Diaphragmatic injurySurgical Grand round25 January 2014

Dr HUI Hon CheungPrincess Margaret Hospital

ContentCase PresentationAnatomyPresentation and associated injuriesInvestigationTreatmentConclusion

Case presentation32 years old manConstruction site workerGood past health

Admitted for injury on dutyhit by a metallic chain on right side of body and then fell down from 2 meters

c/o chest wall pain/abdominal pain/pelvic pain

P/E in AED Department:GCS 15/15BP 80/40 P 120/minBilateral chest wall tenderness, air entry decreased over Left lungAbdomen soft and mild distended, tenderness over upper abdomenPelvis appeared deformed

FAST scan: free fluid inside Morrison pouchXray C-spine NAD

X ray pelvis

CXR

Developed persistent shock even with initial resuscitationPatient was transferred directly to operation theatre after intubationExternal fixation of pelvis done by O&T colleagueLaparotomy then performed in view of FAST scan finding

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

Oozing from liver was controlled by packingDiaphragmatic rupture was repaired by non-absorbable monofilament suture in continuous mannerPelvic packing done

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

Anatomy of diaphragmDome-shaped musculo-tendinous partitionTrifoliate shaped central tendon, moving during respirationPeripheral muscular part attaches to inferior margin of the thoracic cage and lumbar vertebrateArterial supply: -Thoracic surface-Pericardiophrenic and superior phrenic artery-Abdominal surface- Inferior phrenic artery

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

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

Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning SystemsPeripheral muscular part:Sternal partCostal partLumbar part

Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning SystemsThree openings:Caval openingEsophgageal hiatusAortic hiatus

MechanismPenetrating 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.

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

Kinetic energy of blunt traumaSudden increase in trans-diaphragmatic pleuroperitoneal pressureDiaphragmatic disruptiontransdiaphragmatic migration and herniation of abdominal visceraCurrent Surgical Therapy, 9th Edition,2008, Cameron

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

PresentationDiaphragmatic injury occurs in ~2-3% of all abdominal injuries3 clinical phases of diaphragmatic injuries: -Acute -Latent -Obstructive

Acute phasestarts at the time of injury and ends with control of bleeding and gastrointestinal spillage

Latent phaseUndiagnosed 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

Obstructive phaseHerniation and strangulationLeading to vascular compromise of the abdominal organs or intestinal obstruction of herniated gut Peritonitis, empyema thoraces, sepsis

PresentationDiagnosis of diaphragmatic rupture is challengingSymptoms 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

Associated InjuriesPercentages of patient suffered from diaphragmatic injury has concomitant associated injuryReiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002.

Lung contusion44.9%Rib fracture63.9%Thoracic aorta15.4%Spleen53.4%Liver36.3%Pelvic fracture42.5%

InvestigationNon-invasive- Imaging:**Chest X-ray**Computed tomographyUltrasoundContrast studiesMagnetic resonance imaging

Invasive:LaparoscopyThoracoscopy

Chest X-raymost commonly performed radiologic study in trauma patientAllow immediate evaluation in acute phase of diaphragmatic injuries Sensitivity for diaphragmatic rupturewith 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;85:10441048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587591-J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 1824

Specific findings of diaphragmatic tears on CXR include:intrathoracic herniation of a hollow viscus or visualization of a nasogastric tube above the hemidiaphragmcontralateral shifting of the mediastinum Hemothorax

Computed tomographyReliable imaging for hemodynamically stable patientReadily 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 179:451457-Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR 27. 184:2430P-Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:12801289

CT findings of diaphragmatic injury:Discontinuity of hemi-diaphragmIntrathoracic visceral herniation Collar sign , hump signDependent viscera sign Thickening of the peripheral diaphragm

Discontinuity of hemi-diaphragmDiaphragmatic injuries after blunt trauma: are they still a challenge? GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, ItalyEmergency Radiol2012

Intrathoracic visceral herniationDiaphragmatic injuries after blunt trauma: are they still a challenge? GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, ItalyEmergency Radiol2012

Collar signDiaphragmatic injuries after blunt trauma: are they still a challenge? GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, ItalyEmergency Radiol2012

Dependent viscera signDiaphragmatic injuries after blunt trauma: are they still a challenge? GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, ItalyEmergency Radiol2012

Laparoscopyhigh accuracy to diagnose occult diaphragmatic ruptureuseful in patients who otherwise have no indication for undergoing laparotomy Be cautious about risk of tension pneumothorax

Video-assisted thoracic surgeryHigh accuracyLimited use nowadays for diagnostic purposeIndicated if the mechanism of injury suggests predominant involvement of the thoracic cavity, abdominal injuries have been ruled out, laparoscopy cannot be safely performed

Treatment of diaphragmatic injuryAnatomic Location of Injuries Current Surgical Therapy, 9th Edition,2008, Cameron

Treatment of diaphragmatic injuryGeneral principles:Adequate resuscitation must be performed during peri-operative periodAcute diaphragmatic injury is better approached via laparotomyHerniated abdominal contents should be carefully reduced via the defectNG tube passing via the defect can release the negative intra-thoracic pressure

Treatment of diaphragmatic injuryGeneral 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 41:223380 -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560561

Treatment of diaphragmatic injuryLaparoscopic repair is becoming an alternative for diaphragmatic ruptureLack of large trial to support outcome and effectivenessBeneficial for patient without other organ injury and haemo-dynamically stableMesh can be used if the defect is too large for primary closure -Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Httl 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.

ConclusionDiaphragmatic injury is seldom isolated injuriesDiagnosis is difficult, need high suspicionLeft side injury is more commonDiaphragmatic injury can be presented years after injury

References-Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon LearningSystems-Current Surgical Therapy, 9th Edition,2008, Cameron-Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am JRoentgenol 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 JSurg. 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 traumaticdiaphragmatic injury:lessons learned from 105 patients over 13 years. Ann Thorac Surg.2008;85:10441048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980),pp. 587591

References-J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp.1824-Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronalreconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451457-Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture.AJR 27. 184:2430P-Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of righthemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:12801289-Diaphragmatic injuries after blunt trauma: are they still a challenge?,GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 andMarianoScaglione, Department of Diagnostic Imaging, Pineta Grande MedicalCenter, Via Domiziana Km. 30, Castel Volturno, 81030, Italy, Emergency Radiol2012-Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Httl TP, Hatz RA,Schildberg FW Surg Endos.2000 Nov;14(11):1010-4.-Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, HaroldKL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BTSurg 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.

References-The current status of traumatic diaphragmatic injury: lessons learned from 105 patientsover 13 years.Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. Ann ThoracSurg. 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 41:223380C-Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma52:560561

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

Contrast studiesContrast to detect herniated hollow viscus in thoracic cavityHigh sensitivityDoubtful use in the acute phase of diaphragmatic injuries

MRIHigh sensitivityHypo-intense band on both T1- and T2-weighted sequences Limited use in acute setting since not readily available and long time to perform

Current Surgical Therapy, 9th Edition,2008, CameronAnterior branchAntero-lateral branchPostero-lateral branchPosterior branchAnatomy of the phrenic nerve

*Chief muscle of repirationPeridacrdio phrenic branch of internal thoracicSupperior phrenic- thoracic aortaInferior phrenic-abdominal aorta*Central tendon incompletely divided into 3 leavesclose to anterior part of the thorax*Central tendon incompletely divided into 3 leavesclose to anterior part of the thorax*Central tendon incompletely divided into 3 leavesclose to anterior part of the thorax*Central tendon incompletely divided into 3 leavesclose to anterior part of the thorax*Worsen by increase IAP after trauma*Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am J Roentgenol Radium Ther Nucl Med. Jan 1951;65(1):56-72

The trauma surgeon should be alert to the possibility of encountering multivisceral organ involvement in cases of right hemidiaphragmatic disruptions *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. Aug 1974;128(2):175-81. [ *Table 3 --American Association for the Surgery of Trauma Organ Injury Scale for Diaphragmatic InjuriesGradeDescriptionContusionLaceration 2 cmLaceration 210 cmILaceration > 10 cm with tissue loss 25 cm2VLaceration with tissue loss >25 cm2*Intermitttent incarceration of bowel contents

Majority of complication develops after 3 years*This injury pattern reflects the massive thoracoabdominal force required to simultaneously disrupt the pelvic ring and cause a massive increase in the intra-abdominal pressure, leading to disruption of the diaphragm and blunt injury of the aortic wall

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;85:10441048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587591-J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 1824

*Old senisivity conventional CT has been reported to vary between 14% and 61% . Due advance in spiral CT scanners and the latest multilayer CT with high spatial resolution, high speed, reduction of artifacts and the ability to get high quality MPR *Disconunity of diaphragmatic : visualized in the axial planes, is more frequently detected in the sagittal images

Collar sing:constriction of the herniated abdominal organs at the site of diaphragm tear produced by diaphragmatic compression

In healthy individuals in supine position, the diaphragm supports the abdominal organs preventing them coming in contact with the posterior chest wall. The dependent viscera sign (sensitivity 5290%; specificity 7196) appears on the right side if the upper third of the liver keeps in contact with the posterior ribs and on the left side if the stomach, bowel or spleen lie against the posterior chest wall

herniated viscera are no longer supported posteriorly by the injured diaphragm and fall into a dependent position against the posterior ribs or retroperitoneum

Thickening: rectraction of diaphragm, hemorrhage*Diaphragmatic injuries after blunt trauma: are they still a challenge?GiorgioBocchini1, FrancoGuida1, GiacomoSica1, UmbertoCodella1 and MarianoScaglione1Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, ItalyEmergency Radiol2012*Abnormal chest radiograph, Entrance wound inferior to nipple lineIntra-abdominal injuriesHigh-velocity mechanismRight-side entrance wound*Abnormal chest radiograph, Entrance wound inferior to nipple lineIntra-abdominal injuriesHigh-velocity mechanismRight-side entrance wound

*Most suptureat the posterolateral aspect of the diaphragm between the lumbar and intercostal attachments and spread centrally in a radial direction ( Fig. 2 ). In decreasing frequency, ruptures following a transverse and central course occur; least frequently noted are peripheral detachments. *being able to assess and treat any associated abdominal injuries

In general, lateral extensions in a radial fashion are safe for central ruptures, whereas medial and parahiatal defects are best extended anteriorly to avoid phrenic nerve injuries

Mobilization of liver

exploration of the left hemidiaphragm begins by dividing the lienophrenic ligament and mobilization of splenic flexure interiorly The left hemidiaphragm is exposed by retracting the spleen and body of the stomach medially. *Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Httl 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.

*Because injuries to the diaphragm are seldom isolated injuries, and in view of the frequent association with severe intracavitary injuries often involving multiple organs, diaphragmatic injuries should also be considered as an occult marker of serious associated injuries. The presence of diaphragmatic rupture therefore demands an aggressive search for concomitant injuries. *The phrenic nerve, running along the posterolateral mediastinum, divides into four branches either at the level of the diaphragm or 1 to 2 cm above it. It gives off an anterior branch toward the sternum, a posterior (crural) branch, and two lateral divisions (anterior and posterolateral) Prosthetic repairs are performed with expanded polytetrafluoroethylene (ePTFE) mesh