Alternativas quirúrgicas en hernias y eventraciones diafragmáticas crónicas / Surgical alternatives for chronic diaphragmatic hernias and eventrations

Introducción: las eventraciones y las hernias diafragmáticas crónicas son dos afecciones que en ocasiones se confunden; tienen una frecuencia relativamente baja y su estrategia quirúrgica varía. Objetivo: mostrar la experiencia del Hospital Universitario Clínico Quirúrgico Comandante Manuel Fajardo en la atención de enfermos con hernias y eventraciones diafragmáticas. Métodos: se presentan 11 pacientes atendidos desde 1998 hasta 2015 por afecciones del diafragma como eventraciones y hernias diafragmáticas crónicas. Del total, 7 fueron operadas con anillos de hasta 10 cm y dos con más de 10 cm. Resultados: se operaron 9 pacientes con hernias diafragmáticas y 2 con eventraciones. Ocho hernias fueron del lado izquierdo y una derecha. En 8 de las hernias el contenido era multivisceral. La hernia derecha tenía un anillo de más de 10 cm y con el hígado en su contenido. Cinco fueron reparadas mediante superposición de colgajos y en cuatro se necesitó una malla protésica. Las eventraciones se presentaron en dos mujeres, ambas parciales, una derecha y otra izquierda, tratadas con plicatura del hemidiafragma en dos planos. Conclusiones: las hernias y las eventraciones diafragmáticas son entidades parecidas con particularidades y terapéutica diferentes. En las eventraciones, la plicatura del diafragma es la técnica de elección, por vía abierta o de preferencia por toracoscopia. En las hernias diafragmáticas, la reparación depende del tamaño del anillo, hasta 10 cm se prefiere la reparación con superposición de colgajos y en defectos mayores el uso de mallas protésicas, preferentemente por una toracotomía(AU)

Introduction: Chronic diaphragmatic hernias and eventrations are two conditions sometimes mistaken for each other. They have a relatively low frequency and their surgical strategy varies. Objective: To show the experience at Comandante Manuel Fajardo Clinical Surgical University Hospital in the caring for patients with diaphragmatic eventrations and hernias. Methods: 11 patients attended from 1998 to 2015 were presented for diaphragmatic conditions, such as hernias and chronic diaphragmatic eventrations. Of the total, 7 were operated with rings of up to 10 cm. Two were operated for rings of more than 10 cm. Results: 9 patients with diaphragmatic hernias and 2 with incisional hernias were operated. Eight hernias were on the left side. One hernia was on the right side. In 8 of the hernias, the content was multivisceral. The right hernia had a ring of more than 10 cm, and had the liver in its content. Five hernias were repaired by flaps. Four hernias required a prosthetic mesh. The eventrations were presented in two women, both partial: one was on the right and the other was on the left, and both were treated with plication of the hemidiaphragm in two planes. Conclusions: Diaphragmatic hernias and eventrations are similar entities with different characteristics and therapeutics. In eventrations, the plication of the diaphragm is the technique of choice, either openly or preferably by thoracoscopy. In diaphragmatic hernias, repair depends on the size of the ring, up to 10 cm, flap repair is preferred, and in larger defects, it is the use of prosthetic meshes, preferably by thoracotomy(AU)

Hernia diafragmática aguda en un adolescente / Acute diaphragmatic hernia in an adolescent

Se presenta el caso clínico de un paciente de 13 años de edad, quien ingresó en el Servicio de Cirugía del Hospital Básico de Latacunga, Ecuador, tras haber sido atropellado por un automóvil que le produjo traumatismos torácico y abdominal cerrados. Los estudios radiológicos confirmaron el diagnóstico de hernia diafragmática traumática izquierda. Durante la cirugía se encontró un defecto de 10 cm en el diafragma izquierdo, con el estómago, bazo y colon herniados en el tórax, para lo cual se efectuó reducción y frenorrafia. Dicho paciente evolucionó satisfactoriamente y egresó al quinto día. Se realizó seguimiento durante 6 meses y no presentó complicaciones.

The case report of a 13 year-old patient is presented who was admitted in the Surgery Service of the Basic Hospital from Latacunga, Ecuador, after being runned over by an automobile that produced him closed thoracic and abdominal traumatisms. The radiological studies confirmed the diagnosis of left traumatic diaphragmatic hernia. During surgery a defect of 10 cm was found in the left diaphragm, with stomach, spleen and colon herniated in the thorax, for which reduction and frenorrafia were carried out. This patient had a satisfactory clinical course and was discharged on the fifth day. Follow-up was carried out during 6 months and there were no complications.

Hérnia diafragmática direita associada à hepatotórax assintomático com correção de cirurgia precoce / Right diaphragmatic hernia associated to asymptomatic hepatotorax with early surgical correction

A ruptura diafragmática decorrente de lesão traumática é uma entidade rara, secundária ao trauma fechado ou penetrante. O diagnóstico é difícil, o que pode fazer com que o tratamento cirúrgico seja retardado, acarretando um aumento da morbimortalidade. Os autores relatam o caso de paciente de 39 anos, do sexo feminino, vítima de trauma com alto impacto devido a atropelamento. Após 13 dias de internamento, radiografia de tórax permaneceu com obliteração do seio costofrênico e velamento do terço inferior do hemitórax direito. Tomografia computadorizada de tórax evidenciou grande parte do fígado em posição intratorácica, sugerindo a possibilidade de ruptura torácica e hepatotórax. O tratamento foi realizado por meio de uma toracotomia anterolateral direita com rafia do defeito diafragmático e redução do saco herniário. Sendo assim, apesar de raro, o hepatotórax é uma entidade que deve sempre ser lembrada em pacientes vítimas de traumas torácicos de alta intensidade.

The diaphragmatic rupture due to traumatic injury is a very rare entity that may be due to blunt or penetrating trauma. Diagnosis is difficult and therefore surgical treatment may be delayed, resulting in increased morbidity and mortality. The authors report the case of a 39-year-old patient, female, who was victim of a high-impact trauma due to trampling. Standard chest X-ray did not showed positive evolution after 13 days of hospitalization, with costophrenic angle obliteration and opacification of the lower third of the right hemithorax. It asked then a chest CT scan that showed much of the liver in intratoracic position. The treatment was carried out successfully by a right anterolateral thoracotomy with suture and correction of diaphragmatic hernia. Thus, although rare, hepatotorax is an entity that should always be remembered in trauma patients with high impact.

Minimally invasive surgery in patients with multiple fractured ribs complicated with traumatic diaphragmatic hernia / 中国内镜杂志

Objective To explore the effect of minimally invasive surgery in patients with multiple fractured ribs complicated with traumatic diaphragmatic hernia. Methods Clinical data of 48 patients with multiple fractured ribs complicated with traumatic diaphragmatic hernia from January 2010 to January 2016 were retrospective analyzed. All the patients were divided into control group and observation group according to the operation method, 24 cases in each. Patients in control group were treated with thoracotomy, while patients in observation group were treated by video-assisted thoracic surgery. Results The incision length, operative time, blood loss, postoperative thoracic drainage time and hospital stay in the observation group were significantly lower than that in control group, and the difference was statistically significant (P < 0.05). Patients with fractured ribs of the two groups were cured after bandage fixation and the observation group were treated with no conversion to thoracotomy. Clinical efficiency of the two groups were 91.67% and 79.16% and the overall complication rate was 8.32% and 37.48% respectively, the difference is statistically significant (P < 0.05). Conclusion The video-assisted thoracic surgery in treatment of multiple fractured ribs complicated with traumatic diaphragmatic hernia has advantages of less trauma and blood loss during operation, shorter operation time, faster postoperative recovery, and better curative effect, lower incidence of complications. It can be further promoted and used in clinical.

Hernia diafragmática traumática en un niño / Diaphragmatic traumatic hernia in the little boy

La hernia diafragmática traumática es una afección poco frecuente sobre todo en edades pediátricas. El objetivo de este trabajo es reportar un caso de hernia diafragmática secundaria a un trauma toracoabdominal cerrado. Se presenta el caso de un paciente de 12 años, masculino ingresado en el Servicio de Cirugía Pediátrica de la Provincia de Santiago de Cuba, por haber sufrido un accidente en el hogar (caída de una pared de ladrillos sobre su cuerpo), que produjo traumatismos a nivel craneal, torácico y lumbar. Los estudios radiológicos confirmaron el diagnóstico de hernia diafragmática traumática izquierda. En el acto quirúrgico se comprueba defecto del diafragma izquierdo de aproximadamente 15 cm, con hernia de estómago, bazo y colon. Se realizó reducción y frenorrafia con puntos de colchonero usando poliéster 0, más pleurostomía mínima baja izquierda. El paciente evolucionó satisfactoriamente y egresó a los 10 días para seguimiento en la consulta externa durante 6 meses hasta el alta definitiva(AU)

Traumatic diaphragmatic hernia is a rare illness at pediatric ages. The objective of this paper was to report a case of diaphragmatic hernia secondary to closed thoracoabdominal trauma. This patient is a 12 years-old boy admitted to the pediatric surgery service of Santiago de Cuba province because of an accident at home (a brick wall fell down upon his body) that caused him cranial, thoracic and lumbar traumas. The radiological studies confirmed the diagnosis of traumatic diaphragmatic hernia on the left side. During the surgical act, there was observed an almost 15cm left diaphragm defect with hernias in stomach, spleen and colon. Reduction and phrenorraphy were performed using mattress sewing stitch type, polyester 0 plus left low minimal pleurostomy. The progression of the patient was satisfactory and was discharged from hospital ten days after surgery to be followed up in the outpatient service for 6 months until his complete recovery(AU)

Hernia diafragmática traumática derecha / Right traumatic diaphragmatic hernia

Paciente masculino, de 47 años de edad que sufrió un accidente automovilístico en el año 1991, con fractura de columna lumbar , que dejó como secuela una paraparesia flácida postraumática con nivel neurológico de lesión del segmento L5, con disminución de la fuerza muscular y de la sensibilidad en las extremidades inferiores. Se le hizo inmovilización con yeso durante 6 meses y fue intervenido quirúrgicamente en ese propio año. Se le realizó fijación y osteosíntesis con material metálico. Se rehabilitó durante varios anos alcanzando buen fortalecimiento muscular y en noviembre de 2008, en horas de la noche, comienza con dolor intenso a nivel de hipocondrio y hemitórax derecho, que se incrementa con el decúbito supino y mejora con el decúbito lateral izquierdo y con disnea moderada. Al examen físico del tórax, se constató aumento de la matidez del tercio inferior del hemitórax derecho y se auscultaron ruidos hidroaéreos a este nivel. Se realizó radiografía (Rx) de tórax vista posteroanterior(PA), donde se constató elevación del hemidiafragma derecho e imagen compatible con presencia de asas intestinales en el tercio inferior de este hemitórax. Se diagnosticó una hernia diafragmática traumática derecha , que es una enfermedad poco frecuente debido al efecto amortiguador del hígado. Se realizó tratamiento médico inicialmente y una hora después , cesa el dolor. Se redujo la hernia de manera espontánea, lo que se corroboró en el Rx de tórax ( vista PA) evolutivo. Posteriormente fue intervenido quirúrgicamente de forma electiva y el resultado fue favorable(AU)

A 47 years-old male patient, who was injured in a car accident in 1991 and suffered lumbar column fracture that left as a sequel a postraumatic flaccid paraparesia with neurological lesion of L5 segment, reduction of muscle strength and sensitivity in lower limbs. He had plaster for 6 months and was surgically treated in that year. He underwent fixation and osteosynthesis with metal material. During several years, he went to rehabilitation program and finally achieved good muscle strengthening. In November 2008, he began feeling intense pain at hypochondrium and right hemithorax at night and also moderate dyspnea. On the physical exam, it was confirmed that there was increase of lower third of right hemithorax and hydroaerial noises were heard. Chest x-ray using posteroanterior view was performed, which revealed increase of right hemidiaphragm and images compatible with intestinal loop in the lower third of this hemithorax. Right traumatic diaphragmatic hernia was diagnosed. This is an infrequent disease due to the shock-absorbing effect of the liver. He was medically treated and one hour later, the pain ceased. Hernia was reduced spontaneously, which was confirmed in the posterior chest x-ray. He was further operated on electively and the final result was favorable(AU)

Post-traumatic synchronous twin inter-muscular abdominal and diaphragmatic hernias: A rare presentation.

Simultaneous occurrence of traumatic abdominal wall hernia (TAWH) and traumatic diaphragmatic hernia (TDH) is uncommon. Our report documents the rare delayed presentation of simultaneous occurrence of TAWH and TDH in a patient who sustained a bicycle handlebar injury as a consequence of the bicycle he was riding colliding with a motorbike in a road-traffic accident. Excellent outcome could be achieved in this patient with surgical repair without requiring the use of a mesh.

Hernia diafragmática secundaria a trauma abdominal cerrado / Diaphragmatic hernia secondary to blunt trauma of the abdomen

La hernia diafragmática traumática (HDT) es una complicación poco común en el trauma abdominal cerrado y puede no ser diagnosticada a menos de que se tenga un alto índice de sospecha. El mecanismo fisiopatológico consiste en un impacto de alta energía con aceleración y desaceleración que condiciona incremento súbito de la presión intraabdominal. El hemidiafragma izquierdo es afectado más comúnmente. El diagnóstico temprano y oportuno es fundamental debido a la elevada incidencia con la que se asocia a lesión a otros órganos y complicaciones. El objetivo de este artículo es presentar el caso de un paciente de 62 años que desarrolló hernia diafragmática secundaria a trauma abdominal cerrado y revisar la literatura relacionada a esta entidad.

Traumatic diaphragmatic hernia is an uncommon complication of abdominal blunt trauma and is easily overlooked unless high index of suspicion is maintained. The underlying mechanism for diaphragmatic rupture is due to a high-energy acceleration-deceleration impact that results in a sudden increase in the intra-abdominal pressure. The left diaphragm is more commonly involved. The diagnosis is important because of the high incidence of associated organ damage and complications. The aim of this paper is to present the case of 62 years old patient who developed traumatic diaphragmatic hernia and review the literature related to this entity.

Hernia diafragmática traumática en pediatría / Traumatic diaphragmatic hernia in pediatrics

El trauma es una condición cada vez más frecuente en la población infantil, sobre todo aquel con una severidad importante y consecuencia de actos de violencia por su mismo grupo etario. Existen pocos registros y casuísticas al respecto, no solo de dichos actos, sino de la condición a describir como centro de enfoque de este escrito. La hernia diafragmática de índole traumática, es una condición particular de una población con mayor exposición a actividades de riesgo en una franja de edad que incluye la población adulto y adulto joven. Durante el desarrollo del artículo, se presenta un caso ejemplo de esta particular condición con los detalles pertinentes a la evolución y desenlace...

Trauma isn’t often a condition seen in children, especially those ones with an important severity related to acts of interpersonal violence by individuals of the same age. There are few records and casuistic in this regard, not only about these acts, but also about the condition to describe and the main focus of this writing. Traumatic diaphragmatic hernia is a particular condition of a population with high exposure to risky activities in an age group that includes the adult and young adult population. In this article, a case example of this particular condition is presented, with relevant details about its evolution and outcome...

Hernia diafragmática traumática crónica: a propósito de un caso / Chronic traumatic diaphragmatic hernia: a case report

La hernia diafragmática traumática se presenta con relativa frecuencia en cualquier medio y se necesita de un alto índice de sospecha para su diagnóstico, especialmente en los casos de trauma cerrado. Se presenta una paciente operada por esta afección luego de sufrir un trauma cerrado abdominal 16 años atrás, a la que se le encontró una hernia diafragmática izquierda, formada por todo el estómago, colon transverso, bazo y epiplón mayor. Se hace referencia a algunos aspectos de interés sobre esta enfermedad los síntomas que presentó la paciente, los complementarios empleados para llegar al diagnóstico, así como a los principios fundamentales para la reparación de estas lesiones. En dependencia del diámetro del anillo herniario el orificio se puede cerrar con puntos de sutura no absorbible o colocar un material protésico para cubrir el defecto, el abordaje puede ser por vía torácica, abdominal o combinada en dependencia del tiempo de evolución de la misma.

Traumatic diaphragmatic hernia is relatively frequent in any conditions and needs a high rate of suspicion to be diagnosed, particularly in the cases of closed trauma. A patient who underwent an operation, due to this affection, after suffering an abdominal closed trauma, 16 years before, presented a left diaphragmatic hernia; it covered the stomach, transverse colon, spleen and the gastrocolic omentum. Some other aspects of interest about the disease and the symptoms were observed. Laboratory findings and the main principles to repair these lesions were taken into consideration to establish the diagnosis. Considering that; the diameter of the hernial ring as well as the orifice can be closed with non-absorbable suture or placing prosthetic material to cover the defect, the approach can be thoracic, abdominal or combined depending on the time of its evolution.

Hérnia diafragmática tardia pós-traumática: relato de caso / Late post-traumatic diaphragmatic hernia: a case report

Objetivo: relatar um caso de hérnia diafragmática crônica pós-traumática (HDT), corrigida, cirurgicamente, por laparotomia em um Pronto Socorro, em Belém/PA. Relato de caso: paciente do sexo masculino, 39 anos, com hérnia diafragmática crônica pós-traumática. Considerações finais: o caso estudado ratifica a alta incidência de diagnóstico tardio de rotura diafragmática e a necessidade do uso de laparotomia, sem drenagem pleural, sugerindo que existem casos de HDT que podem ser resolvidas com menor tempo cirúrgico e menor morbidade pós-operatória, mesmo quando o defeito diafragmático for extenso.

Objective: to report a case of diaphragmatic hernia chronic post-traumatic (HDT), corrected surgically by laparotomy in an emergency room in Bethlehem, PA. Case Report: a male patient, 39 years, with diaphragmatic hernia chronic post-traumatic. Final thoughts: the case study confirms the high incidence of late diagnosis of diaphragmatic rupture and the need to use laparotomy without pleural drainage, suggesting that there are cases of HDT can be solved with less surgical time and less postoperative morbidity, even when the diaphragmatic defect is long.

A Case of Right Diaphragmatic Hernia of Sigmoid Colon Showed by Colonoscopy / 대한소화기내시경학회지

A 53-year-old man complained of constipation and abdominal pain including the right flank area for three days. He had suffered multiple rib and clavicular fractures on the right side 10 years earlier. Colonoscopy was performed to assess the constipation, which showed a twisted constricted lumen in the sigmoid colon or descending colon. Passing through it, the saccular dilated bowel wall demonstrated edematous, erythematous changes in the mucosa with a purplish color and necrosis. The proximal part of the saccular lumen also showed a twisted stricture with necrotic materials. The abdominal CT showed subsegmental atelectasis in the right lung, right pleural effusion and a diaphragmatic hernia of the colon. In addition, multiple dilated bowel loops were observed in the abdomen. The patient underwent emergency surgery with a segmental resection of the sigmoid colon. We report this case of delayed traumatic right diaphragmatic hernia of the sigmoid colon with strangulation, which is extremely rare and was revealed by colonoscopy.

Diagnóstico tardío de evisceración diafragmática secundaria a trauma torácico cerrado veintinueve años antes / Delayed diagnosis of rupture of the diaphragm 29 years after trauma

Mujer de 64 años, del medio rural, referida por imagen radiográfica anormal del tórax. Veintinueve años antes se había caído de un caballo, produciéndose una severa contusión torácica. Estudios con contraste del aparato digestivo mostraron visceras abdominales dentro del hemitórax izquierdo. La enferma rehusó corrección quirúrgica del defecto por estar, asintomática y sólo sentir "burbujas en el pulmón".

A 64 year old woman was referred by her rural doctor due toan abnormal chest X ray. Twenty nine years before she had fallen from a horse suffering a severe thoracic contusion. Contrast studies of the upper and lower gastrointestinal tract showed abdominal viscerae inside the left thoracic cavity. The patient refused surgical correction because she considered herself to be asymptomatic and her only complaint was "feeling bubbles in the lung".

Hérnia diafragmática traumática crônica e fístula gastropleurocutânea / Chronic traumatic diaphragmatic hernia and gastricpleuralcutaneous fistula

Traumatic diaphragmatic hernia is defined as a laceration of the diaphragm with an abdominal viscera herniation into the thorax. It is usually asymptomatic, with the exception of the cases with obstruction, strangulation, necrosis or perforation of the herniaded viscera. It is classified as acute, latent or chronic, in accordance with the evolutive period. At the latent phase, symptoms are indefinite and the radiological signals, which are suggestive of thoracic affections, are frequent and can induce a diagnosis error, leading to inadequate treatment.This article presents a case of chronic traumatic diaphragmatic hernia which was complicated by a gastricpleuralcutaneous fistula, due to an inadequate thoracic drainage. Considering that this is a chronic affection with an unquestionable surgical indication, due to the complications risk, it is essential to have a detailed diagnostic investigation, which aims at both avoiding an intempestive or inadequate therapeutics behaviour and reducing the affection morbimortality. Recently, the videolaparoscopic approach has proved to be more precise when compared to the other diagnostic methods, by direct visualization of the diaphragmatic laceration, allowing its correction by an immediate suture.

Effects of Patient Controlled Analgesia with Morphine after Obstetric or Gynecologic SurgerAnesthesia for Traumatic Diaphragmatic Hernia Detected after Operation of the Femur Fracture / 대한마취과학회지

Injury of diaphragm mainly occur in penetrating, crush and blunt injuries to the lower chest or upper abdomen, and it is most often secondary to automobile accidents. Diaphragmatic rupture is most frequent in blunt chest trauma and the rate is below 1% of them. Traumatic rupture of the diaphragm is responsible for the herniation of abdominal viscera. Physical finding and radiographic sign of diaphragmatic hernia is nonspecific and misreading. Therefore, the diagnosis of traumatic rupture of diaphragm may be difficult during the early period after the injury, especially when clinical features are dominated by associated injuries. Emergency surgical management is necessary when it is complicated with serious complication. We experienced the case of traumatic diaphragmatic hernia detected after the operation of femur fracture. The patient was injured by motor vehicle accident 6 days before the operation of the femur fracture. There was no specific symptom and sign and the manifestation of the diaphragmatic hernia. in radiographic studies until operation of the femur fracture was done. Diaphragmatic hernia was confirmed by chest X-ray and arterial blood gas analysis after operation of the femur fracture. The repair of the diaphragmatic hernia was directly performed after the diagnosis. The prognosis was favorable, and she was discharged to ward from intensive care unit after 1 day of operation. We must consider the possibility of traumatic diaphragmatic hernia in the patient who have the history of blunt chest or abdominal trauma.