Tag Archives: diaphragm

Thorax

Delayed Presentation Of Right Diaphragm Injury

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Diaphragm injury from blunt trauma is uncommon, occurring in only a few percent of patients after high-energy mechanisms. They usually occur on the left side and are more frequently seen after t-bone type car crashes and in pedestrians struck by a car.

Blunt diaphragm injury on the right side is very unusual. Even so, it is more easily detected due to obvious displacement of the liver that can be seen on chest x-ray. Blunt injuries on the right side usually result in a large rent in the central tendon or detachment of the diaphragm from the chest wall. This allows the liver to herniate into the chest, and the chest x-ray finding is not subtle.

This image shows an acute herniation of the liver through the diaphragm. Due to the size of the liver, only part of it can typically fit through the rent. Radiologists call this the “cottage loaf” sign. Why? Here’s the bakery item it is named after. Get it now?

Thankfully, most of these injuries are identified in the acute setting. They must be addressed surgically because, if left untreated, more and more of the liver will slowly move into the chest resulting in respiratory problems in the long run.

Acute management usually consists of laparotomy to address both the diaphragm tear and any other associated intra-abdominal injuries. The liver should be reduced by sliding a hand next to it laterally into the chest cavity and pushing the dome downwards. The right triangular ligaments should be taken down (if they are not already destroyed) to mobilize the organ better so the diaphragm laceration can be closed. This is typically accomplished with some type of large (size 0) permanent suture. A chest tube will be needed to evacuate the iatrogenic pneumothorax created by opening the abdomen.

Chronic right diaphragm injuries are a different animal entirely. There is no longer any need to evaluate for intra-abdominal injury, so the procedure is usually performed through the chest. For smaller injuries, thoracoscopic procedures have been described that push the liver downwards and then either suture the diaphragm primarily or (more likely) incorporate a piece of mesh.

Larger injury requires conversion to an open procedure so more muscle power can be used to push the liver downwards to facilitate the repair. However, do not underestimate the adhesions that will be present between diaphragm and liver (and possibly the lung) in long-standing injuries. It may take some time to dissect them away. Rarely, a laparotomy (or laparoscopy) may be needed to assist for very large and complex injuries.

References:

  • Management of Delayed Presentation of a Right-Side Traumatic
    Diaphragmatic Rupture. World J Surg 36:260-265, 2012.
  • Delayed Discovery of Diaphragmatic Injury After Blunt Trauma:
    Report of Three Cases. Surg Today 35:407-410, 2005.
Abdomen

Guidelines For Diagnosis Of Diaphragmatic Injury

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In today’s post, I will review the diaphragmatic injury practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  I will follow this up on Friday with an interesting delayed diaphragm injury case.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly curved, so it does not lend itself well to diagnosis by axial imaging. The addition of sagittal and coronal reconstructions to a thoracoabdominal CT has been helpful but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as a chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious, the patient most assuredly has an operative problem.
  • Thoracoabdominal CT scan – this technology keeps improving, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. Then, they critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoracoabdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left-sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater than the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but it can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends using laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoracoabdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries (stabs and gunshots) are included, and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. Again, it applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. This is because the liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce operation-related mortality and morbidity.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires an operation, such as a right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. However, since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more challenging to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case-by-case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy to repair these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus, and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

Thorax

Delayed Presentation Of Right Diaphragm Injury

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Diaphragm injury from blunt trauma is uncommon, occurring in only a few percent of patients after high energy mechanisms. They usually occur on the left side, and are more frequently seen after t-bone type car crashes and in pedestrians struck by a car.

Blunt diaphragm injury on the right side is very unusual. Even so, it is more easily detected due to obvious displacement of the liver that can be seen on chest x-ray. Blunt injuries on the right side usually result in a large rent in the central tendon, or detachment of the diaphragm from the chest wall. This allows the liver to herniate into the chest, and the chest x-ray finding is not subtle.

This image shows an acute herniation of the liver through the diaphragm. Due to the size of the liver, only part of it can typically fit through the rent. Radiologists call this the “cottage loaf” sign. Why? Here’s the bakery item it is named after. Get it now?

Thankfully, most of these injuries are identified in the acute setting. They must be addressed surgically because, if left untreated, more and more of the liver will slowly move into the chest resulting in respiratory problems in the long run.

Acute management usually consists of laparotomy to address both the diaphragm tear and any other associated intra-abdominal injuries. The liver should be reduced by sliding a hand next to it laterally into the chest cavity and pushing the dome downwards. The right triangular ligaments should be taken down (if they are not already destroyed) to mobilize the organ better so the diaphragm laceration can be closed. This is typically accomplished with some type of large (size 0) permanent suture. A chest tube will be needed to evacuate the iatrogenic pneumothorax created by opening the abdomen.

Chronic right diaphragm injuries are a different animal entirely. There is no longer any need to evaluate for intra-abdominal injury, so the procedure is usually performed through the chest. For smaller injuries, thoracoscopic procedures have been described that push the liver downwards and then either suture the diaphragm primarily or (more likely) incorporate a piece of mesh.

Larger injury requires conversion to an open procedure so more muscle power can be used to push the liver downwards to facilitate the repair. However, do not underestimate the adhesions that will be present between diaphragm and liver (and possibly the lung) in long-standing injuries. It may take some time to dissect them away. Rarely, a laparotomy (or laparoscopy) may be needed to assist for very large and complex injuries.

References:

  • Management of Delayed Presentation of a Right-Side Traumatic
    Diaphragmatic Rupture. World J Surg 36:260-265, 2012.
  • Delayed Discovery of Diaphragmatic Injury After Blunt Trauma:
    Report of Three Cases. Surg Today 35:407-410, 2005.
Guidelines

5 Guidelines For Diaphragmatic Injury

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Today’s post is another review of some of the practice guidelines published by the Eastern Association for the Surgery of Trauma (EAST).  This one covers the evaluation and management of diaphragmatic injury.

Diaphragm injury is a troublesome one to diagnose. It is essentially an elliptical sheet of muscle that is doubly-curved, so it does not lend itself well to diagnosis by axial imaging. Addition of sagittal and coronal reconstructions to a thoraco-abdominal CT has been helpful, but still has a far from perfect diagnostic record.

From an evaluation standpoint, there are several possibilities:

  • Observation – not generally recommended. It is usually combined with imaging such as chest x-ray to see if interval changes occur that would indicate the injury.
  • Chest x-ray – this is not often diagnostic, but when herniation of abdominal contents is obvious the patient most assuredly has an operative problem.
  • Thoraco-abdominal CT scan – this technology keeps getting better, especially with thinner cuts and different planes of reconstruction. Sometimes even subtle injuries can be detected. But this exam is still imperfect.
  • Laparoscopy or thoracoscopy – this technique yields excellent accuracy when the injury is in an area that can be viewed from the operative entry point chosen.
  • Laparotomy or thoracotomy – this is the ultimate choice and should be nearly 100% accurate. It is almost the most invasive and has more potential associated complications.

EAST reviewed a large body of literature and selected 56 pertinent papers for their quality and design. They critically reviewed them and applied a standard methodology to answer several questions.

Here are the questions with the recommendations from EAST, along with my comments:

  • Should laparoscopy or CT be used to evaluate left-sided thoraco-abdominal stab wounds? First, these patients must be hemodynamically stable and not have peritonitis. If either is present, there is no further need for diagnosis; a therapeutic procedure must be performed.
    Left sided diaphragm injuries from stabs are evil. The hole is small, and since the pressure within the abdomen is greater that the chest, things always try to wiggle their way through this small hole. It can remain asymptomatic if the wiggler is just a piece of fat, but can be catastrophic if a bit of the stomach or colon pushes through and becomes strangulated. Furthermore, these holes enlarge over time, so more and more stuff can push up into the chest.
    EAST recommends the use of laparoscopy for evaluation to decrease the incidence of missed injury. However, if the injury is in a less accessible location (posterior), the patient has body habitus issues, or adhesions from previous surgery may lead to incomplete evaluation, laparotomy should be strongly considered.
  • Should operative or nonoperative management be used to evaluate right-sided thoraco-abdominal penetrating wounds? Note that this is different than the last question. All penetrating injuries are included (stabs and gunshots), and this one is for management, not evaluation. And the same caveats regarding hemodynamic stability and peritonitis apply. It applies to both stabs and gunshots.
    Unlike left-sided injuries, right-sided ones are much more benign. The liver keeps anything from pushing up through small holes, and they do not tend to enlarge over time due to this protection. For that reason, EAST recommends nonoperative management to reduce mortality and morbidity related to operation.
  • Should stable patients with acute diaphragm injury undergo repair via an abdominal or thoracic approach? This question applies to any diaphragm injury that requires operation, such as right-sided penetrating injury or any blunt injury. EAST recommends an approach from the abdomen to reduce morbidity and mortality. Since abdominal injury frequently occurs in these cases, an approach from the chest limits the ability to identify and repair abdominal injuries. Otherwise, you may find yourself doing a laparotomy in addition to the thoracotomy.
  • Should patients with delayed visceral herniation through a diaphragm injury undergo repair via an abdominal or thoracic approach?  For years, the preferred approach for delayed presentations has been through the chest because the injury is easier to appreciate and repair.  However, if ischemic or gangrenous viscera are present, it will be more difficult to manage and repair from the chest. EAST does not make a specific recommendation for this question and suggests the surgical approach be determined on a case by case basis.
  • Should patients with an acute diaphragm injury from penetrating injury without concern for other intra-abdominal injuries undergo open or laparoscopic repair? The quality and quantity of data addressing this question were very low, but EAST recommends laparoscopy for repair of these injuries to reduce morbidity and mortality. This includes blunt injuries, which tend to be larger. There were some conversions to an open procedure, especially in the blunt cases. The usual caveats on exposure, injury location, body habitus and previous surgery apply.

Reference: Evaluation and management of traumatic diaphragmatic injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma 85(1):198-207.

Abdomen, Thorax

How To Evaluate A Stab To The Diaphragm – Part 2

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Yesterday I gave a little perspective on the use of CT in assessing the diaphragm after penetrating injury. Today, I’ll break it down into some practical steps you can follow the next time you see one.

Step 1. Stable or unstable? If your patient arrives with unstable vital signs, and there is no other source but the abdomen, the answer is simple. Go to the OR for a laparotomy. Period. They are exsanguinating and the hemorrhage needs to be stopped.

Step 2. Mark the sites of penetration and take a chest x-ray. This will let you evaluate the potential trajectory of the object, and will give you your first glimpse of the diaphragm.

Step 3. Examine the abdomen. Actually, you should be doing this at the same time you are setting up for Step 2. If your patient has peritoneal signs, no further evaluation is needed. Just go to the OR for laparotomy. Look at the chest x-ray once you get there.

Step 4. Right side? If your appreciation of the path of penetration involves just the liver, take the patient to CT for evaluation of chest, abdomen, and pelvis. You need to see all three of these areas to assess for blood and fluid in both body cavities. After the study, if you still think the injury is limited to the liver, admit the patient for observation.

Step 5. Left side? Look at that chest x-ray again. If there are any irregularities at all, strongly consider going to the OR and starting with diagnostic laparoscopy. These irregularities can be glaring, like in the x-ray above. But they can be subtle, like some haziness above the diaphragm or small hemothorax. Obviously, if the injury is as clear as on the x-ray above, just open the abdomen. But if in doubt, start small. And remember my advice on “lunchothorax.”

Step 6. Admit and observe. Check the abdomen periodically, and repeat the chest x-ray daily. If anything changes, consider diagnostic laparoscopy. As a general rule, I don’t keep patients NPO “just in case.” Most will pass this test, and I don’t see a reason to starve my patients for the low likelihood they need to go to the OR.

Step 7. Make sure your patient gets a follow up evaluation. See them in your outpatient clinic, get a final chest x-ray and abdominal exam before you completely clear them.