Diaphragmatic Injuries

Herniation of abdominal viscera into the chest through a traumatic rent in the diaphragm was first described by Sennertus in 1541. At necropsy, the stomach of a man who had received a stab wound seven months previously was found to have herniated into the left chest. Bowditch (1853) reported the first case of traumatic diaphragmatic hernia to be diagnosed ante mortem in the USA. He enumerated five criteria for establishing the diagnosis: (1) Prominence and immobility of the left thorax. (2) Displacement to the right of the area of cardiac dullness. (3) Absent breath sounds in the left chest. (4) Presence of bowel sounds in the chest. (5) Hyperresonance in the chest. In earlier days the finding of a diaphragmatic hernia usually followed a direct wound of the diaphragm. Now, however, almost all result from indirect injury in road accidents, especially where the patient has been run over or has been crushed between two vehicles. The point of injury in such cases is usually the abdomen or pelvis, resulting in a momentary increase in intra-abdominal pressure. A fall from a height may also cause tearing of the diaphragm. Where the diaphragm is torn by indirect violence, the tear is usually a radial one, extending outwards from the hiatus, though the hiatus itself commonly remains intact. The pressure differential between the thorax and abdomen encourages herniation of abdominal viscera through the defect. The left diaphragm is almost always involved, since the right side is buffered by the liver. The greatly varied clinical presentation of ruptured diaphragm has been noted by many surgeons, and three phases may be recognized. Immediate symptoms are due to the spaceoccupying effect of the herniated contents in the chest, leading to collapse of the ipsilateral lung, and displacement of the mediastinum to the other side. The symptoms are respiratory, with increasing dyspncea, and their significance may not be appreciated in the presence of other serious injuries. If the viscera, especially the stomach, become obstructed, they become enormously distended, and a rapidly fatal outcome is likely. In the so-called interval phase, where the degree of herniation is less marked initially, symptoms of obstruction of the herniated viscus develop, with minimal or absent respiratory symptoms.