Unifying classification for transdiaphragmatic intercostal hernia and other costal margin injuries.

OBJECTIVES: Taxonomy of injuries involving the costal margin is poorly described and surgical management varies. These injuries, though commonly caused by trauma, may also occur spontaneously, in association with coughing or sneezing, and can be severe. Our goal was to describe our experience using sequential segmental analysis of computed tomographic (CT) scans to perform accurate assessment of injuries around the costal margin. We propose a unifying classification for transdiaphragmatic intercostal hernia and other injuries involving the costal margin. We identify the essential components and favoured techniques of surgical repair. METHODS: Patients presenting with injuries to the diaphragm or to the costal margin or with chest wall herniation were included in the study. We performed sequential segmental analysis of CT scans, assessing individual injury patterns to the costal margin, diaphragm and intercostal muscles, to create 7 distinct logical categories of injuries. Management was tailored to each category, adapted to the individual case when required. Patients with simple traumatic diaphragmatic rupture were considered separately, to allow an estimation of the relative incidence of injuries to the costal margin compared to those of the diaphragm alone. RESULTS: We identified 38 patients. Of these, 19 had injuries involving the costal margin and/or intercostal muscles (group 1). Sixteen patients in group 1 underwent surgery, 2 of whom had undergone prior surgery, with 4 requiring a novel double-layer mesh technique. Nineteen patients (group 2) with diaphragmatic rupture alone had a standard repair. CONCLUSIONS: Sequential analysis of CT scans of the costal margin, diaphragm and intercostal muscles defines accurately the categories of injury. We propose a 'Sheffield classification' in order to guide the clinical team to the most appropriate surgical repair. A variety of surgical techniques may be required, including a single- or double-layer mesh reinforcement and plate and screw fixation.

[Traumatic diaphragmatic hernias: retrospective analysis].

AIMS: This study classifies cases of traumatic diaphragmatic hernias (TDH) in patients admitted to the Intensive Care Unit (ICU) of the Coimbra University Hospitals (HUC) from 1990 to 2004. METHODS: Retrospective analysis of 34 cases of TDH, studying anatomical location, place and time of diagnosis, complementary tests aiding diagnosis, herniated organs, associated traumatism, morbidity and mortality. RESULTS: Twenty-eight male and six female patients with an average age of 40.5 years +/- 20.5, average SAPS score 38.8. Average length of stay was 19.1 +/- 13.6 days, all suffered from closed traumatism and were put on artificial ventilation. The left-side diaphragm was more frequently affected (94.1%) then the right. Diagnosis in 19 cases was made up in the first six hours following the diagnosis of traumatism, in four cases within 12 hours and in the remaining cases between 48 hours and 16 years after traumatism. In 13 patients the diagnosis was established intra-operatively. The stomach was typically one of the herniated organs. The most frequently associated lesions at the thoracic level were pulmonary contusion, haemothorax and pneumothorax, and at the abdominal level, haemoperitoneum and splenic lesion. The rates for complications and mortality were 55.8% and 11.7% respectively. CONCLUSIONS: TDH mainly occurs on the left side through closed thoraco-abdominal trauma following road traffic accidents. This group of patients, on average younger than others admitted to ICU, presents a longer average hospitalisation period, but has lower rates of mortality and lower SAPS severity scores. The most commonly herniated organ was the stomach and the most frequently encountered lesions were cranial-encephalic, splenic and pleural traumatisms. Pre-operative diagnosis of diaphragmatic injuries is difficult and a high index of clinical suspicion is needed after thoraco-abdominal trauma. This diagnosis should always be considered a possibility in cases of closed thoraco-abdominal traumas.

Hernia giafragmatica traumatica de aparicion precos / Early traumatic diapharmatic hernia

Las hernias diafmgmáticas de origen traumático son una patología poco frecuente en los mños y generalmente esta asociada a lesiones en otros órganos. Se presenta este caso por la forma de evolución y al presentar solo lesión diafragmática, fue importante el seguimiento de la paciente para un diagnóstico temprano, la conducta fue quirúrgica con laparatomia y sutura del dliafragma roto

Hernia diafragmática traumática, HDT, complicada en urgencia: tres casos clínicos / Traumatic diafragmatic hernia complicated in emergency: 3 clinical cases

Las HDT, son la consecuencia de un trauma contuso o penetrante tóracoabdominal que al romper el diafragma y por la diferencia de presiones entre las cavidades toráxica y abdominal los órganos abdominales izquierdos tienden a ser aspirados al tórax. Pudiendo sufrir complicaciones irreversibles por isquemia, gangrena, y perforación de ellas, iniciándose así el período de la complicación, que de no corregirse adecuadamente puede terminar con la vida del paciente. Se presentan tres casos clínicos evaluados en urgencia en los últimos seis años, en los cuales se careció de diagnóstico a su ingreso. Uno de ellos se corrigió adecuadamente en laparotomía de urgencia y en dos de ellos, lamentablemente, fue un hallazgo de autopsia, como feconeumotorax hipertensivo

[The systematization and the etiopathogenicity of diaphragmatic hernias]. / Sistematizarea si etiopatogenia herniilor diafragmatice.

The author, based on up to date published dates, intends to present the classification and ethiopathogeny of the diaphragmatic hernias, except the aesophagic hiatus oms. This is an interesting chapter of the borderline surgery (abdominal and thorax). They are placed on the second position in frequency (after the hiatal hernias) in the diaphragmatic pathology; they are internal hernias, through congenital or obtained holes which allow to abdominal viscera to pass into thorax. They are--in the most cases, even elderly ones-congenital, result of the abnormalities in the embrionary growth of the diaphragm. A special place' is represented by the traumatic hernias.

Laparoscopic management of traumatic ruptures of the diaphragm.

INTRODUCTION: As a result of the relatively high frequency of high-speed accidents, diaphragmatic rupture is a diagnosis that is increasingly being established. Not all of these, usually multi-traumatized, patients are diagnosed as having diaphragmatic rupture immediately following the traumatic event--rather, an appreciable number of these injuries are not detected until some time later--often after a considerable delay. Most of the cases involve rupture of the left diaphragm, with most defects occurring in the region of the central tendon. METHODS: During the course of the second half of the year 1998, we operated on three patients with left diaphragmatic rupture. Two of these patients were treated immediately following traumatization, while the third case was a 10-year-old rupture originally misdiagnosed as a para-esophageal hernia. In all three cases, we were able to reduce the hernia and close the diaphragmatic defect laparoscopically. In the case of the two patients with a fresh rupture, the post-operative course was unremarkable, while in the patient with the missed rupture, a serous pleural effusion requiring drainage occurred on the left side. CONCLUSION: Overall, it would appear that in the case of an acute traumatic diaphragmatic rupture in particular, laparoscopic management, with its low level of traumatization and excellent access, offers a favorable alternative to conventional surgery. A point to be considered, however, is the fact that probably not every hospital will have the facilities for laparoscopic management available on a 24-h basis. In the case of longstanding ruptures, reduction of herniated bowel and treatment of the rupture will make considerable demands on the surgeon.

[Diaphragmatic injuries--classification, diagnosis and therapy]. / Zwerchfellverletzungen--Klassifikation, Diagnostik und Therapie.

Diagnosis of diaphragmatic rupture is often missed after blunt thoracic and abdominal injuries. Rupture of the diaphragm is caused either by direct or indirect violence. The clinical manifestations are unpredictable and of infinite variety, and, especially in massively traumatized patients, masked by other injuries. Between 1987 and 1995, 17 patients were treated for traumatic injury of the diaphragm. Four of 17 patients sustained isolated diaphragmatic rupture; in 13 the rupture was combined with other injuries. Preoperatively the following diagnostic procedures were performed: ultrasonography in 12 patients, chest X-ray in 6, computed tomography of the abdomen in 2, water soluble enema into the stomach in 1, and computed tomography of the thorax in 1 patient. Therapy of diaphragmatic injury was performed in 15 patients within 2 days, in one within 1 year and in one 23 years after the accident. Two patients died due to accompanying injuries.