Diaphragm Trauma(Archived)

The diagnosis of traumatic diaphragm injuries (TDI) can be difficult but is critical, as a delayed diagnosis can carry significant sequelae. TDIs can occur with both penetrating and blunt trauma and are often occult. Patients may vary in their presentation based on the extent and location of injury (right versus left hemidiaphragm), the presence and extent of abdominal viscera displacement, and the presence of other injuries. For this reason, the mechanism of injury (MOI) plays a crucial role in establishing a high index of suspicion for diaphragmatic injuries. The first report of diaphragm herniation was described in 1541, but it wasn't until a few centuries later, in 1853, that Bowditch diagnosed the first antemortem diaphragmatic injury secondary to trauma. The first successful traumatic diaphragm injury repair was completed in 1888. The embryologic development of the diaphragm originates from the septum transversum during the 4th week of gestation. Additional tissue contribution is supplied by the esophageal mesentery, pleuroperitoneal membranes, and chest wall muscle. After development, the diaphragm is conformed into a domelike muscle with a tendinous central septum. It attaches to the sternum, sixth through twelfth ribs, the last thoracic vertebra, and the first three lumbar vertebrae. Its most important function is in respiration, but it also provides a floor for the thoracic cavity and a partition between the abdomen and thorax. It provides additional power with expulsive maneuvers such as defecation and vomiting by contributing to the changes in intra-thoracic and intra-abdominal pressure gradients. The diaphragm is innervated by the phrenic nerve, which originates from the third through fifth cervical roots. The nerve transverses the thorax in the posterolateral mediastinum and branches at the level of the diaphragm. There is a small contribution to the sensory component of the diaphragm along the periphery, which arises anterolaterally from the intercostal innervation. A traumatic diaphragm injury's overall incidence is exceedingly low, but prompt diagnosis is essential, as a missed injury is associated with significant morbidity and mortality (30 to 60%). Morbidity can include anything from organ herniation and strangulation to severe respiratory compromise and even death. Currently, there is no accepted standard in diagnostic modalities that have been shown to accurately and consistently detect the presence of a diaphragm injury. A review of the literature suggests varying reports of the successful use of high-resolution CT versus laparoscopy in early diagnosis. Appropriate management of TDIs is highly dependent on the type of diaphragm injury (blunt versus penetrating), hemodynamic stability, the timing of diagnosis, and the presence of contamination. Blunt injuries tend to be larger and require more in-depth repair, whereas penetrating injuries are usually reapproximated primarily with little difficulty. If patients are hemodynamically unstable, TDI repair may need to wait until a later time when the patient has been fully resuscitated. An acute versus delayed diagnosis dictates the surgical approach, which can vary from an open to minimally invasive abdominal versus thoracic approach. Diaphragm repairs include primary suture repair, prosthetic mesh placement, and in worse cases, diaphragm reconstruction. The type of repair is also partially dependent on whether the diagnosis is acute or delayed. Occasionally, in extreme cases, reconstruction may be required in a staged approach with the use of myocutaneous and rotational muscle flaps to redevelop thoracoabdominal integrity.