Diaphragmatic injuryDiaphragmatic injurySurgical Grand roundSurgical Grand round

25 January 201425 January 2014

Dr HUI Hon CheungDr HUI Hon CheungPrincess Margaret HospitalPrincess Margaret Hospital

ContentContent

Case PresentationCase Presentation AnatomyAnatomy Presentation and associated injuriesPresentation and associated injuries InvestigationInvestigation TreatmentTreatment ConclusionConclusion

Case presentationCase presentation 32 years old man32 years old man Construction site workerConstruction site worker Good past healthGood past health

Admitted for injury on dutyAdmitted for injury on duty hit by a metallic chain on right side hit by a metallic chain on right side

of body and then fell down from 2 of body and then fell down from 2 meters meters

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

P/E in AED Department:P/E in AED Department:

GCS 15/15GCS 15/15

BP 80/40 P 120/minBP 80/40 P 120/min

Bilateral chest wall tenderness, air entry decreased over Left Bilateral chest wall tenderness, air entry decreased over Left lunglung

Abdomen soft and mild distended, tenderness over upper Abdomen soft and mild distended, tenderness over upper abdomenabdomen

Pelvis appeared deformedPelvis appeared deformed

FAST scan: free fluid inside Morrison pouchFAST scan: free fluid inside Morrison pouch

Xray C-spine NADXray C-spine NAD

X ray pelvisX ray pelvis

CXRCXR

Developed persistent shock even with Developed persistent shock even with initial resuscitationinitial resuscitation

Patient was transferred directly to Patient was transferred directly to operation theatre after intubationoperation theatre after intubation

External fixation of pelvis done by External fixation of pelvis done by O&T colleagueO&T colleague

Laparotomy then performed in view of Laparotomy then performed in view of FAST scan findingFAST scan finding

Intra-op findings:Intra-op findings:- 100ml fresh blood in peritoneal 100ml fresh blood in peritoneal

cavitycavity- Two hepatic lacerations with mild Two hepatic lacerations with mild

oozing oozing - 10cm oblique laceration over Left 10cm oblique laceration over Left

hemi-diaphragmhemi-diaphragm

Oozing from liver was controlled by Oozing from liver was controlled by packingpacking

Diaphragmatic rupture was repaired Diaphragmatic rupture was repaired by non-absorbable monofilament by non-absorbable monofilament suture in continuous mannersuture in continuous manner

Pelvic packing done Pelvic packing done

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

Anatomy of diaphragmAnatomy of diaphragm

Dome-shaped musculo-tendinous partitionDome-shaped musculo-tendinous partition Trifoliate shaped central tendon, moving Trifoliate shaped central tendon, moving

during respirationduring respiration Peripheral muscular part attaches to Peripheral muscular part attaches to

inferior margin of the thoracic cage and inferior margin of the thoracic cage and lumbar vertebratelumbar vertebrate

Arterial supply: Arterial supply: -Thoracic surface-Pericardiophrenic and -Thoracic surface-Pericardiophrenic and

superior phrenic arterysuperior phrenic artery-Abdominal surface- Inferior phrenic artery-Abdominal surface- Inferior phrenic artery

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

Anatomy of diaphragm

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

Central tendon

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

Peripheral muscular part:

Sternal part

Costal part

Lumbar part

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

Three openings:

Caval opening

Esophgageal hiatus

Aortic hiatus

MechanismMechanism

Penetrating diaphragmatic injury:Penetrating diaphragmatic injury: Direct trauma to diaphragm by sharp Direct trauma to diaphragm by sharp

or high energy object (bullet)or high energy object (bullet) Should be readily suspected in any Should be readily suspected in any

penetrating injury to the lower chest, penetrating injury to the lower chest, upper abdomen, or any midtorso- upper abdomen, or any midtorso- traversing injury. traversing injury.

Blunt diaphragmatic injury:Blunt diaphragmatic injury: Blunt force which cause an abrupt Blunt force which cause an abrupt

increase in intra-abdominal pressure increase in intra-abdominal pressure and shear the diaphragmand shear the diaphragm

Patient with history of crush injury, Patient with history of crush injury, high energy trauma or direct impacts high energy trauma or direct impacts on the thoraco-abdominal area on the thoraco-abdominal area

Kinetic energy of blunt Kinetic energy of blunt traumatrauma

Sudden increase in trans-Sudden increase in trans-diaphragmatic diaphragmatic pleuroperitoneal pressurepleuroperitoneal pressure

Diaphragmatic disruptionDiaphragmatic disruption transdiaphragmatic transdiaphragmatic

migration and herniation migration and herniation of abdominal visceraof abdominal viscera

Current Surgical Therapy, 9th Edition,2008, Cameron

Left hemi-diaphragm rupture is more Left hemi-diaphragm rupture is more common than right side due to common than right side due to protective effect of the liverprotective effect of the liver

Right hemi-diaphragm rupture is Right hemi-diaphragm rupture is associated with more severe associated with more severe abdominal injuryabdominal injury

PresentationPresentation

Diaphragmatic injury occurs in ~2-Diaphragmatic injury occurs in ~2-3% of all abdominal injuries3% of all abdominal injuries

3 clinical phases of diaphragmatic 3 clinical phases of diaphragmatic injuries:injuries:

-Acute-Acute

-Latent-Latent

-Obstructive-Obstructive

Acute phaseAcute phase

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

Latent phaseLatent phase

Undiagnosed or untreated diaphragmatic Undiagnosed or untreated diaphragmatic ruptures at the initial exploration enter ruptures at the initial exploration enter the latent phase the latent phase

diaphragmatic muscle starts to retract diaphragmatic muscle starts to retract and begins to atrophy rapidly and begins to atrophy rapidly

gradual herniation of abdominal contents gradual herniation of abdominal contents Asymptomatic, vague, intermittent Asymptomatic, vague, intermittent

abdominal pain and upper gastrointestinal abdominal pain and upper gastrointestinal distress or chest discomfortdistress or chest discomfort

Obstructive phaseObstructive phase

Herniation and strangulationHerniation and strangulation Leading to vascular compromise of Leading to vascular compromise of

the abdominal organs or intestinal the abdominal organs or intestinal obstruction of herniated gut obstruction of herniated gut

Peritonitis, empyema thoraces, Peritonitis, empyema thoraces, sepsissepsis

PresentationPresentation

Diagnosis of diaphragmatic rupture is Diagnosis of diaphragmatic rupture is challengingchallenging

Symptoms and physical findings are non Symptoms and physical findings are non specific and are masked by associated specific and are masked by associated injuries. injuries.

53% of diaphragmatic ruptures caused by 53% of diaphragmatic ruptures caused by blunt injuries and 44% caused by blunt injuries and 44% caused by penetrating injuries have normal clinical penetrating injuries have normal clinical findingsfindings

Associated InjuriesAssociated Injuries

Lung contusionLung contusion 44.9%44.9%

Rib fractureRib fracture 63.9%63.9%

Thoracic aortaThoracic aorta 15.4%15.4%

SpleenSpleen 53.4%53.4%

LiverLiver 36.3%36.3%

Pelvic fracturePelvic fracture 42.5%42.5%

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.

InvestigationInvestigation

Non-invasive- Imaging:Non-invasive- Imaging: **Chest X-ray**Chest X-ray **Computed tomography**Computed tomography UltrasoundUltrasound Contrast studiesContrast studies Magnetic resonance imagingMagnetic resonance imaging

Invasive:Invasive: LaparoscopyLaparoscopy ThoracoscopyThoracoscopy

Chest X-rayChest X-ray

most commonly performed radiologic most commonly performed radiologic study in trauma patientstudy in trauma patient

Allow immediate evaluation in acute Allow immediate evaluation in acute phase of diaphragmatic injuries phase of diaphragmatic injuries

Sensitivity for diaphragmatic ruptureSensitivity for diaphragmatic rupture

with herniation: ~60-90% with herniation: ~60-90%

without herniation: 30~60%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

Specific findings of diaphragmatic Specific findings of diaphragmatic tears on CXR include:tears on CXR include:

- intrathoracic herniation of a hollow intrathoracic herniation of a hollow viscus or visualization of a nasogastric viscus or visualization of a nasogastric tube above the hemidiaphragmtube above the hemidiaphragm

- contralateral shifting of the contralateral shifting of the mediastinum mediastinum

- HemothoraxHemothoraxhttp://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

Computed tomographyComputed tomography

Reliable imaging for Reliable imaging for hemodynamically stable patienthemodynamically stable patient

Readily available in most centersReadily available in most centers

Sensitivity: ~80%Sensitivity: ~80% Specificity: ~90%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

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

diaphragm diaphragm

Discontinuity of hemi-Discontinuity of hemi-diaphragmdiaphragm

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, ItalyEmergency Radiol 2012

Intrathoracic visceral Intrathoracic visceral herniationherniation

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, ItalyEmergency Radiol 2012

Collar signCollar 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, ItalyEmergency Radiol 2012

Dependent viscera signDependent 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, ItalyEmergency Radiol 2012

LaparoscopyLaparoscopy

high accuracy to diagnose occult high accuracy to diagnose occult diaphragmatic rupturediaphragmatic rupture

useful in patients who otherwise useful in patients who otherwise have no indication for undergoing have no indication for undergoing laparotomy laparotomy

Be cautious about risk of tension Be cautious about risk of tension pneumothoraxpneumothorax

Video-assisted thoracic Video-assisted thoracic surgerysurgery

High accuracyHigh accuracy Limited use nowadays for Limited use nowadays for

diagnostic purposediagnostic purpose Indicated if Indicated if 1.1. the mechanism of injury suggests the mechanism of injury suggests

predominant involvement of the thoracic predominant involvement of the thoracic cavity, cavity,

2.2. abdominal injuries have been ruled out, abdominal injuries have been ruled out, 3.3. laparoscopy cannot be safely performed laparoscopy cannot be safely performed

Treatment of diaphragmatic Treatment of diaphragmatic injuryinjury Anatomic Location of Injuries Anatomic Location of Injuries

Current Surgical Therapy, 9th Edition,2008, Cameron

Treatment of diaphragmatic Treatment of diaphragmatic injuryinjury

General principles:General principles: Adequate resuscitation must be performed Adequate resuscitation must be performed

during peri-operative periodduring peri-operative period Acute diaphragmatic injury is better Acute diaphragmatic injury is better

approached via laparotomyapproached via laparotomy Herniated abdominal contents should be Herniated abdominal contents should be

carefully reduced via the defectcarefully reduced via the defect NG tube passing via the defect can release NG tube passing via the defect can release

the negative intra-thoracic pressurethe negative intra-thoracic pressure

Treatment of diaphragmatic Treatment of diaphragmatic injuryinjury

General principles:General principles: All identified injuries of the diaphragm should All identified injuries of the diaphragm should

be repaired. be repaired. Repair starts with aggressive debridement of Repair starts with aggressive debridement of

nonviable tissue nonviable tissue Diaphragmatic rupture is repaired with Diaphragmatic rupture is repaired with

interrupted figure-of-eight or horizontal interrupted figure-of-eight or horizontal mattress sutures of non-absorable size 0 to 2-0 mattress sutures of non-absorable size 0 to 2-0 sutures*sutures*

For large diaphragmatic defect, can consider For large diaphragmatic defect, can consider closure with a running sutureclosure 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

Treatment of diaphragmatic Treatment of diaphragmatic injuryinjury

Laparoscopic repair is becoming an Laparoscopic repair is becoming an alternative for diaphragmatic rupturealternative for diaphragmatic rupture

Lack of large trial to support outcome and Lack of large trial to support outcome and effectivenesseffectiveness

Beneficial for patient without other organ Beneficial for patient without other organ injury and haemo-dynamically stableinjury and haemo-dynamically stable

Mesh can be used if the defect is too Mesh can be used if the defect is too large for primary closure 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.

ConclusionConclusion

Diaphragmatic injury is seldom Diaphragmatic injury is seldom isolated injuriesisolated injuries

Diagnosis is difficult, need high Diagnosis is difficult, need high suspicionsuspicion

Left side injury is more commonLeft side injury is more common Diaphragmatic injury can be Diaphragmatic injury can be

presented years after injury presented years after injury

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

SystemsSystems

-Current Surgical Therapy, 9th Edition,2008, Cameron-Current Surgical Therapy, 9th Edition,2008, Cameron-Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. -Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am JAm JRoentgenol Radium Ther Nucl MedRoentgenol Radium Ther Nucl Med. Jan 1951;65(1):56-72 . Jan 1951;65(1):56-72 -Blunt diaphragmatic and thoracic aortic rupture: an emerging injury -Blunt diaphragmatic and thoracic aortic rupture: an emerging injury

complex.complex.Ann Thorac Surg. 1994 Nov;58(5):1404-8.Ann Thorac Surg. 1994 Nov;58(5):1404-8.-Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. -Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am JAm JSurgSurg. Aug1974;128(2):175-81. . Aug1974;128(2):175-81. -Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002-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-Hanna W, Ferri L, Fata P, Razek T, Mulder D. The current status of traumaticdiaphragmatic injury:diaphragmatic injury:lessons learned from 105 patients over 13 years. Ann Thorac Surg.lessons learned from 105 patients over 13 years. Ann Thorac Surg.2008;85:10442008;85:1044––1048 1048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980),-M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980),pp. 587pp. 587––591591

ReferencesReferences

-J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp.-J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp.1818––2424-Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronal-Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronalreconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451reconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451––457457-Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture.-Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture.AJR 27. 184:24AJR 27. 184:24––30P30P-Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right-Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of righthemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:1280hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:128012891289-Diaphragmatic injuries after blunt trauma: are they still a challenge?,-Diaphragmatic injuries after blunt trauma: are they still a challenge?,GiorgioGiorgio  Bocchini1, FrancoBocchini1, Franco  Guida1, GiacomoGuida1, Giacomo  Sica1, UmbertoSica1, Umberto  Codella1 andCodella1 andMarianoMariano  Scaglione, Department of Diagnostic Imaging, Pineta Grande MedicalScaglione, Department of Diagnostic Imaging, Pineta Grande MedicalCenter, Via Domiziana Km. 30, Castel Volturno, 81030, Italy, Emergency RadiolCenter, Via Domiziana Km. 30, Castel Volturno, 81030, Italy, Emergency Radiol   20122012-Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, H-Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüüttl TP, Hatz RA,ttl TP, Hatz RA,Schildberg FW Surg Endos.2000 Nov;14(11):1010-4.Schildberg FW Surg Endos.2000 Nov;14(11):1010-4.-Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, Harold-Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, HaroldKL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BTKL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BTSurg Endosc. 2003 Feb;17(2):254-8. Epub 2002 Oct 29.Surg Endosc. 2003 Feb;17(2):254-8. Epub 2002 Oct 29.-Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg -Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg Endosc.2002 Sep;16(9):1345-9. Epub 2002 May 3.Endosc.2002 Sep;16(9):1345-9. Epub 2002 May 3.

ReferencesReferences

-The current status of traumatic diaphragmatic injury: lessons learned from -The current status of traumatic diaphragmatic injury: lessons learned from 105 patients105 patients

over 13 years.Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. Ann Thoracover 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.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 -Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223–380C41:223–380C

-Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J TraumaTrauma

52:560–56152:560–561

Ultrasonography Ultrasonography

may visualize hydrothorax, large may visualize hydrothorax, large disruptions or herniation disruptions or herniation

no large series has substantiated its no large series has substantiated its usefulness in the diagnosis of usefulness in the diagnosis of diaphragmatic rupture. diaphragmatic rupture.

Contrast studiesContrast studies

Contrast to detect herniated hollow Contrast to detect herniated hollow viscus in thoracic cavityviscus in thoracic cavity

High sensitivityHigh sensitivity Doubtful use in the acute phase of Doubtful use in the acute phase of

diaphragmatic injuries diaphragmatic injuries

MRIMRI

High sensitivityHigh sensitivity Hypo-intense band on both T1- and Hypo-intense band on both T1- and

T2-weighted sequences T2-weighted sequences Limited use in acute setting since not Limited use in acute setting since not

readily available and long time to readily available and long time to performperform

Current Surgical Therapy, 9th Edition,2008, Cameron

Anterior branch

Antero-lateral branch

Postero-lateral branch

Posterior branch

Anatomy of the phrenic nerve