Minimally invasive repair of traumatic right-sided diaphragmatic hernia with delayed diagnosis

Abstract

Background: Traumatic diaphragmatic hernias are a diagnostic and therapeutic challenge due to variable presentations. Early repair is important because of risks of incarceration and strangulation of abdominal contents along with respiratory and cardiovascular compromise. Minimally invasive techniques have been useful for diagnosis and treatment of diaphragmatic hernias in both blunt and penetrating trauma.

Method: We present the case of a 54-year-old victim of a motor vehicle crash who presented with a delayed diagnosis of a right-sided traumatic diaphragmatic hernia. By using a 4-port technique and intracorporeal suturing, the hernia was repaired. This case highlights the difficulties associated with diagnosing diaphragmatic hernias and the role of minimally invasive techniques to repair them.

Conclusion: Minimally invasive surgical techniques are being increasingly used to both diagnose and repair traumatic diaphragmatic injuries with excellent results.

Figure 1.

Initial chest x-ray reveals elevation of the right hemidiaphragm with linear atelectasis at the right base.

Figure 2.

Chest x-ray on readmission shows a moderate right pleural effusion with opacity at the right lung base.

Figure 3.

Computed tomographic scan of the chest and abdomen showing right diaphragmatic hernia with stable right pleural effusion, right lower lobe atelectasis, mediastinal shift to the left, and herniation of bowel alongside the liver into the thorax.

Figure 4.

Herniation of the right lobe of the liver though the defect in the right diaphragm.

Figure 5.

Retraction of the liver reveals a collapsed right lung, pleural fluid, and a large defect.

Figure 6.

Intraoperative photographs showing the closed defect.

Figure 7.

Preoperative (A) and postoperative (B) chest x-rays.