Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review

Abstract

Introduction: Diaphragmatic injuries are rare consequences of thoracoabdominal trauma and they often occur in association with multiorgan injuries. The diaphragm is a difficult anatomical structure to study with common imaging instruments due to its physiological movement. Thus, diaphragmatic injuries can often be misunderstood and diagnosed only during surgical procedures. Diagnostic delay results in a high rate of mortality.

Methods: We report the management of a clinical case of a 45-old man who came to our observation with a stab wound in the right upper abdomen. The type or length of the knife used as it was extracted from the victim after the fight. CT imaging demonstrated a right hemothorax without pulmonary lesions and parenchymal laceration of the liver with active bleeding. It is observed hemoperitoneum and subdiaphragmatic air in the abdomen, as a bowel perforation. A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy.

Conclusion: In countries with a low incidence of inter-personal violence, stab wound diaphragmatic injury is particularly rare, in particular involving the right hemidiaphragm. Diaphragmatic injury may be underestimated due to the presence of concomitant lesions of other organs, to a state of shock and respiratory failure, and to the difficulty of identifying diaphragmatic injuries in the absence of high sensitivity and specific diagnostic instruments. Diagnostic delay causes high mortality with these traumas with insidious symptoms. A diaphragmatic injury should be suspected in the presence of a clinical picture which includes hemothorax, hemoperitoneum, anemia and the presence of subdiaphragmatic air in the abdomen.

Keywords: Diaphragmatic injury; Diaphragmatic repair; Liver laceration; Penetrating abdominal trauma; Stab wound.

Figure 1

Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen.

Figure 2

Characteristics of the stab wound and intra-operative findings. a) bleeding stab wound in the right upper quadrant; b) liver laceration and right diaphragmatic injury; c) application of hemostatic matrix (Floseal®) on liver lesion; d) repair of diaphragmatic lesion with non-absorbables sutures and positioning of medicated sponge containing thrombin and human fibrinogen (Tachosil®).