TRAUMATIC DIAPHRAGMATIC-HERNIA - A CONTINUING CHALLENGE

Traumatic diaphragmatic hernia is an uncommon but important problem in the patient with multiple injuries. Since diaphragmatic injuries are difficult to diagnose, those that are missed may present with latent symptoms of bowel obstruction and strangulation. From 1957-1982, 41 patients were treated with traumatic diaphragmatic hernias. In 39 patients (95%), diaphragmatic hernia followed blunt trauma. The herniation occurred on the right side in 14 patients and on the left side in 29; it was bilateral in 2. Patients had diagnostic chest radiographs, and an additional 11 had abnormal but nondiagnostic studies. Peritoneal lavage was of little value in making the preoperative diagnosis. Patients (23) underwent laparotomy only, 13 required thoracotomy alone, and 5 had combined laparotomy and thoracotomy. There were 7 deaths (17%) from associated injuries. Only 1 missed injury was encountered; a 2nd delayed hernia, initially treated elsewhere, was repaired 45 yr after the original trauma. Traumatic diaphragmatic hernia should be suspected on the basis of an abnormal chest radiograph in the trauma victim with multiple injuries. Right-sided injuries occur more commonly than previously thought and often require dual incisions (laparotomy and thoracotomy) for diagnosis and treatment. The organization of emergency care for such patients is critical in avoiding the potential of long-term sequelae.