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ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 48-53

Thoracoscopic examination of the thoracic cavity during laparotomy in traumatic diaphragm injuries


1 Department of General Surgery, Sabuncuoglu Serefeddin Research and Training Hospital, Amasya University, Amasya, Turkey
2 Department of Thoracic Surgery, Sabuncuoglu Serefeddin Research and Training Hospital, Amasya University, Amasya, Turkey

Date of Submission26-Sep-2020
Date of Acceptance12-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Yavuz Pirhan
Department of General Surgery, Sabuncuoglu Serefeddin Research and Training Hospital, Amasya University, Amasya 05200
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_40_20

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  Abstract 

Background: Traumatic diaphragmatic injury (TDI) is one of the injuries that can occur after blunt and penetrating trauma and can be neglected or missed due to the masking of accompanying organ injuries. In this study, we delved into the difficulties in the diagnostic and treatment approaches for TDI patients.
Methods: We retrospectively examined 22 TDI cases who were urgently operated following blunt (n = 14) and penetrating (n = 8) traumas in thoracic and general surgery clinics between January 2004 and 2019. We recorded information such as trauma type, diagnostic techniques, concomitant organ injuries, the location of diaphragmatic injury and its stage, the herniated organs toward the chest cavity, and surgical method.
Results: The average mean age of the cases in the study was 41.5 years (22–66 years), and all of them were male. Among these, the percentage of pericardial rupture was significant (23%). In abdominal approaches, thorax was examined with an optical camera through the diaphragmatic rupture. TDI was classified into five groups based on the severity of the injury. Additionally, diaphragmatic ruptures in the central tendon or subpericardial area were examined. The entire central diaphragmatic injury was found as blunt trauma. This group was diagnosed with a high rate of multiple organ injuries (100%) and pericardial rupture (30%). Morbidity was 36%, and mortality was 14%.
Conclusion: TDI should be taken into consideration in thoracoabdominal traumas. The frequency of organ injury in high-level TDI is also high. Therefore, laparoscopic and thoracoscopic evaluations should be needed. A good preoperative and peroperative strategy diminishes mortality and morbidity. We suggest that laparoscopy and thoracoscopy will be a lifesaving method in high-grade TDIs.

Keywords: Central tendon ruptures, diaphragmatic and pericardial ruptures, laparoscopy and thoracoscopy diagnoses and treatment, multiple organ injuries


How to cite this article:
Pirhan Y, Özalp T. Thoracoscopic examination of the thoracic cavity during laparotomy in traumatic diaphragm injuries. Saudi Surg J 2020;8:48-53

How to cite this URL:
Pirhan Y, Özalp T. Thoracoscopic examination of the thoracic cavity during laparotomy in traumatic diaphragm injuries. Saudi Surg J [serial online] 2020 [cited 2021 Feb 24];8:48-53. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/48/307421


  Introduction Top


Traumatic diaphragmatic injury (TDI) can be witnessed as a result of not only blunt but also penetrating trauma of the thorax and abdomen. The percentage of rupture incidence usually varies between 1% and 8%.[1],[2] It is one of those injuries that can be ignored or cannot be diagnosed due to masking of concomitant organ injuries.[3] The most significant factor in the determination of TDI in a traumatic patient is the suspicion of injury and radiological examinations.[4] An extra-abdominal organ injury is found in 80%–100% of TDI, whereas intra-abdominal organ injury is found in 50%–80%.[5] The most probable cause of mortality and morbidity has been found as multiple organ injuries and delay in diagnosis.[6] The purpose of this study was to delve into the difficulties in diagnosis, to determine the effects of early diagnosis on patient mortality, and to reassess the importance of using laparoscopy/thoracoscopy as well as surgical treatment strategy.


  Methods Top


Between January 2004 and 2019, 25 patients who were followed up and operated in our thoracic surgery and general surgery clinics with the diagnosis of TDI were retrospectively examined. Three patients who did not accept surgery were excluded from the study. Of the remaining 22 cases, 4 were first examined in our hospital but underwent surgery at another center. The information of these patients was obtained from the centers where they were followed up. We recorded information such as age, gender, trauma type, symptoms, diagnostic techniques, concomitant organ injuries, the location of diaphragmatic injury and its stage, the herniated organs toward the chest cavity, surgical method, morbidity, and mortalities. The patients were routinely examined by chest X-ray, thorax and abdominal computed tomography (CT), and biochemical tests. At the first stage of the intervention, we conducted tube thoracostomy on some of the patients with hemothorax or pneumothorax. We conducted fast resuscitation through thoracotomy and/or laparotomy on hemodynamically unstable patients (hypotension, bleeding of >1200 mL, and tachycardia). Bleeding was controlled. The herniated organs from the rupture site to the thorax were placed into the abdomen. Additional organ injuries were repaired. After the herniated organs were placed into the abdomen, the intrathoracic area was first examined through the diaphragmatic rupture in the abdomen with an optical camera. Nonabsorbable sutures were employed to repair the diaphragm, and nonabsorbable polypropylene mesh was utilized in cases requiring mesh. TDI was classified into five groups according to the American Association for the Surgery of Trauma-Organ Injury Scale[7] Grade 1: contusion; Grade 2: laceration <2 cm; Grade 3: laceration between 2 and 10 cm; Grade 4: laceration >10 cm, tissue loss <25 cm2; Grade 5: >25 cm2 tissue laceration. The relationship of the groups with pericardial and multiorgan injuries was examined. Multiple organ injuries were also investigated in patients with central diaphragmatic injury (CDI).

Ethical consideration

Informed consent was obtained from the patients. Our work was done in accordance with Helsinki declaration. We conducted the study after receiving the permission of the Ethical Committee of the noninvasive Clinical Research Ethics Committee of University of Amasya (2019-8-41).


  Results Top


The average age of the patients was 41.5 years (22–66) and all of them were male. TDI developed after 14 (64%) blunt and 8 (36%) penetrating traumas. Eleven patients were admitted as a result of a traffic accident, six as a piercing device injury, two falling from a height, two firearm injuries, and one under debris. Nearly 91% of the TDI were on the left. Hypovolemic shock clinic was observed in 64% of cases [Table 1]. Twelve had hemothorax and five had pneumothorax. Two patients had both hemothorax and pneumothorax. The diagnosis of diaphragm rupture was determined by radiological examinations in 64%, while 36% could be diagnosed intraoperatively. Almost 50% of the patients were diagnosed with chest X-ray. Six patients were diagnosed by thoracotomy intraoperatively, while two were diagnosed by laparotomy [Table 2]. Surgery was performed in 22 cases, of these, 18 patients had surgery in our clinic and 4 at another center. Tube thoracostomy was applied in nine cases. Eight patients underwent thoracotomy and laparotomy together, two patients had thoracotomy, two patients laparotomy and two patients laparoscopy. Thoracotomy and laparotomy were performed in four patients with penetrating injuries, thoracotomy was performed in two, and laparotomy was performed in two patients. Eight of the 12 cases that were operated by opening both cavities were started with thoracotomy and four with laparotomy. The intra-thoracic area was evaluated because of diaphragmatic rupture in patients with abdominal intervention (n = 12). In the thoracoscopic procedure performed by entering transdiaphragmatic, pericardial rupture and one lung laceration were detected in two cases. After TDI was graded, one case fell under Grade 1, seven cases under Grade 2, six cases under Grade 3, seven cases under Grade 4, and one case under Grade 5. While the diaphragm primer was repaired in the subsequent case, synthetic patch grafts were used in two cases with a large defect that did not allow primary repair. While all cases with blunt trauma had at least Grade 3 TDI, nine of them had CDI [Table 3]. Pericardial injury was observed in five cases. Three of them were pericardial injuries due to blunt trauma and were accompanied by Grade 4 TDI. In two of them, the heart was herniated from the pericardial rupture, and in one case, it was almost about to stop. Two of them were pericardial rupture due to penetrating trauma and were with Grade 2 TDI, accompanied by myocardial injury. The pericardial rupture rate was 21% in cases after blunt trauma. Central diaphragm injury (CDI) was present in nine cases (64%) and all were due to blunt trauma. Multiorgan injury accompanied in 100% of CDI [Table 4]. Injuries accompanying TDI and herniated organs are shown in [Table 4]. In the postoperative follow-up, 36% morbidity was observed. There were pneumonia, atelectasis, and fever in two cases; lung intraparenchymal hematoma in two cases; hemothorax in two cases; hemopericardium in one case; and bleeding in the liver in one case. No complications related to diaphragm developed in the long-term follow-up of the cases. The average length of hospital stay was 10 days (5–24 days). The mortality rate was 14% (n = 3). Two patients died from retroperitoneal bleeding and one case from bowel strangulation. The patient who developed bowel strangulation delayed the surgical intervention by not accepting the treatment despite all kinds of warnings.
Table 1: Demographic findings

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Table 2: Radiological findings

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Table 3: Diagnosis, surgery, and staging

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Table 4: Concomitant organ injuries

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  Discussion Top


The development of TDI following blunt trauma is the unexpected increase in intra-abdominal pressure due to a compression to the upper abdomen and the diaphragm rupture that cannot resist this high pressure.[8] In these kind of injuries, the left diaphragm is mostly affected due to embryological reasons and the right side is less injured due to the blocking effect of the liver.[9] Nearly 12%–69% of TDIs cannot be diagnosed preoperatively.[10] Symptoms differ according to the type of trauma and injury. Traumatic diaphragmatic hernias could occur clinically at different times. Symptoms may occur and be diagnosed following trauma, within minutes or hours, or days, months, or even years.[11] Of the 22 TDY patients, 4 were operated as post-traumatic emergency, 16 patients days later and 2 patients approximately 1 year later. The most common diaphragmatic defect was seen as gastric, small intestine and colon, and rarely liver and spleen hernia.[12] In our study, the small intestine was mostly herniated into the thorax. The most common findings in conventional radiographic studies can be listed as elevation of the diaphragm, intestinal haustra and intestinal gas within the thorax, mediastinal shift, atelectasis, lung mass appearance, pleural effusion, pneumothorax, and hydropneumothorax.[13] The sensitivity of simple X-ray to diagnose diaphragmatic rupture ranges between 27% and 73%.[5] The loss of diaphragm continuity on ultrasonography is useful in the diagnosis.[13] However, CT is a more specific and sensitive method than other radiological methods in revealing intra-abdominal and intrathoracic injuries. While there are studies which report a sensitivity of 14% and 82%,[5] specific findings regarding diaphragmatic damage are very few. However, both thoracoscopy and laparoscopy allow the evaluation of all diaphragmatic surfaces, thus helping to reveal additional pathologies.[14] In our study, the rate of diagnosis was found as 50% on simple X-ray and 64% on CT. Because the cases were not stable and we operated on the additional injuries, videothorocoscopic or laparoscopic approach could not be considered in the first place except the two cases that we performed with laparoscopy. On the other hand, thoracoscopic examination of the thorax with laparotomy was so accurate that two cases of pericardial rupture could be detected after these evaluations. We believe that this finding can be regarded as one of the most striking contributions to the literature. This condition could have caused patients to lose their lives. Nearly 36% of our patients could not be diagnosed radiologically at the first time and they were diagnosed intraoperatively, and most of them were penetrating trauma. TDI is often associated with multiple organ injuries. In a study conducted by the National Trauma Data Base, accompanying pathologies were reported as liver injuries, hemopneumothorax, spleen injuries, rib fractures, bowel injuries, extremity injuries, kidney injuries, pelvic injuries, head trauma, medulla spinalis, and aortic injuries.[15] The frequency of multiple organ injuries was also very high in our cases [Table 4]. Although rib and other bone fractures were most commonly seen, it was significant that the pericardial injury was higher than that reported in the literature. It has been reported that pericardial rupture is rarely seen in blunt TDI[1],[16],[17] and pericardial rupture occurs in only 22 of 20,000 patients with blunt trauma.[18] As a result of the collective literature review conducted by Shah et al. in 1995, the rate of pericardial rupture was found to be 0.9%.[4] In our series, the rate of pericardial rupture was found to be 23%, that of acute blunt traumas to be 21%, and that of central injuries to be 30%. Two of these were associated with cardiac herniation and were detected during surgery. As understood by these cases, it is difficult to diagnose pericardial rupture associated with TDI and is usually diagnosed intraoperatively.[19] However, as evidenced from our study, using laparotomy or diagnostic laparoscopy and thoracoscopic endovision methods will provide an opportunity to detect pericardial injuries that may be overlooked. Cardiac herniation may develop into pericardial ruptures[17],[20] and may be asymptomatic. Pericardial rupture is usually asymptomatic unless there is a hernia from the heart defect or hemorrhage develops. Pericardial rupture must be operated as it may lead to cardiac herniation, vascular destruction, and sudden death.[19] In our study, three pericardial injuries were detected, and the mortality rate reduced with the repair of the pericardium. During laparotomy, additional thoracoscopic procedure of the diaphragmatic rupture may result in an additional intrathoracic injury. In our study, pericardial injuries were subtle to be diagnosed in three patients with blunt trauma. Pericardial injury was detected in two cases we started surgery with laparotomy, thanks to the idea of evaluating the thorax using a thoracoscopy. In this case, because the effective treatment of diaphragmatic injuries is surgical repair of the damage,[6] laparotomy is usually the surgical method in emergency cases diagnosed with diaphragmatic rupture if there is no evidence of significant bleeding.[1] As it can be seen in our study, laparotomy may be needed especially in cases where abdominal organs are herniated into thorax. However, thoracoscopic evaluation of the intrathoracic structures from the diaphragmatic rupture will make the surgeon more comfortable. In the event of organ injury or bleeding, the most convenient surgical method is preferred. Additional surgical pathologies, localization, and size of the diaphragmatic injury should be considered when performing surgical intervention.[6] A thoracoabdominal approach may be conducted if injuries to both sides are suspected.[21] Thoracotomy should be preferred when there is rupture of the right diaphragm and there is no liver damage. Because it is very difficult to see and repair the diaphragm on the liver side with laparotomy. Thoracotomy is the best method in cases above 1 week after trauma because there will be strong adhesions between herniated organs in the thorax and lung pericardium. In our cases, approach was preferred from both sides. In most of them, the procedure was started with thoracotomy. The reason for this was that thoracic trauma was urgent in our cases. It is not recommended to turn the lateral or semi-lateral position of patients with hypovolemia who are unstable. Supine states should be maintained as much as possible. The rate of hypovolemic shock was 64% in our cases, and we were able to perform interventions mostly in the supine position. After debriding the edges of the diaphragm rupture, the diaphragm is repaired with nonabsorbable material in the case of a primary or defect, using a muscle flap of the abdominal wall or synthetic mesh. If necessary, the sutures are passed around the ribs and supported by Teflon pledges.[11] We repaired 9% of our cases with synthetic mesh. Muscle flap of the abdominal wall was not used. Primary repair was enough with nonabsorbable suture material in 91% of the cases. Penetrating injury suggests the possibility of diaphragm injury more easily. There is a possibility of injury to the diaphragm in the thoracoabdominal region, especially in a penetrating trauma that is lower than the 4th rib.[22] In addition, it is more common to skip diagnosis and delay in the etiology of perforating trauma. The most common injury is stabbing. It is usually below 2 cm. In the acute period, herniation may not occur. Over time, the ruptured area can become larger. Many cases are diagnosed in operations performed due to incarceration and strangulation. In two cases, we diagnosed TDI months later. In gun injuries, the damage may be greater. It requires a more careful examination.[11] The complication rate in diaphragmatic injury is between 30% and 68%, and these complications may include atelectasis, pneumonia, pleural effusion, sepsis, multiple organ failure, and hepatic abscesses. In our study, complications were equally distributed. Mortality is usually caused by additional organ injuries in the acute phase. This rate has been reported to be 15% and 40% for blunt trauma and 10% and 30% for penetrating injuries. In our study, the mortality rate was 14%. Two of the cases with mortality were blunt and one was due to penetrating trauma. The main cause of mortality was retroperitoneal bleeding and sepsis due to intestinal strangulation. This has indicated that, in such traumas, simultaneous evaluations and urgent interventions from the thorax and abdomen are important. However, it should not be forgotten that shock, organ injuries, respiratory failure and coma make diagnosis difficult and cause diagnosis delay.[23] Mortality is usually due to additional organ injuries in the acute period. In such traumas, simultaneous evaluation and interventions from thorax and abdomen are of vital importance. There is no correlation between the size of laceration of the diaphragm and mortality–morbidity.[24] However, the location and size of laceration in blunt traumas, pericardial rupture, or retroperitoneal hemorrhage may be significant parameters.


  Conclusion Top


In thoracoabdominal traumas, TDI and additional pathologies accompanying it can be skipped. These pathologies can be detected by laparoscopic and thoracoscopic evaluations. Rapid approach with a good preoperative and peroperative strategy reduces the mortality and morbidity. Based on our study, we suggest that utilizing thoracoscopy during laparoscopy or laparotomy in high-grade TDIs would be lifesaving.

Acknowledgments

The authors thank Mr. Ali Duran for excellent language assistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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