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KEY POINTS

KEY POINTS

  • Traumatic diaphragm injury is rare (<1%) following blunt trauma, whereas penetrating thoracoabdominal trauma has an incidence of 24% to 38%.

  • Most traumatic diaphragm injuries are identified at surgical exploration.

  • The overall accuracy of chest x-ray is quite poor; the only direct sign of diaphragmatic injury is the visualization of herniated abdominal viscera into the chest.

  • Laparoscopy is recommended over computed tomography for the diagnosis of left-sided thoracoabdominal stab wounds.

  • The two principles of repairing acute diaphragmatic hernias are complete reduction of the herniated organs back into the abdominal cavity and watertight closure of the defect.

  • Repair of the acutely blunt-injured diaphragm is best performed via laparotomy, although laparoscopic or thoracoscopic repair is feasible.

INTRODUCTION

The diaphragm, the most important muscle of respiration, separates the thoracic and abdominal cavities. It can be injured in isolation or involved with injury in either body cavity. The most challenging aspect of management is the identification of injury. Penetrating injuries in particular may be initially asymptomatic but later develop herniation and strangulation of the stomach or other abdominal viscera.

HISTORY

Traumatic diaphragmatic rupture was first reported by Sennertus in 1541, and Ambroise Paré was the first to report a series of diaphragmatic perforations found at autopsy.1 Paré also described the consequences of gastric and colonic incarceration in a ruptured diaphragm.2 The first documented antemortem diagnosis was by Bowditch in 1853,3 and it was not until 1886 that Riolfi was credited with the first successful repair.4 The first acute repair was by Walker in 1899, in a patient who had been struck by a falling tree.5 The largest early review of 378 diaphragmatic hernias was by Hedblom in 1925.4

ANATOMY

The diaphragm is a dome-shaped musculofibrous septum separating the abdomen and thorax. It is bounded above by both pleural spaces and the pericardium, which is attached to the central tendon. Structures immediately adjacent to the inferior side of the diaphragm include the liver, spleen, stomach, and to varying degrees the colon, omentum, and small bowel. The origin of the diaphragm includes the lower sternum, lower six costal cartilages and adjacent ribs, and medial and lateral lumbocostal arches. The crura, two tendinous pillars, arise from the lumbar vertebrae. The insertion of the diaphragm is into the central tendon, an aponeurosis, located at the top of the dome, oriented transversely and separated into three segments. At rest, the diaphragm rises to the level of the fourth intercostal space on the right and the fifth intercostal space on the left. At maximal contraction, the diaphragm descends two rib spaces bilaterally. The aorta passes behind the diaphragm and between the crura, where it has no attachments. Along with the aorta, the thoracic duct and azygous vein pass through this opening. The esophagus traverses the esophageal hiatus, which is mostly composed of the ...

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