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

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

3. Case presentation 32 years old man Construction site worker
Good past health
Admitted for injury on duty
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
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
Patient was transferred directly to operation theatre after intubation
External fixation of pelvis done by O&T colleague
Laparotomy then performed in view of FAST scan finding

8. 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
Diaphragmatic rupture was repaired by non-absorbable monofilament suture in continuous manner
Pelvic packing done

10. 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
Trifoliate shaped central tendon, moving during respiration
Peripheral muscular part attaches to inferior margin of the thoracic cage and lumbar vertebrate
Arterial supply:
-Thoracic surface-Pericardiophrenic and superior phrenic artery
-Abdominal surface- Inferior phrenic artery
Chief muscle of repiration
Peridacrdio phrenic –branch of internal thoracic
Supperior phrenic- thoracic aorta
Inferior phrenic-abdominal aorta

12. Anatomy of diaphragm Central tendon incompletely divided into 3 leaves
close to anterior part of the thorax
Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

13. Central tendon Central tendon incompletely divided into 3 leaves
close to anterior part of the thorax
Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

14. Peripheral muscular part: Sternal part Costal part Lumbar part
Central tendon incompletely divided into 3 leaves
close to anterior part of the thorax
Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

15. Three openings: Caval opening Esophgageal hiatus Aortic hiatus
Central tendon incompletely divided into 3 leaves
close to anterior part of the thorax
Atlas of Human Anatomy 3rd Edition, Frank H. Netter, M.D., Icon Learning Systems

16. Mechanism Penetrating diaphragmatic injury:
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.

17. Blunt diaphragmatic injury:
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

18. Kinetic energy of blunt trauma
Sudden increase in trans-diaphragmatic pleuroperitoneal pressure
Diaphragmatic disruption
transdiaphragmatic migration and herniation of abdominal viscera
Worsen by increase IAP after trauma
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
Right hemi-diaphragm rupture is associated with more severe abdominal injury
Traumatic diaphragmatic hernia. Carter BN, Giuseffi J, Felson B. Am J Roentgenol Radium Ther Nucl Med. Jan 1951;65(1):56-72
The trauma surgeon should be alert to the possibility of encountering multivisceral organ involvement in cases of right hemidiaphragmatic disruptions

20. Presentation
Diaphragmatic injury occurs in ~2-3% of all abdominal injuries
3 clinical phases of diaphragmatic injuries:
-Acute
-Latent
-Obstructive
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. Aug 1974;128(2): [

21. Acute phase
starts at the time of injury and ends with control of bleeding and gastrointestinal spillage
Table 3   -- American Association for the Surgery of Trauma Organ Injury Scale for Diaphragmatic Injuries
GradeDescription
Contusion
Laceration ≤ 2 cm
Laceration 2–10 cmI
Laceration > 10 cm with tissue loss 25 cm2V
Laceration with tissue loss >25 cm2

22. 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
gradual herniation of abdominal contents
Asymptomatic, vague, intermittent abdominal pain and upper gastrointestinal distress or chest discomfort
Intermitttent incarceration of bowel contents
Majority of complication develops after 3 years

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

24. Presentation Diagnosis of diaphragmatic rupture is challenging
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

25. Associated Injuries Lung contusion 44.9% Rib fracture 63.9%
Percentages of patient suffered from diaphragmatic injury has concomitant associated injury
Lung contusion
44.9%
Rib fracture
63.9%
Thoracic aorta
15.4%
Spleen
53.4%
Liver
36.3%
Pelvic fracture
42.5%
This injury pattern reflects the massive thoracoabdominal force required to simultaneously disrupt the pelvic ring and cause a massive increase in the intra-abdominal pressure, leading to disruption of the diaphragm and blunt injury of the aortic wall
Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002
Reiff DA, McGwin G Jr, Metzger J, and others: J Trauma 53:1139, 2002.

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

27. Chest X-ray most commonly performed radiologic study in trauma patient
Allow immediate evaluation in acute phase of diaphragmatic injuries
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
-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
Readily available in most centers
Sensitivity: ~80%
Specificity: ~90%
Old senisivity conventional CT has been reported to vary between 14% and 61% . Due advance in spiral CT scanners and the latest multilayer CT with high spatial resolution, high speed, reduction of artifacts and the ability to get high quality MPR
-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
Intrathoracic visceral herniation
Collar sign , hump sign
Dependent viscera sign
Thickening of the peripheral diaphragm
Disconunity of diaphragmatic : visualized in the axial planes, is more frequently detected in the sagittal images
Collar sing:constriction of the herniated abdominal organs at the site of diaphragm tear produced by diaphragmatic compression
In healthy individuals in supine position, the diaphragm supports the abdominal organs preventing them coming in contact with the posterior chest wall. The dependent viscera sign (sensitivity 52–90%; specificity 71–96) appears on the right side if the upper third of the liver keeps in contact with the posterior ribs and on the left side if the stomach, bowel or spleen lie against the posterior chest wall
herniated viscera are no longer supported posteriorly by the injured diaphragm and fall into a dependent position against the posterior ribs or retroperitoneum
Thickening: rectraction of diaphragm, hemorrhage

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
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
useful in patients who otherwise have no indication for undergoing laparotomy
Be cautious about risk of tension pneumothorax
Abnormal chest radiograph,
Entrance wound inferior to nipple line
Intra-abdominal injuries
High-velocity mechanism
Right-side entrance wound

36. Video-assisted thoracic surgery
High accuracy
Limited use nowadays for diagnostic purpose
Indicated if
the mechanism of injury suggests predominant involvement of the thoracic cavity,
abdominal injuries have been ruled out,
laparoscopy cannot be safely performed
Abnormal chest radiograph,
Entrance wound inferior to nipple line
Intra-abdominal injuries
High-velocity mechanism
Right-side entrance wound

37. Treatment of diaphragmatic injury
Anatomic Location of Injuries
Most suptureat the posterolateral aspect of the diaphragm between the lumbar and intercostal attachments and spread centrally in a radial direction ( Fig. 2 ). In decreasing frequency, ruptures following a transverse and central course occur; least frequently noted are peripheral detachments.
Current Surgical Therapy, 9th Edition,2008, Cameron

38. Treatment of diaphragmatic injury
General principles:
Adequate resuscitation must be performed during peri-operative period
Acute diaphragmatic injury is better approached via laparotomy
Herniated abdominal contents should be carefully reduced via the defect
NG tube passing via the defect can release the negative intra-thoracic pressure
being able to assess and treat any associated abdominal injuries
In general, lateral extensions in a radial fashion are safe for central ruptures, whereas medial and parahiatal defects are best extended anteriorly to avoid phrenic nerve injuries
Mobilization of liver
exploration of the left hemidiaphragm begins by dividing the lienophrenic ligament and mobilization of splenic flexure interiorly
The left hemidiaphragm is exposed by retracting the spleen and body of the stomach medially.

39. Treatment of diaphragmatic injury
General principles:
All identified injuries of the diaphragm should be repaired.
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*
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
Lack of large trial to support outcome and effectiveness
Beneficial for patient without other organ injury and haemo-dynamically stable
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):
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 Sep;16(9): Epub 2002 May 3.
-Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüttl TP, Hatz RA, Schildberg FW. Surg Endosc 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 Sep;16(9): Epub 2002 May 3.

41. Conclusion Diaphragmatic injury is seldom isolated injuries
Diagnosis is difficult, need high suspicion
Left side injury is more common
Diaphragmatic injury can be presented years after injury
Because injuries to the diaphragm are seldom isolated injuries, and in view of the frequent association with severe intracavitary injuries often involving multiple organs, diaphragmatic injuries should also be considered as an occult marker of serious associated injuries. The presence of diaphragmatic rupture therefore demands an aggressive search for concomitant injuries.

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):56-72
-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, 2002
-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

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 60:1280
1289
-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 2012
-Laparoscopic repair of traumatic diaphragmatic hernias. Meyer G, Hüttl 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

45. THANK YOU

47. Ultrasonography
may visualize hydrothorax, large disruptions or herniation
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
High sensitivity
Doubtful use in the acute phase of diaphragmatic injuries

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

50. Anatomy of the phrenic nerve
Anterior branch
Antero-lateral branch
Postero-lateral branch
Posterior branch
The phrenic nerve, running along the posterolateral mediastinum, divides into four branches either at the level of the diaphragm or 1 to 2 cm above it. It gives off an anterior branch toward the sternum, a posterior (crural) branch, and two lateral divisions (anterior and posterolateral)
Current Surgical Therapy, 9th Edition,2008, Cameron 50

51. Prosthetic repairs are performed with expanded polytetrafluoroethylene (ePTFE) mesh