Gielis Manuel, Bruera Nicolás, Pinsak Agustín, Olmedo Ignacio, Fabián Paez Walter, Viscido German
Department of General Surgery, Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Córdoba PA 5000, Argentina.
Department of General Surgery, Clínica Universitaria Reina Fabiola, Universidad Católica de Córdoba, Córdoba PA 5000, Argentina.
Int J Surg Case Rep. 2022 Apr;93:106910. doi: 10.1016/j.ijscr.2022.106910. Epub 2022 Mar 4.
Traumatic diaphragmatic injuries are rare and usually occur after thoracoabdominal trauma. Most patients will have other potentially life-threatening injuries. High index of suspicion is the most important attribute. Unfortunately, it is incorrectly diagnosed in up to 33% of cases. If left untreated, the onset of complications carries mortality rates between 25 and 80%.
We report a case of an acute diaphragmatic laceration in a 29-year-old male with thoracoabdominal trauma due to a road traffic accident. Physical examination revealed an absence of normal breath sounds in the left hemithorax. CT-scan confirmed a voluminous left diaphragmatic hernia with omental, gastric, and transverse colon content, so surgical intervention was advised. During laparoscopy, a 15 cm long and 5 cm wide diaphragmatic defect was identified. The hernia was reduced laparoscopically, and the defect repaired with interrupted non-absorbable sutures. As a reinforcement, a visceral contact prosthesis was placed. The patient had an uneventful recovery and after 12-month follow-up he has no evidence of recurrence.
Diaphragmatic injuries do not close spontaneously. An abdominal approach is recommended as it allows for evaluation of the entire abdomen and treatment of any associated injury. Watertight closure with nonabsorbable suture and in case of large defects, the placement of a mesh on the peritoneal side of the diaphragm is recommended to reinforce the primary repair.
Laparoscopic emergency surgery has proved to be effective and safe in selected patients with hemodynamic stability. Patients can expect the benefits of minimal invasive surgery with recurrence rate like the open approach.
创伤性膈肌损伤较为罕见，通常发生在胸腹联合创伤后。大多数患者还会有其他可能危及生命的损伤。高度的怀疑指数是最重要的因素。不幸的是，高达33%的病例被误诊。若不治疗，并发症的发生会导致25%至80%的死亡率。
我们报告一例29岁男性因道路交通事故导致胸腹联合创伤后出现急性膈肌撕裂伤的病例。体格检查发现左半胸呼吸音消失。CT扫描证实存在巨大的左侧膈肌疝，疝内容物为网膜、胃和横结肠，因此建议进行手术干预。在腹腔镜检查中，发现一个长15厘米、宽5厘米的膈肌缺损。通过腹腔镜将疝内容物回纳，并用间断不可吸收缝线修复缺损。作为加强措施，放置了一个内脏接触假体。患者恢复顺利，经过12个月的随访，没有复发迹象。
膈肌损伤不会自行闭合。建议采用腹部入路，因为这样可以评估整个腹部并治疗任何相关损伤。建议用不可吸收缝线进行水密缝合，对于大的缺损，建议在膈肌的腹膜侧放置补片以加强初次修复。
对于血流动力学稳定的特定患者，腹腔镜急诊手术已被证明是有效且安全的。患者可以期待微创手术的益处，且复发率与开放手术相当。
