Diagnosis of traumatic rupture of diaphragma) Laparoscopyb) Chest X rayc) Diagnostic peritoneal lavaged) IPPV
• Diaphragmatic injuries are often caused by penetrating injuries.
• Patients sustaining penetrating injuries below the nipples and above the costal margins should be investigated to rule out diaphragmatic injury.
Etiology
• Penetrating trauma (knife, bullet, repair of hiatus hernia)
• Blunt trauma (motor vehicle accident, fall from height, bout of hyperemesis):
−− Caused by compressive force applied to the pelvis and abdomen.
−− Rupture is usually large, with herniation of abdominal content into chest
Clinical Features
• Most diaphragmatic injuries are silent and the presenting features are those of injury to the surrounding organs.
• Late complication: Herniation of abdominal contents in to the chest.
• Herniation of organ: Stomach >Colon >Small intestine >Omentum >Spleen >Kidney and pancreas.
Diagnosis
• There is no single standard investigation to diagnose diaphragmatic injuries.
• Chest X-ray after placement of a nasogastric tube may be helpful (as this may show the stomach herniated into the chest)
• Contrast study of upper or lower GIT, CT scan and diagnostic peritoneal lavage all lack positive or negative predictive value.
• Most accurate evaluation is by video assisted thracoscopy (VATS) or laparoscopy, offering the advantage of allowing the surgeon to proceed to repair and additional evaluation of the abdominal organs.
Treatment
• Operative repair is recommended in all cases.
• All penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury.
Bergvist Triad: Rib fracture + Fracture of spine /pelvis + Traumatic rupture of diaphragm
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