Ross Madelyn N, Torres Adolfo A, Anderson Jamie, Munie Semeret, Corsello Jennalee, Nease Darren B
Medical Education, Marshall University Joan C. Edwards School of Medicine, Huntington, USA.
General Surgery, Marshall University Joan C. Edwards School of Medicine, Huntington, USA.
Cureus. 2025 Jan 2;17(1):e76785. doi: 10.7759/cureus.76785. eCollection 2025 Jan.
Traumatic diaphragmatic injuries following blunt or penetrating trauma have a low incidence rate. Symptoms can be obscured by distracting injuries or, in some cases, patients can be asymptomatic, making diagnosis difficult. A 57-year-old female who underwent a robotic Roux-en-Y gastric bypass with a hiatal hernia repair in 2021, presented as an alerted trauma in February 2024 following a motor vehicle accident (MVA). She was an unrestrained driver traveling 35 mph with airbag deployment. During an assessment, it was noted that she had extensive left breast and chest ecchymosis; however, trauma scans were negative. She was admitted for observation and was discharged the next day. Three weeks following the accident, she presented with dull epigastric pain and early satiety, which progressed to dysphagia to solids and significant reflux. Her initial CT scan was concerning a recurrent hiatal hernia. A nasogastric tube was placed and repeat imaging with oral contrast revealed that her gastric remnant had herniated into her chest. Given her recent trauma, there was concern for a missed diaphragmatic injury. The patient was admitted, and the decision was made to perform a robotic reduction and repair of the diaphragmatic hernia on hospital day 3. Intraoperatively, it was noted that her previous hiatal hernia repair was intact and there was a large traumatic defect in the 3 o'clock position of the left hiatus. The excluded gastric remnant and omentum were reduced back into the abdomen and the diaphragmatic defect was repaired primarily. The gastric remnant had multiple areas concerning for devascularization and a subtotal gastric resection was performed. The patient did well after surgery and was discharged home the next day. She regularly follows up with the bariatric clinic and reported doing well with no complaints at her six-month follow-up. This case shows the significance of missed diaphragmatic injuries in trauma, the value of having a high clinical suspicion for injury, and the added complexity of this being a bariatric patient with a previous gastric bypass. It also highlights the successful outcome of a robotic repair.
钝性或穿透性创伤后创伤性膈肌损伤的发生率较低。症状可能被其他损伤掩盖，或者在某些情况下患者可能无症状，这使得诊断困难。一名57岁女性，2021年接受了机器人辅助Roux-en-Y胃旁路术并修复了食管裂孔疝，2024年2月在机动车事故（MVA）后作为创伤患者就诊。她是一名未系安全带的驾驶员，行驶速度为每小时35英里，安全气囊已弹出。评估时发现她左侧乳房和胸部有广泛瘀斑；然而，创伤扫描结果为阴性。她入院观察，第二天出院。事故发生三周后，她出现上腹部隐痛和早饱感，随后发展为固体食物吞咽困难和严重反流。她最初的CT扫描显示有复发性食管裂孔疝。插入了鼻胃管，口服造影剂后的重复成像显示她的胃残端疝入了胸腔。鉴于她近期有创伤史，担心存在漏诊的膈肌损伤。患者入院，决定在住院第3天进行机器人辅助膈肌疝复位和修复术。术中发现她之前的食管裂孔疝修复完好，左裂孔3点钟位置有一个大的创伤性缺损。将疝出的胃残端和大网膜回纳到腹腔，主要修复膈肌缺损。胃残端有多个区域疑似缺血，遂行胃次全切除术。患者术后恢复良好，第二天出院。她定期到减重门诊随访，在六个月的随访中报告情况良好，无任何不适。本病例显示了创伤中漏诊膈肌损伤的重要性、对损伤保持高度临床怀疑的价值，以及作为一名曾接受胃旁路术的减重患者所增加的复杂性。它还突出了机器人修复术的成功结果。
