reported a mortality of 40.5%. Ninety-seven percent of their patients had associated injuries, and 87% of those who died were in severe hypovolemic shock when admitted to the hospital.

Penetrating Diaphragmatic Injuries

Penetrating diaphragmatic injuries usually result from stab wounds or gunshot wounds of the lower chest (i.e., below the nipples), the upper abdomen (i.e., epigastrium), the flanks, or the back; one-half of the patients treated at our institution (1986) had a wound of the chest below the nipples, but injuries of all other sites of the trunk were associated with a diaphragmatic wound. Injury to either diaphragmatic leaf occurs with almost equal frequency.

Pathology

The diaphragmatic injury is generally small, and herniation of the abdominal viscera into the chest is usually absent early. Only if the injury is missed does late herniation occur because of the different pressures in the two cavities.

Symptomatology

The history and physical examination per se do not indicate diaphragmatic injury. The presence of abdominal complaints or findings in a patient who has sustained a chest wound, however, is strongly suggestive of diaphragmatic injury, as is the presence of chest findings when the site of entrance of the wound is the abdomen or flank. Many patients, however, only have findings associated with the cavity of entrance, and the diaphragmatic injury remains unsuspected until the time of exploration or, unfortunately, is occasionally missed entirely when exploration of either the chest or abdomen was thought not to be indicated. This latter event most often occurs with stab wounds, because patients with gunshot wounds of the trunk usually undergo either emergency abdominal or thoracic exploration.

Radiographic Findings

In 93 instances of penetrating injuries of the diaphragm, Miller and associates (1984) reported the radiograph of the chest to have been normal in 43% and abnormal in 57%. The abnormalities were a hemothorax, pneumothorax, or both in 96% and herniated abdominal contents or pneumoperitoneum in 2% each. The author and associates (1986) found the radiograph results to be normal in one-third of 185 patients with this type of injury.

Diagnosis

A high index of suspicion of the presence of a diaphragmatic injury must be present in all penetrating injuries of the trunk and particularly in those with wounds from the nipple

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line to the umbilicus. Miller and associates (1984), among others, have suggested that all such penetrating injuries, symptomatic or not, should be explored and complete inspection of both leaves of the diaphragm carried out. In their series, 13% of the patients had no associated injuries. The author concurs with this policy for any gunshot wound, but at times a more conservative approach can be used in the management of stab wounds, most of which are explored because of associated symptomatology. In the absence of any findings or suggestion of injury to the diaphragm or any visceral injury, however, exploration may not be mandatory. A few stab wound injuries to the diaphragm will undoubtedly be missed with this approach, possibly as high as 13%, according to Miller and associates' (1984) report. Pneumoperitoneum and abdominal paracentesis generally are of no aid in identifying these missed injuries early, and ultrasonography and computed tomographic examinations are of limited value.

When the diagnosis cannot be established with these tests, and chest radiography shows an otherwise unexplained, persistent abnormality of the diaphragm or the lower lung field or both, laparoscopy, as reported by Ivatury (1992), Lindsey (1997) and Murray (1998) and their co-workers, can be diagnostic. Nel and Warren (1994) reported that video-assisted thoracoscopic techniques reliably diagnose or rule out diaphragmatic injury. In 55 patients with penetrating thoracic injuries, they found that thoracoscopic evaluation was 100% sensitive, 90% specific, and 94% accurate. Freeman (2001) and Martinez (2001) and their associates confirmed this observation.

Treatment

In the absence of intrathoracic organ injury or major intrapleural bleeding, the abdominal approach is always preferred because it permits detection and treatment of nonevident intraabdominal injury and enables the surgeon to examine both diaphragmatic leaflets, which is not possible through a transthoracic approach. Diaphragmatic injuries detected at video-assisted thoracoscopy are repaired through this approach, as reported by Smith and colleagues (1993) and Martinez and associates (2001). Any injury to the diaphragm can be repaired readily with No. 0 nonabsorbable interrupted sutures.

Mortality

Diaphragmatic injury should not cause death. Associated organ injury, however, results in a variable number of deaths. Of 185 patients with penetrating injuries treated at our institution, 4 deaths occurred, a mortality of 2.2%.

LATE RECOGNITION

The initial injury to the diaphragm, from either blunt or penetrating trauma, may be undetected during the patient's first hospitalization and may only become manifest because of symptoms or signs related to a hernia of one or more abdominal viscera into the chest. Although no large body of data is available, it is most likely that more late diaphragmatic hernias result from missed stab wound injuries than from blunt trauma. In a small series reported by Hegarty and colleagues (1978), 22 of 25 late hernias were from previous stab wounds. Nonetheless, many examples of herniation caused by blunt injuries have been observed (Figs. 74-4 and 74-5).

These hernias may be recognized any time from a few weeks to over three or four decades after the original injury. The hernias resulting from blunt trauma tend to be larger, especially those involving the left hemidiaphragm, and to contain multiple abdominal viscera. In order of frequency, as the author and associates (1986) have noted, the stomach, colon, small bowel, omentum, and spleen herniate through a left diaphragmatic traumatic defect, whereas the colon and liver are the most commonly herniating organs through a right defect. Those from penetrating trauma tend to contain only colon or a portion of the stomach, or both.

Symptomatology

The larger hernias are more likely to produce ventilatory signs and symptoms caused by reduction of the lung volume on the side of the hernia. Gastrointestinal problems caused by interference of the normal functioning of the contained viscera may occur also. The smaller hernias that contain only a loop of large bowel or stomach become symptomatic because of partial, and at times complete, obstruction of the contained segment. When complete obstruction occurs, strangulation of the herniated visceral segment may develop and is an ominous complication.

Diagnosis

The diagnosis of traumatic diaphragmatic hernia should be suspected in any patient who has sustained blunt or penetrating trauma of the trunk, particularly of the chest or epigastrium, and in whom chest radiography shows an abnormal diaphragmatic silhouette or lower lung field. The abnormality may include only an obscured or abnormal diaphragmatic shadow, a radiodensity, a radiolucency, or one or more air fluid levels in the lung fields with or without mediastinal shift. The radiographic examination of the chest, however, does not differentiate diaphragmatic hernia from various other conditions that can cause these abnormalities, unless a nasogastric tube has been inserted and is seen in the chest cavity, which indicates the stomach is herniated in the thorax.

The most important studies for the diagnosis are either barium by mouth or a barium enema, as Felson (1973) pointed out. He noted that whichever of the organs is herniated,

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stomach or colon, the point of entry and exit through the torn diaphragmatic leaf is most often through a small single defect. Moreover, the edges of the defect are closely applied to the herniated viscus. Thus, the points of entry and exit are closely applied and constricted. This results in a side-by-side beaklike narrowing of the barium column (Figs. 74-6 and 74-7). B. N. Carter and associates (1951) reported that if the herniated bowel becomes obstructed, the number of beaks is reduced to one, and dilatation proximal to the site of constriction is observed (Fig. 74-8). The obstruction within the hernia is often of the closed loop type, so distention of the loop within the hernia may be great. These authors also noted that the combination of a high left hemidiaphragm and the presence of splenic flexure obstruction is almost diagnostic of a traumatic diaphragmatic hernia.

Fig. 74-4. Chest radiographs of a 46-year-old man who was involved in a car accident 6 years earlier. A. Supine chest radiograph shows radiodensity of the lower left lung field and radiolucency of the upper left field with displacement of the mediastinum. B. Erect frontal view shows two air fluid levels. C. Upper gastrointestinal series and barium enema demonstrate both the stomach and large bowels in the left chest. From Symbas PN, Vlasis SE, Hatcher C Jr: Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 42:158, 1986. With permission.

Other diagnostic studies such as pneumoperitoneum, pneumothorax, and angiography are less rewarding than the

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barium studies. Ultrasonography and computed tomographic studies may be helpful at times but probably less so than in the evaluation of patients thought to have acute injury of the diaphragm.

Fig. 74-5. Traumatic diaphragmatic hernia through the left paracardiac portion of the left hemidiaphragm discovered 15 years after the initial injury. A. Posteroanterior radiograph of chest showing multiple air fluid spaces in the lower one-half of the left chest. B. Lateral radiograph made with the patient in the upright position.

Fig. 74-6. Counterincision breakdown after hiatal hernia repair. Nonobstructive hernia. The medial portion of the diaphragm is visible (vertical arrow). The lovebird sign is well shown (horizontal arrows). From Felson B: Chest Roentgenology. Philadelphia: WB Saunders, 1973, p. 421. With permission.

Thoracoscopy remains an excellent method to diagnose a late diaphragmatic tear. Hartz and associates (1984) first used the video thoracoscopic technique to diagnose pleural ascites in a cirrhotic patient with an 8-year-old right-sided blunt diaphragmatic injury. Koehler and Smith reported two additional late right-sided diaphragmatic injuries in 1994. In 2002, Sattler and colleagues reported on nine patients diagnosed using this method over a 4-year period.

Treatment

Once the hernia is recognized, reduction of the hernia and repair of the diaphragmatic defect through the transthoracic route is indicated. The frequent presence of marked adhesions between the herniated viscus and thoracic contents necessitates this route. In the presence of obstruction, with or without strangulation of the contained viscus, the incarcerated diaphragmatic hernia must be approached by the transthoracic route. After mobilization of the obstructed or strangulated viscus, the abdomen may need to be entered

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through an abdominal incision to complete the necessary operative repair or resection and diversion of the involved viscus. The repair of the diaphragmatic defect is accomplished by direct suture repair in almost all instances. Only rarely in the presence of large tears from original blunt trauma is a prosthetic graft necessary.

Fig. 74-7. Barium enema showing apposition of loops of large bowel herniating into the thorax through a previous stab wound of the diaphragm. From Symbas PN, Vlasis SE, Hatcher C Jr: Blunt and penetrating diaphragmatic injuries with or without herniation of organs into the chest. Ann Thorac Surg 42:158, 1986. With permission.

Fig. 74-8. Obstruction of the distal segment, lateral view. Note the single beak (arrow). The stomach, outlined with barium, is not herniated. The proximal colon shows moderate gaseous distention (arrowhead). From Felson B: Chest Roentgenology. Philadelphia: WB Saunders, 1973, p. 421. With permission.

Video-assisted thoracoscopy and repair has been reported by Koehler and Smith (1994). In 2002, Thoman and colleagues performed a literature search and found 11 case reports of chronic traumatic diaphragmatic hernias repaired laparoscopically. None of the reports noted any complications or recurrences. The average operative time was 98 minutes, and average length of stay was 4.5 days. All reports claimed that there was less postoperative pain and an earlier return to full activity with the laparoscopic approach. In 2003, Matthews and associates reported on 10 patients with chronic traumatic diaphragmatic hernias. Eight could be repaired laparoscopically. Injuries near the esophageal hiatus were best approached through a laparotomy.

Morbidity and Mortality

The morbidity after repair of a diaphragmatic hernia that was recognized late is that seen after any major thoracotomy. The mortality, however, may vary greatly, depending on the status of the hernia at the time of its repair. When the procedure is done electively, the mortality should approach zero. In marked contrast, however, is the excessive mortality experienced in those patients who present with a strangulated, gangrenous viscus in the hernia. In such instances, the mortality may be as high as 80%, as Hegarty and associates (1978) reported. These missed hernias, therefore, must be recognized and repaired before obstruction and gangrene of the contained visceral segment occur.

REFERENCES

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Goudet P, et al: Lateral approach to laparoscopic repair of left diaphragmatic ruptures. World J Surg 25:1150, 2001.

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Reading References

Clay RC, Hanlon CR: Pneumoperitoneum in the differential diagnosis of diaphragmatic hernia. J Thorac Cardiovasc Surg 21:57, 1951.

Ebert PA, Gaertner RA, Zuidema GD: Traumatic diaphragmatic hernia. Surg Gynecol Obstet 125:59, 1967.

Fagan CJ, et al: Traumatic diaphragmatic hernia into the pericardium: verification of diagnosis by computed tomography. J Comput Assist Tomogr 3:405, 1979.

Hood RM: Traumatic diaphragmatic hernia [collective review]. Ann Thorac Surg 12:311, 1971.

Lucido JL, Wall CA: Rupture of the diaphragm due to blunt trauma. Arch Surg 86:989, 1963.

Mansour KA, et al: Diaphragmatic hernia caused by trauma: experience with 35 cases. Am Surg 41:97, 1975.

Nelson JB Jr, et al: Diaphragmatic injuries and posttraumatic hernia. J Trauma 2:36, 1960.

Sutton JP, Carlisle RB, Stephenson SE Jr: Traumatic diaphragmatic hernia: a review of 25 cases. Ann Thorac Surg 3:136, 1967.

Symbas PN: Blunt traumatic rupture of the diaphragm. Ann Thorac Surg 26:193, 1978.