Robotic Repair of a Missed Traumatic Diaphragmatic Injury in a Prior Gastric Bypass Patient With Herniation of the Gastric Remnant.

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.