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Diaphragmatic injury Surgical Grand round 25 January 2014 Dr HUI Hon Cheung Princess Margaret Hospital.

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Presentation on theme: "Diaphragmatic injury Surgical Grand round 25 January 2014 Dr HUI Hon Cheung Princess Margaret Hospital."— Presentation transcript:

1 Diaphragmatic injury Surgical Grand round 25 January 2014 Dr HUI Hon Cheung Princess Margaret Hospital

2 Content Case Presentation Case Presentation Anatomy Anatomy Presentation and associated injuries Presentation and associated injuries Investigation Investigation Treatment Treatment Conclusion Conclusion

3 Case presentation 32 years old man 32 years old man Construction site worker Construction site worker Good past health Good past health Admitted for injury on duty Admitted for injury on duty hit by a metallic chain on right side of body and then fell down from 2 meters hit by a metallic chain on right side of body and then fell down from 2 meters

4 c/o chest wall pain/abdominal pain/pelvic pain c/o chest wall pain/abdominal pain/pelvic pain P/E in AED Department: GCS 15/15 BP 80/40 P 120/min Bilateral chest wall tenderness, air entry decreased over Left lung Abdomen soft and mild distended, tenderness over upper abdomen Pelvis appeared deformed FAST scan: free fluid inside Morrison pouch Xray C-spine NAD

5 X ray pelvis

6 CXR

7 Developed persistent shock even with initial resuscitation Developed persistent shock even with initial resuscitation Patient was transferred directly to operation theatre after intubation Patient was transferred directly to operation theatre after intubation External fixation of pelvis done by O&T colleague External fixation of pelvis done by O&T colleague Laparotomy then performed in view of FAST scan finding Laparotomy then performed in view of FAST scan finding

8 Intra-op findings: Intra-op findings: - 100ml fresh blood in peritoneal cavity - Two hepatic lacerations with mild oozing - 10cm oblique laceration over Left hemi- diaphragm

9 Oozing from liver was controlled by packing Oozing from liver was controlled by packing Diaphragmatic rupture was repaired by non-absorbable monofilament suture in continuous manner Diaphragmatic rupture was repaired by non-absorbable monofilament suture in continuous manner Pelvic packing done Pelvic packing done

10 Patient condition stabilized after the operation and subsequently he was discharged after further management for his pelvic fracture Patient condition stabilized after the operation and subsequently he was discharged after further management for his pelvic fracture

11 Anatomy of diaphragm Dome-shaped musculo-tendinous partition Dome-shaped musculo-tendinous partition Trifoliate shaped central tendon, moving during respiration Trifoliate shaped central tendon, moving during respiration Peripheral muscular part attaches to inferior margin of the thoracic cage and lumbar vertebrate Peripheral muscular part attaches to inferior margin of the thoracic cage and lumbar vertebrate Arterial supply: Arterial supply: -Thoracic surface-Pericardiophrenic and superior phrenic artery -Abdominal surface- Inferior phrenic artery

12 Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems Anatomy of diaphragm

13 Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems Central tendon

14 Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems Peripheral muscular part: Sternal part Costal part Lumbar part

15 Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems Three openings: Caval opening Esophgageal hiatus Aortic hiatus

16 Mechanism Penetrating diaphragmatic injury: Direct trauma to diaphragm by sharp or high energy object (bullet) Direct trauma to diaphragm by sharp or high energy object (bullet) Should be readily suspected in any penetrating injury to the lower chest, upper abdomen, or any midtorso- traversing injury. Should be readily suspected in any penetrating injury to the lower chest, upper abdomen, or any midtorso- traversing injury.

17 Blunt diaphragmatic injury: Blunt force which cause an abrupt increase in intra-abdominal pressure and shear the diaphragm Blunt force which cause an abrupt increase in intra-abdominal pressure and shear the diaphragm Patient with history of crush injury, high energy trauma or direct impacts on the thoraco-abdominal area Patient with history of crush injury, high energy trauma or direct impacts on the thoraco-abdominal area

18 Kinetic energy of blunt trauma Kinetic energy of blunt trauma  Sudden increase in trans- diaphragmatic pleuroperitoneal pressure  Diaphragmatic disruption  transdiaphragmatic migration and herniation of abdominal viscera Current Surgical Therapy, 9th Edition,2008, Cameron

19 Left hemi-diaphragm rupture is more common than right side due to protective effect of the liver Left hemi-diaphragm rupture is more common than right side due to protective effect of the liver Right hemi-diaphragm rupture is associated with more severe abdominal injury Right hemi-diaphragm rupture is associated with more severe abdominal injury

20 Presentation Diaphragmatic injury occurs in ~2-3% of all abdominal injuries Diaphragmatic injury occurs in ~2-3% of all abdominal injuries 3 clinical phases of diaphragmatic injuries: 3 clinical phases of diaphragmatic injuries: -Acute -Acute -Latent -Latent -Obstructive -Obstructive

21 Acute phase starts at the time of injury and ends with control of bleeding and gastrointestinal spillage starts at the time of injury and ends with control of bleeding and gastrointestinal spillage

22 Latent phase Undiagnosed or untreated diaphragmatic ruptures at the initial exploration enter the latent phase Undiagnosed or untreated diaphragmatic ruptures at the initial exploration enter the latent phase diaphragmatic muscle starts to retract and begins to atrophy rapidly diaphragmatic muscle starts to retract and begins to atrophy rapidly gradual herniation of abdominal contents gradual herniation of abdominal contents Asymptomatic, vague, intermittent abdominal pain and upper gastrointestinal distress or chest discomfort Asymptomatic, vague, intermittent abdominal pain and upper gastrointestinal distress or chest discomfort

23 Obstructive phase Herniation and strangulation Herniation and strangulation Leading to vascular compromise of the abdominal organs or intestinal obstruction of herniated gut Leading to vascular compromise of the abdominal organs or intestinal obstruction of herniated gut Peritonitis, empyema thoraces, sepsis Peritonitis, empyema thoraces, sepsis

24 Presentation Diagnosis of diaphragmatic rupture is challenging Diagnosis of diaphragmatic rupture is challenging Symptoms and physical findings are non specific and are masked by associated injuries. Symptoms and physical findings are non specific and are masked by associated injuries. 53% of diaphragmatic ruptures caused by blunt injuries and 44% caused by penetrating injuries have normal clinical findings 53% of diaphragmatic ruptures caused by blunt injuries and 44% caused by penetrating injuries have normal clinical findings

25 Associated Injuries Lung contusion 44.9% Rib fracture 63.9% Thoracic aorta 15.4% Spleen53.4% Liver36.3% Pelvic fracture 42.5% Percentages of patient suffered from diaphragmatic injury has concomitant associated injury Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002.

26 Investigation Non-invasive- Imaging: **Chest X-ray **Chest X-ray **Computed tomography **Computed tomography Ultrasound Ultrasound Contrast studies Contrast studies Magnetic resonance imaging Magnetic resonance imagingInvasive: Laparoscopy Laparoscopy Thoracoscopy Thoracoscopy

27 Chest X-ray most commonly performed radiologic study in trauma patient most commonly performed radiologic study in trauma patient Allow immediate evaluation in acute phase of diaphragmatic injuries Allow immediate evaluation in acute phase of diaphragmatic injuries Sensitivity for diaphragmatic rupture Sensitivity for diaphragmatic rupture with herniation: ~60-90% without herniation: 30~60% -Hanna W, Ferri L, Fata P, Razek T, Mulder D. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85:1044–1048 -M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587–591 -J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 18–24

28 Specific findings of diaphragmatic tears on CXR include: Specific findings of diaphragmatic tears on CXR include: - intrathoracic herniation of a hollow viscus or visualization of a nasogastric tube above the hemidiaphragm - contralateral shifting of the mediastinum - Hemothorax

29 Computed tomography Reliable imaging for hemodynamically stable patient Reliable imaging for hemodynamically stable patient Readily available in most centers Readily available in most centers Sensitivity: ~80% Sensitivity: ~80% Specificity: ~90% Specificity: ~90% -Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451–457 -Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR :24–30P -Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60:1280–1289

30 CT findings of diaphragmatic injury: Discontinuity of hemi-diaphragm Discontinuity of hemi-diaphragm Intrathoracic visceral herniation Intrathoracic visceral herniation Collar sign, hump sign Collar sign, hump sign Dependent viscera sign Dependent viscera sign Thickening of the peripheral diaphragm Thickening of the peripheral diaphragm

31 Discontinuity of hemi-diaphragm Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

32 Intrathoracic visceral herniation Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

33 Collar sign Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

34 Dependent viscera sign Diaphragmatic injuries after blunt trauma: are they still a challenge? Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione1,Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy Emergency Radiol 2012

35 Laparoscopy high accuracy to diagnose occult diaphragmatic rupture high accuracy to diagnose occult diaphragmatic rupture useful in patients who otherwise have no indication for undergoing laparotomy useful in patients who otherwise have no indication for undergoing laparotomy Be cautious about risk of tension pneumothorax Be cautious about risk of tension pneumothorax

36 Video-assisted thoracic surgery High accuracy High accuracy Limited use nowadays for diagnostic purpose Limited use nowadays for diagnostic purpose Indicated if Indicated if 1. the mechanism of injury suggests predominant involvement of the thoracic cavity, 2. abdominal injuries have been ruled out, 3. laparoscopy cannot be safely performed

37 Treatment of diaphragmatic injury Anatomic Location of Injuries Anatomic Location of Injuries Current Surgical Therapy, 9th Edition,2008, Cameron

38 Treatment of diaphragmatic injury General principles: Adequate resuscitation must be performed during peri-operative period Adequate resuscitation must be performed during peri-operative period Acute diaphragmatic injury is better approached via laparotomy Acute diaphragmatic injury is better approached via laparotomy Herniated abdominal contents should be carefully reduced via the defect Herniated abdominal contents should be carefully reduced via the defect NG tube passing via the defect can release the negative intra-thoracic pressure NG tube passing via the defect can release the negative intra-thoracic pressure

39 Treatment of diaphragmatic injury General principles: All identified injuries of the diaphragm should be repaired. All identified injuries of the diaphragm should be repaired. Repair starts with aggressive debridement of nonviable tissue Repair starts with aggressive debridement of nonviable tissue Diaphragmatic rupture is repaired with interrupted figure-of-eight or horizontal mattress sutures of non-absorable size 0 to 2-0 sutures* Diaphragmatic rupture is repaired with interrupted figure-of-eight or horizontal mattress sutures of non-absorable size 0 to 2-0 sutures* For large diaphragmatic defect, can consider closure with a running suture For large diaphragmatic defect, can consider closure with a running suture * -Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223 – 380 -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560 – 561

40 Treatment of diaphragmatic injury Laparoscopic repair is becoming an alternative for diaphragmatic rupture Laparoscopic repair is becoming an alternative for diaphragmatic rupture Lack of large trial to support outcome and effectiveness Lack of large trial to support outcome and effectiveness Beneficial for patient without other organ injury and haemo-dynamically stable Beneficial for patient without other organ injury and haemo-dynamically stable Mesh can be used if the defect is too large for primary closure Mesh can be used if the defect is too large for primary closure -Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüttl TP, Hatz RA, Schildberg FW. Surg Endosc Nov;14(11): Meyer GHüttl TPHatz RASchildberg FWSurg Endosc. -Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT. Surg Endosc Feb;17(2): Epub 2002 Oct 29.Matthews BDBui HHarold KLKercher KWAdrales GPark ASing RF Heniford BTSurg Endosc. -Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg Endosc Sep;16(9): Epub 2002 May 3.Thoman DSHui TPhillips EHSurg Endosc.

41 Conclusion Diaphragmatic injury is seldom isolated injuries Diaphragmatic injury is seldom isolated injuries Diagnosis is difficult, need high suspicion Diagnosis is difficult, need high suspicion Left side injury is more common Left side injury is more common Diaphragmatic injury can be presented years after injury Diaphragmatic injury can be presented years after injury

42 References -Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems -Current Surgical Therapy, 9th Edition,2008, Cameron -Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am J Roentgenol Radium Ther Nucl Med. Jan 1951;65(1): Blunt diaphragmatic and thoracic aortic rupture: an emerging injury complex. Ann Thorac Surg Nov;58(5): Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic hernia. Am J Surg. Aug1974;128(2): Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, Hanna W, Ferri L, Fata P, Razek T, Mulder D. The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. Ann Thorac Surg. 2008;85:1044 – M.L. Waldschmidt, H.L. Laws Injuries of the diaphragm J Trauma, 20 (1980), pp. 587 – 591

43 References -J.H. Payne Jr, A.E. Yellin Traumatic diaphragmatic hernia Arch Surg, 117 (1982), pp. 18 – 24 -Larici AR, Gotway MB, Litt HI et al (2002) Helical CT with sagittal and coronal reconstructions: accuracy for detection of diaphragmatic injury. AJR 179:451 – 457 -Nchimi A, Szapiro D, Ghaye B et al (2005) Helical CT of blunt diaphragmatic rupture. AJR :24 – 30P -Rees O, Mirvis SE, Shanmuganathan K (2005) Multidetector-row CT of right hemidiaphragmatic rupture caused by blunt trauma: a review. Clin Radiol 60: Diaphragmatic injuries after blunt trauma: are they still a challenge?, Giorgio Bocchini1, Franco Guida1, Giacomo Sica1, Umberto Codella1 and Mariano Scaglione, Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno, 81030, Italy, Emergency Radiol Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, H ü ttl TP, Hatz RA, Schildberg FW Surg Endos.2000 Nov;14(11): Laparoscopic repair of traumatic diaphragmatic injuries. Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A, Sing RF, Heniford BT Surg Endosc Feb;17(2): Epub 2002 Oct 29. -Laparoscopic diaphragmatic hernia repair. Thoman DS, Hui T, Phillips EH. Surg Endosc.2002 Sep;16(9): Epub 2002 May 3.

44 References -The current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years.Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. Ann Thorac Surg Mar;85(3): doi: /j.athoracsur Karmy-Jones R, Jurkovich GJ (2004) Blunt chest trauma. Curr Probl Surg 41:223–380C -Anderson DW (2002) Bilateral diaphragm rupture: a unique presentation. J Trauma 52:560–561

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47 Ultrasonography may visualize hydrothorax, large disruptions or herniation may visualize hydrothorax, large disruptions or herniation no large series has substantiated its usefulness in the diagnosis of diaphragmatic rupture. no large series has substantiated its usefulness in the diagnosis of diaphragmatic rupture.

48 Contrast studies Contrast to detect herniated hollow viscus in thoracic cavity Contrast to detect herniated hollow viscus in thoracic cavity High sensitivity High sensitivity Doubtful use in the acute phase of diaphragmatic injuries Doubtful use in the acute phase of diaphragmatic injuries

49 MRI High sensitivity High sensitivity Hypo-intense band on both T1- and T2- weighted sequences Hypo-intense band on both T1- and T2- weighted sequences Limited use in acute setting since not readily available and long time to perform Limited use in acute setting since not readily available and long time to perform

50 Current Surgical Therapy, 9th Edition,2008, Cameron Anterior branch Antero-lateral branch Postero-lateral branch Posterior branch Anatomy of the phrenic nerve

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