A review on delayed presentation of diaphragmatic rupture

Abstract

Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture.

Figure 1

Plain abdominal x-ray on presentation. Note nonvisualization of the left hemidiaphragm and bowel gas at the left lung base.

Figure 2

Axial post IV contrast CT through the lower chest/upper abdomen showing loops of bowel herniating through the disrupted left hemidiaphragm.

Figure 3

Coronal CT scan showing disrupted left hemidiaphragm.

Figure 4

Saggittal CT showing disrupted left hemidiaphragm with herniation of bowel.

Figure 5

Previous Chest radiograph with a discontinuous left lower posterior 9th rib. Note the normal left hemidiaphragm.

Figure 6

Intraoperative pictures.

Figure 7

(a and b): Post operative CT (Coronal and axial views). Note the repaired left diaphragam and tip of the chest drain in situ with some patchy basal consolidation (Arrow pointing to protec stapler).