Traumatic diaphragmatic hernias in patients with closed chest and abdominal trauma

The OBJECTIVE of the study was the pathomorphological features, diagnosis, and treatment outcomes of diaphragm ruptures in closed trunk trauma.

MATERIALS AND METHODS. We prospectively studied diaphragmatic ruptures in 35 hospitalized patients with blunt trunk trauma and diaphragmatic defects in 9 patients with chronic traumatic diaphragmatic hernia, previously not recognized in other hospitals. Damage severity was assessed using the MFS-D (MI) scale; statistical data were processed using the WinPepi program: calculation of the boundaries of 95 % CI of medium and extensive values using the fisher method.

RESULTS. Diaphragmatic ruptures were observed in 3.25 % of the victims. Damage to the left side occurred 2.4 times more often than the right side; on the left, they were mainly localized in the lumbar and adjacent costal parts. The average length of the rupture of the right half was 13.5, the left half was 9.8 (2-25) cm. More often, the greater omentum, colon, liver and stomach fell into the pleural cavity. During the first day, 2/3 of diaphragm ruptures were diagnosed, mainly during thoracotomy and laparotomy due to bleeding. Missing a rupture of the left half of the diaphragm was allowed at 6 laparotomies. Mortality rate was 31.4 %, the main causes were acute blood loss, severe brain damage; 2 out of 11 deaths were due to a complicated course of an unrecognized diaphragmatic rupture. All patients with chronic diaphragmatic hernia recovered after surgery.

CONCLUSION. Diagnosis of diaphragmatic rupture in severe trunk injury on the first day is difficult, radiation methods: radiography, MSCT, ultrasound are not informative enough. When performing diagnostic studies and abdominal operations, it is necessary to study the diaphragm. Repeated survey radiography and MSCT of the chest during the first three weeks of inpatient treatment of the victim increases the detection of acute traumatic diaphragmatic hernia.

1. Bryusov P. G., Samokhvalov I. M., Petrov A. N. Problems of military field surgery and injury surgery in the program of the 47th World Congress of Surgeons // Military Medical Journal. 2018;339(2):93-96. (In Russ.).

2. Sapozhnikova M. A. Morphology of closed trauma of the chest and abdomen. Moscow, Medicine, 1988;160. (In Russ.).

3. Aliev S. A., Bairamov N. Yu., Aliev E. S. Features of diagnostics and surgical strategy of diaphragmatic rupture in patients with closed chest and abdominal polytrauma. Grekov's Bulletin of Surgery. 2014;173(4):66-72. (In Russ.). Doi: 10.24884/0042-4625-2014-173-4-66-72.

4. Ermolova I. V., Abakumov M. M., Pogodin A. N. et al. Diaphragm Injury in Combined Trauma // XI Congress of Surgeons of the Russian Federation: materials of the Congress. Volgograd: VolGMU Publishing House. 2011:597-598. (In Russ.).

5. Shan R., Sabanathan S., Mearns F. J. Traumatic rupture of diaphragm // Ann. Thorac. Surg. 2008;(60):1444-1449.

6. Losik E. A., Fadeeva M. V., Shchegelsky V. V., Rzaev R. T., Stepanov A. V., Puzakov K. B., Skhirtladze M. R. Asymptomatic Post-Traumatic Rupture of the Right Diaphragm Dome. Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2018;28(4):102-109. (In Russ.). Doi: 10.22416/1382-4376-2018-28-4-102-109.

7. Parshin V. D., Musaev G. K., Mirzoyan O. S., Berikkhanov Z. K., Khetagurov M. Giant posttraumatic diaphragmatic hernia in 17 years after rupture of the diaphragm // Surgery. Journal them. N. I. Pirogov. 2019;(4):56-60. (In Russ.). Doi: 10.17116/hirurgia201904156.

8. Singh S., Kalan M., Moreyra C. Diaphragmatic event // presenting 50 years after traumatic event // Trauma. 2010;(49):156-159.

9. Yermolov A. S., Abakumov M. M., Sokolov V. A., Kartavenko V. I., Galankina I. Ye., Garayev D. A. He structure of hospital mortality in concomitant injury and ways to reduce it // Surgery. Journal them. N. I. Pirogov. 2006;(9):16-20. (In Russ.).

10. Plekhanov A.N. Surgery of traumatic diaphragmatic hernias // Bulletin of surgery im I. I. Grekov. 2012;171(5):107-110. (In Russ.).

11. Plaksin S. A., Petrov M. E., Perminov D. E. Epidemiology and surgical tactics for closed chest trauma // Collection of abstracts of the 5th International Congress «Actual directions of modern cardiothoracic surgery« June 25-27, 2015. SPb., 2015:86-87. (In Russ.).

12. Belokonev V. I., Terekhin A. A., Izmailov E. P., Afanasenko V. P., Katkov S. A. Features of the clinic, tactics and surgical treatment of injuries to the organs of the left subphrenic space // Surgery. Journal them. N. I. Pirogov. 2006;(8):38-42. (In Russ.).