Traumatic diaphragmatic hernia: A new indication for laparoscopy

Correspondence to: D. N . Ada rn t hwaite, C he1 rnsford Medical Centre, 107 Chelrnsford Road, Berea, Durban 4001, South Africa Laparoscopy is well-established in gynaecological practice and in the diagnosis of intraperitoneal d i s e a ~ e ~ , ~ . Its use in the emergency department, however, in the assessment of abdominal pain or abdominal trauma, has been limited to the occasional enthusiast. In cases of intra-abdominal pathology where investigative methods are inconclusive, laparoscopy may prove of value as the procedure is frequently diagnostic and in some cases may circumvent surgical exploration. In cases where a clinical suspicion of traumatic diaphragmatic hernia (TDH) cannot be confirmed, laparoscopy provides a means of proving the diagnosis by visualizing the peritoneal side of the diaphragm, and ten such cases are reported. Patients and methods Pa tien ts Eight patients were men and two women, with a mean age of 28 years (range 19-52). Seven presented in the acute phase and three in the chronic phase with a delay of 10 days to 7 years postinjury. The injury resulted from penetrating stab wounds in seven cases (five wounds of the chest and two wounds of the abdomen) and from blunt thoraco-abdominal trauma in two cases. Eight patients were symptomatic, all complained of dyspnoea, two had left shoulder tip pain, and two had upper abdominal pain. Two of the patients were asymptomatic. Investigation Chest radiographs were taken in all cases and were suggestive of TDH in six cases and negative in four, although two cases demonstrated a pneumothorax where the only injury was an abdominal stab wound, a finding which is suggestive of TDH. The chest X-rays were repeated after the introduction of a radio-opaque nasogastric tube, to visualize the position of the stomach, but this was negative in all cases. One ofthese represented a false negative result where the gastric fundus had herniated through the diaphragm. A dilute barium meal study was performed in four cases, contraindicated in four, and omitted in two cases. The contrast meal comprised the oral administration of 75 cm3 microfine barium sulphate diluted by an equal volume of normal saline, ingested I5 min after the intravenous administration of 20 mg metoclopramide. The stomach and small bowel are rapidly outlined and the colon is often visualized within 2 h. The studies were negative in all four cases because in two the spleen alone had herniated, in one the omentum had herniated, and in one there was no visceral herniation through the diaphragmatic tear. CT scanning was performed in two cases. The scan was suggestive in one case where the spleen had herniated through the diaphragm, and negative in the second case in which a knuckle of small bowel had herniated through the diaphragm. Laparoscopy was performed in all cases. The patients were examined using a Richard Wolf operating laparoscope with 170" lens. The procedure was conducted under regional or general anaesthesia depending on the general condition of the patient. A CO,/N,O (50:50) pneumoperitoneum was induced using a C0,PNEU insufflator (Richard Wolf) via a Verres needle. A trocar and cannula with air seal was introduced into the peritoneum through a subumbilical incision and the operating laparoscope inserted through the cannula into the peritoneal cavity. Visualization of the diaphragm anteriorly was easy; however, to visualize the posterior aspects of the diaphragm, traction was required on the stomach and this was possible using a grasping forceps passed through the laparoscope. The suprasplenic diaphragm was visualized by retraction on the stomach and placing the patient in the left lateral position. In six cases a diaphragmatic hernia was visualized, in two cases a diaphragmatic tear without visceral herniation was seen, and in two patients an intact diaphragm was noted. The risk of inducing a pneumothorax by gas passing through the diaphragmatic tear is present in acute cases. In one of the cases in which the diaphragmatic tear was not plugged by visceral hernia an intercostal drain had previously been inserted for a pneumothorax. In a second case the communication between the peritoneal and thoracic cavities did not produce any problem. Results All eight patients with visualized diaphragmatic lesions on laparoscopy were operated upon. Where present the hernia was reduced, and the diaphragmatic defect was repaired with interrupted, nonabsorbable sutures. Other visceral injuries were treated on their merits. The herniating viscera were spleen (3), omentum (2 ) , stomach ( l ) , colon ( l ) , and ileum (1). There were n o postoperative complications. The two patients in whom the diaphragm was seen to be intact on laparoscopy were managed conservatively with a successful outcome. Discussion The diagnosis of TDH is not always easily made and simple investigative methods may be negative or only suggestive of the lesion4ys. Specialized investigations including contrast studies of the GIT6, CT scanning7, hepatic-splenic scintigraphy8, or a r t e r i ~ g r a p h y ~ may be used but may provide an additional risk t o the patient, cause a delay in the management, or provide a false negative result. In the acute case seen within 24 h of injury thoracoscopy provides the quickest, and most reliable, means of diagnosis but is inaccurate after this time because of the development of intrapleural adhesionslo'lI. In acute cases seen more than 24 h aRer injury and all chronic cases, where other diagnostic methods have failed to demonstrate the lesion but a clinical suspicion of T D H remains, and in hospitals where specialized radiographic facilities are not available, laparoscopy provides a means of diagnosis through indirect visualization of the diaphragm. T h e procedure is rapid and safe, and can be performed under regional or general anaesthesia. The reported cases demonstrate the efficacy of the procedure where TDH was confirmed in six cases, a diaphragmatic tear without herniation seen in two cases, and saved the patient a n unnecessary laparotomy in two cases where the diaphragm was shown to be intact. The author feels justified in recommending laparoscopy for the investigation ofTDH.