Zierold D, Perlstein J, Weidman E R, Wiedeman J E
Department of Surgery, David Grant Medical Center, 101 Bodin Cir, Travis Air Force Base, CA 94535, USA.
Arch Surg. 2001 Jan;136(1):32-7. doi: 10.1001/archsurg.136.1.32.
Recent use of minimally invasive techniques to evaluate the chest and abdomen in patients with penetrating thoracoabdominal trauma has led to the discovery of many occult diaphragm injuries. Surgical repair of these injuries is relatively straightforward. However, diagnosis can be difficult, and the natural history of these injuries is controversial. By developing a penetrating diaphragm injury model, the ultrasonographic characteristics and natural history of this injury can be better understood.
Surgical laboratory of a tertiary care hospital.
Seven pigs (Sus scrofa), weighing between 55 and 80 kg, received a 3-cm right-sided (n = 3) or left-sided (n = 4) diaphragm injury via thoracoscopy.
Thoracoabdominal x-ray and ultrasonographic examinations were performed preoperatively; at 2, 4, 8, and 12 weeks postoperatively; and when symptoms related to the diaphragm injury occurred. At 12 weeks, or at the time of earlier death, a postmortem thoracoabdominal examination was performed.
x-Ray and ultrasonographic characteristics, and evidence of wound healing, in a penetrating diaphragm injury model.
Perioperative recovery occurred in all pigs. No pigs had radiographic evidence of immediate postoperative herniation. Pigs in the right-sided injury group died early (</=10 days postoperatively). At the time of death, x-ray and ultrasonographic examination revealed hollow viscus herniation into the thorax (n = 2). Pigs in the left-sided injury group remained asymptomatic, without radiographic evidence of herniation, although subtle ultrasonographic signs of diaphragm injury were seen at the 2-week (n = 2), 4-week (n = 2), and 8-week (n = 3) intervals. Postmortem examination of the right-sided injury group revealed the liver afforded no protection against herniation. Right-sided defects (n = 3) did not change size or character despite small-bowel herniation. Conversely, the left hemidiaphragm was well protected by the relatively fixed liver, spleen, and large stomach. The 4 left-sided defects (100%) spontaneously healed.
We developed a penetrating diaphragm injury model with high and low risk of herniation. Ultrasonography may prove to be an important diagnostic adjunct in evaluating diaphragm injuries with and without herniation. Moreover, since the "protected" diaphragm injuries in our model healed spontaneously, a role may exist for the nonoperative treatment of diaphragm injuries in clinical practice. This pig model may prove useful in further defining future management and repair techniques for such injuries.
近期采用微创技术评估穿透性胸腹联合伤患者的胸腹部情况，已发现许多隐匿性膈肌损伤。对这些损伤进行手术修复相对简单直接。然而，诊断可能困难，且这些损伤的自然病程存在争议。通过建立穿透性膈肌损伤模型，可更好地了解该损伤的超声特征及自然病程。
一家三级护理医院的外科实验室。
7头体重在55至80千克之间的猪（野猪），通过胸腔镜造成右侧（n = 3）或左侧（n = 4）3厘米的膈肌损伤。
术前、术后2周、4周、8周和12周以及出现与膈肌损伤相关症状时进行胸腹X线和超声检查。术后12周或更早死亡时，进行尸检胸腹检查。
穿透性膈肌损伤模型中的X线和超声特征以及伤口愈合证据。
所有猪围手术期恢复良好。无猪术后立即出现影像学证据显示的疝形成。右侧损伤组的猪早期死亡（术后≤10天）。死亡时，X线和超声检查显示有中空脏器疝入胸腔（n = 2）。左侧损伤组的猪无症状，无疝形成的影像学证据，尽管在术后2周（n = 2）、4周（n = 2）和8周（n = 3）时可见膈肌损伤的细微超声征象。对右侧损伤组进行尸检发现肝脏对疝形成无保护作用。尽管有小肠疝入，右侧缺损（n = 3）大小和特征未改变。相反，左侧半膈肌受到相对固定的肝脏、脾脏和大胃的良好保护。4处左侧缺损（100%）自发愈合。
我们建立了一个疝形成风险有高有低的穿透性膈肌损伤模型。超声检查可能被证明是评估有无疝形成的膈肌损伤的重要辅助诊断方法。此外，由于我们模型中“受保护”的膈肌损伤自发愈合，临床实践中对膈肌损伤进行非手术治疗可能有一定作用。该猪模型可能有助于进一步明确此类损伤未来的处理和修复技术。
