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Diaphragmatic injury

Diaphragmatic injury. Surgical Grand round 25 January 2014 Dr HUI Hon Cheung Princess Margaret Hospital. Content. Case Presentation Anatomy Presentation and associated injuries Investigation Treatment Conclusion. Case presentation. 32 years old man Construction site worker

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Diaphragmatic injury

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  1. Diaphragmatic injury Surgical Grand round 25 January 2014 Dr HUI Hon Cheung Princess Margaret Hospital

  2. Content Case Presentation Anatomy Presentation and associated injuries Investigation Treatment Conclusion

  3. Case presentation 32 years old man Construction site worker Good past health Admitted for injury on duty hit by a metallic chain on right side of body and then fell down from 2 meters

  4. c/o chest wall pain/abdominal pain/pelvic pain P/E in AED Department: GCS 15/15 BP 80/40 P 120/min Bilateral chest wall tenderness, air entry decreased over Left lung Abdomen soft and mild distended, tenderness over upper abdomen Pelvis appeared deformed FAST scan: free fluid inside Morrison pouch Xray C-spine NAD

  5. X ray pelvis

  6. CXR

  7. Developed persistent shock even with initial resuscitation Patient was transferred directly to operation theatre after intubation External fixation of pelvis done by O&T colleague Laparotomy then performed in view of FAST scan finding

  8. Intra-op findings: • 100ml fresh blood in peritoneal cavity • Two hepatic lacerations with mild oozing • 10cm oblique laceration over Left hemi-diaphragm

  9. Oozing from liver was controlled by packing Diaphragmatic rupture was repaired by non-absorbable monofilament suture in continuous manner Pelvic packing done

  10. Patient condition stabilized after the operation and subsequently he was discharged after further management for his pelvic fracture

  11. Anatomy of diaphragm Dome-shaped musculo-tendinous partition Trifoliate shaped central tendon, moving during respiration Peripheral muscular part attaches to inferior margin of the thoracic cage and lumbar vertebrate Arterial supply: -Thoracic surface-Pericardiophrenic and superior phrenic artery -Abdominal surface- Inferior phrenic artery

  12. Anatomy of diaphragm Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

  13. Central tendon Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

  14. Peripheral muscular part: Sternal part Costal part Lumbar part Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

  15. Three openings: Caval opening Esophgageal hiatus Aortic hiatus Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

  16. Mechanism Penetrating diaphragmatic injury: Direct trauma to diaphragm by sharp or high energy object (bullet) Should be readily suspected in any penetrating injury to the lower chest, upper abdomen, or any midtorso- traversing injury.

  17. Blunt diaphragmatic injury: Blunt force which cause an abrupt increase in intra-abdominal pressure and shear the diaphragm Patient with history of crush injury, high energy trauma or direct impacts on the thoraco-abdominal area

  18. Kinetic energy of blunt trauma Sudden increase in trans-diaphragmatic pleuroperitoneal pressure Diaphragmatic disruption transdiaphragmatic migration and herniation of abdominal viscera Current Surgical Therapy, 9th Edition,2008, Cameron

  19. Left hemi-diaphragm rupture is more common than right side due to protective effect of the liver Right hemi-diaphragm rupture is associated with more severe abdominal injury

  20. Presentation Diaphragmatic injury occurs in ~2-3% of all abdominal injuries 3 clinical phases of diaphragmatic injuries: -Acute -Latent -Obstructive

  21. Acute phase starts at the time of injury and ends with control of bleeding and gastrointestinal spillage

  22. Latent phase Undiagnosed or untreated diaphragmatic ruptures at the initial exploration enter the latent phase diaphragmatic muscle starts to retract and begins to atrophy rapidly gradual herniation of abdominal contents Asymptomatic, vague, intermittent abdominal pain and upper gastrointestinal distress or chest discomfort

  23. Obstructive phase Herniation and strangulation Leading to vascular compromise of the abdominal organs or intestinal obstruction of herniated gut Peritonitis, empyema thoraces, sepsis

  24. Presentation Diagnosis of diaphragmatic rupture is challenging Symptoms and physical findings are non specific and are masked by associated injuries. 53% of diaphragmatic ruptures caused by blunt injuries and 44% caused by penetrating injuries have normal clinical findings

  25. Associated Injuries • Percentages of patient suffered from diaphragmatic injury has concomitant associated injury Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002.

  26. Investigation Non-invasive- Imaging: **Chest X-ray **Computed tomography Ultrasound Contrast studies Magnetic resonance imaging Invasive: Laparoscopy Thoracoscopy

  27. Chest X-ray most commonly performed radiologic study in trauma patient Allow immediate evaluation in acute phase of diaphragmatic injuries Sensitivity for diaphragmatic rupture with herniation: ~60-90% without herniation: 30~60% -Hanna W, Ferri L, Fata P, Razek T, Mulder D. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85:1044–1048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587–591 -J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 18–24

  28. Specific findings of diaphragmatic tears on CXR include: intrathoracic herniation of a hollow viscus or visualization of a nasogastric tube above the hemidiaphragm contralateral shifting of the mediastinum Hemothorax http://westjem.com/images/diaphragmatic-rupture-secondary-to-blunt-thoracic-trauma.html http://list.mistral.net/pipermail/trauma-list/attachments/20060524/e959b160/CXR2003-1-0001.jpg

  29. Computed tomography Reliable imaging for hemodynamically stable patient Readily available in most centers Sensitivity: ~80% Specificity: ~90% -Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451–457 -Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR 27. 184:24–30P -Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:1280–1289

  30. CT findings of diaphragmatic injury: Discontinuity of hemi-diaphragm Intrathoracic visceral herniation Collar sign , hump sign Dependent viscera sign Thickening of the peripheral diaphragm

  31. Discontinuity of hemi-diaphragm Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1 ,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

  32. Intrathoracic visceral herniation Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1 ,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

  33. Collar sign Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1 ,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

  34. Dependent viscera sign Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1 ,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

  35. Laparoscopy high accuracy to diagnose occult diaphragmatic rupture useful in patients who otherwise have no indication for undergoing laparotomy Be cautious about risk of tension pneumothorax

  36. Video-assisted thoracic surgery High accuracy Limited use nowadays for diagnostic purpose Indicated if the mechanism of injury suggests predominant involvement of the thoracic cavity, abdominal injuries have been ruled out, laparoscopy cannot be safely performed

  37. Treatment of diaphragmatic injury Anatomic Location of Injuries Current Surgical Therapy, 9th Edition,2008, Cameron

  38. Treatment of diaphragmatic injury General principles: Adequate resuscitation must be performed during peri-operative period Acute diaphragmatic injury is better approached via laparotomy Herniated abdominal contents should be carefully reduced via the defect NG tube passing via the defect can release the negative intra-thoracic pressure

  39. Treatment of diaphragmatic injury General principles: All identified injuries of the diaphragm should be repaired. Repair starts with aggressive debridement of nonviable tissue Diaphragmatic rupture is repaired with interrupted figure-of-eight or horizontal mattress sutures of non-absorable size 0 to 2-0 sutures* For large diaphragmatic defect, can consider closure with a running suture *-Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223–380 -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560–561

  40. Treatment of diaphragmatic injury Laparoscopic repair is becoming an alternative for diaphragmatic rupture Lack of large trial to support outcome and effectiveness Beneficial for patient without other organ injury and haemo-dynamically stable Mesh can be used if the defect is too large for primary closure -Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüttl TP, Hatz RA, Schildberg FW. Surg Endosc. 2000 Nov;14(11):1010-4. -Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT. Surg Endosc. 2003 Feb;17(2):254-8. Epub 2002 Oct 29. -Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg Endosc. 2002 Sep;16(9):1345-9. Epub 2002 May 3.

  41. Conclusion Diaphragmatic injury is seldom isolated injuries Diagnosis is difficult, need high suspicion Left side injury is more common Diaphragmatic injury can be presented years after injury

  42. References -Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems -Current Surgical Therapy, 9th Edition,2008, Cameron -Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am J Roentgenol Radium Ther Nucl Med. Jan 1951;65(1):56-72 -Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg. 1994 Nov;58(5):1404-8. -Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg. Aug1974;128(2):175-81. -Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002 -Hanna W, Ferri L, Fata P, Razek T, Mulder D. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85:1044–1048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587–591

  43. References -J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 18–24 -Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451–457 -Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR 27. 184:24–30P -Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:1280 1289 -Diaphragmatic injuries after blunt trauma: are they still a challenge?, GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione, Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy, Emergency Radiol2012 -Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüttl TP, Hatz RA, Schildberg FW Surg Endos.2000 Nov;14(11):1010-4. -Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT Surg Endosc. 2003 Feb;17(2):254-8. Epub 2002 Oct 29. -Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg Endosc.2002 Sep;16(9):1345-9. Epub 2002 May 3.

  44. References -The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years.Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. Ann Thorac Surg. 2008 Mar;85(3):1044-8. doi: 10.1016/j.athoracsur.2007.10.084. -Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223–380C -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560–561

  45. THANK YOU

  46. Ultrasonography may visualize hydrothorax, large disruptions or herniation no large series has substantiated its usefulness in the diagnosis of diaphragmatic rupture.

  47. Contrast studies Contrast to detect herniated hollow viscus in thoracic cavity High sensitivity Doubtful use in the acute phase of diaphragmatic injuries

  48. MRI High sensitivity Hypo-intense band on both T1- and T2-weighted sequences Limited use in acute setting since not readily available and long time to perform

  49. Anatomy of the phrenic nerve Anterior branch Antero-lateral branch Postero-lateral branch Posterior branch Current Surgical Therapy, 9th Edition,2008, Cameron

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