Background: Diaphragmatic hernia after blunt trauma is an uncommon and often undiagnosed condition.



Objectives: We aimed to review patients who presented with delayed blunt traumatic hernia of diaphragm.



Patients and Methods: In this retrospective study, the medical records of six patients treated for blunt diaphragmatic hernias who were admitted to Kashan Shahid Beheshti hospital between June 2007 and June 2011 were analyzed.



Results: Six patients with mean age of 41 years were included in the study. Male to female ratio was 2:1. Mean duration between trauma and admission to the hospital was 6.5 years (2 – 26 years). Five patients had left-sided diaphragmatic hernia. Chest X-ray was obtained from all patients which was diagnostic in 50 percent of the cases (n = 4). Additional diagnostic imaging with computerized tomography (CT) was used in six patients and upper gastrointestinal (GI) contrast study was performed in one patient. All patients underwent thoracotomy incision. Mesh repair was utilized in one patient. The mean hospitalization time was 14.1 days. There was one postoperative death (16.7%).



Conclusions: Late presentation of blunt diaphragmatic hernia is an uncommon and challenging situation for the surgeon. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and perforation of herniated organ

Abdolrahim-Kashi, E.

Davoodabadi, A.

Fakharian, E.

Mirzadeh, A.S.

Mohammadzadeh, M.

kashan university of medical sciences

Research
 Archives of 
Blunt Traumatic Hernia of Diaphragm With Late Presentation
Abdolhossein Davoodabadi 1, Esmaeil Fakharian 1, Mahdi Mohammadzadeh 1*, Esmaeil Ab-dorrahim Kashi 1, Azadeh Sadat Mirzadeh 2
1 Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran2 Student Research Center Committee, Kashan University of Medical Sciences, Kashan, IR Iran
* Corresponding author: Mahdi Mohammadzadeh, Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran. Tel.: +98-9132632168, Fax: + 98-3615620634, E-mail: dmmzn58@gmail.com.
c  2012, Kashan University of Medical Sciences; Published by Kowsar  This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which per-mits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A R T I C L E  I N F O A B S T R A C T
Article history:Received: 05 Aug 2012Revised: 10 Sep 2012Accepted: 18 Sep 2012
Keywords:Diaphragmatic HerniaTraumaDiaphragm
Article type:Research Article Background: Diaphragmatic hernia after blunt trauma is an uncommon and often un-diagnosed condition.
Objectives: We aimed to review patients who presented with delayed blunt traumatic hernia of diaphragm.
Patients and Methods: In this retrospective study, the medical records of six patients treated for blunt diaphragmatic hernias who were admitted to Kashan Shahid Beheshti hospital between June 2007 and June 2011 were analyzed.
Results: Six patients with mean age of 41 years were included in the study. Male to female ratio was 2:1. Mean duration between trauma and admission to the hospital was 6.5 years (2 – 26 years). Five patients had left-sided diaphragmatic hernia. Chest X-ray was obtained from all patients which was diagnostic in 50 percent of the cases (n = 4). Additional diag-nostic imaging with computerized tomography (CT) was used in six patients and upper gastrointestinal (GI) contrast study was performed in one patient. All patients under-went thoracotomy incision. Mesh repair was utilized in one patient. The mean hospital-ization time was 14.1 days. There was one postoperative death (16.7%).
Conclusions: Late presentation of blunt diaphragmatic hernia is an uncommon and challenging situation for the surgeon. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and perfora-tion of herniated organ. Published by Kowsar, 2012. cc 3.0.
  Please cite this paper as: Davoodabadi A, Fakharian E, Mohammadzadeh M, Abdorrahim Kashi E, Mirzadeh AS. Blunt Traumatic Diaphragmatic Hernia With Late Presentation.  Arch Trauma Res. 2012:1(3): 89-92. DOI: 10.5812/atr.7593
 Implication for health policy/practice/research/medical education:Despite the fact that the incidence of traumatic hernia of diaphragma is uncommon, delayed diagnosis and treatment of ruptured diaphragm is associated with increased rates of morbidity and mortality.
1. BackgroundTraumatic injury to diaphragm is an uncommon condi-tion associated with severe blunt trauma which is usually missed in the early presentation to emergency (1, 2). Its incidence is approximately 2% in non-penetrating trau-
ma. The increasing incidence of road traffic accidents has resulted in growing its incidence despite of advanced therapeutic modalities and awareness of medical staff (3, 4). The initial diagnosis of a blunt traumatic injury to the diaphragm is generally difficult because the early clinical and radiological findings are not clear. In acute circum-
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Davoodabadi A et al. Blunt Traumatic Diaphragmatic Hernia 
stances, it is usually found on the table during explor-atory laparotomy, although even then it may be missed (5). Nearly half of the patients remain asymptomatic and present with complications of the diseases several years after the onset of initial trauma (4, 6, 7). Undiagnosed patients with diaphragmatic injury may present with a diverse range of complaints from abdominal discomfort to diaphragmatic tear and visceral herniation second-ary to sudden increase in the intra-abdominal pressure resulting in respiratory and gastrointestinal obstruction symptoms (8, 9). The incidence of diaphragmatic rupture after any kind of thoraco-abdominal trauma is reported between 0.8 and 5%, of which up to 30% present with a delay (10, 11). Less than 2.7% of the diaphragmatic injuries were detected before four months from the initial dam-age (8). Inaccurate interpretation of the imaging studies or intermittent and trivial symptoms of the hernia are main reasons for missed diagnosis (12, 13).
2. ObjectivesClinical presentation and management of 6 cases of delayed blunt traumatic hernia of diaphragm were dis-cussed to highlight challenges in diagnosis and handling of complications.
3. Patients and MethodsSix patients with the diagnosis of delayed blunt trau-matic hernia of diaphragm treated in Kashan Shahid Beheshti university hospital between June 2007 and June 2011 were enrolled to this study. The mechanism, dura-tion of complaints, clinical presentation, site of injury, kind of visceral herniation, surgical repair, and outcome of the patients have been scrutinized. Diaphragmatic hernia repair and organ reduction were performed in all patients through thoracic approach.
4. ResultsMean age (± SD) of the patients was 41 years (± 15) (rang-ing from 25 to 67 years), with a male to female ratio of 2:1. The mean duration between the incident and admission to the hospital was 6.5 years (ranging from 2 to 26 years). All of the patients were victims of car accident. Five out of six patients were affected by left and one by right dia-phragmatic hernias. All of the patients suffered from ab-dominal pain and two patients were admitted with the symptoms of intestinal obstruction. Four patients dem-onstrated respiratory symptoms, including dyspnea. Chest X-ray was performed for all patients as the initial di-agnostic imaging work up. It was diagnostic in 3 patients and showed small bowel and colon loops in hemithorax, while it was recorded as atypical in the other 3 cases in-cluding 2 cases of lung empyema and diaphragmatic dome elevation in the last case. Both thoracic CT scan and barium study were diagnostic in all patients (Figure 
1). Barium study (lateral view) shows that the stomach 
Figure 1. Upper Gastrointestinal (GI) Contrast Study of a Patient Present-ed With Intermittent Abdominal Pain, Vomiting, and Dyspnea, Especially after Heavy Meal, 26 Years from Car Accident
Variants
Number , No. 6
Age, Mean 41
Gender , Male: Female 4:2
Time between operation and trauma, y 6.5
Hospitalization time ,d, Mean 14.1
Presenting symptomsAbdomen pain 6Dyspnea 3Vomiting 3Fever 2
Localization, Left: Right 5:1
Diameter, cm, Mean 11.6
Chest X-rayDiagnostic 3Atypical 3
Herniated organ Stomach 4Transverse colon 3Omentum 2Small bowel 1Liver 2Spleen 1
Table 1. Demographic Features, Clinical Findings, Diagnosis, and Manage-ment of Patients
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Davoodabadi A et al.Blunt Traumatic Diaphragmatic Hernia 
lies in left hemithorax (Figure 1). The most common her-niated organ was stomach (n = 4). Transverse colon was herniated in 3 and liver in 2 patients. Two patients needed herniated organ resection due to micro-perforation and necrosis. The mean diameter of defect in the diaphragm after reduction was 11.1 cm (range: 6 - 16 cm). Primary re-pair was used in 5 patients and Prolene mesh in 1 patient. Mean hospitalization time was 14.1 days (± 3.4days). There was one postoperative death (16.7%), a 67 year-old man with history of car accident 2 years before operation who was admitted with abdominal pain, vomiting, and respi-ratory septic features (fever, tachycardia, tachypnea). The patient underwent left posterlateral thoracotomy with the diagnosis of thoracic empyma due to diaphragmatic herniation, and stomach torsion and gangrene. He died 2 days after the operation. Other patients were discharged without any complication (Table 1).
5. DiscussionEarly diagnosis of diaphragmatic injury is difficult and often delayed. It was detected in 1.3% of the patients in the acute phase with an Injury Severity Score (ISS) of > 15 upon admission to a trauma center. Approximately half of the cases had herniated tissues through the dia-phragmatic tear (12). Sudden intra-abdominal pressure changes may produce diaphragmatic injury, either as a laceration or an avulsion (2). The rupture typically origi-nates at the central tendineum or musculotendinous junction. Although the natural history of the diaphrag-matic injury is unknown, some animal studies have shown that it might heal without development of hernia (14, 15). If diagnosis of the injury is missed after the first admission, patients may be asymptomatic or have in-termittent chronic abdominal or respiratory symptoms due to increased intra-abdominal pressure including constipation, cough, or distension after heavy meal. Sud-den increased intra-abdominal pressure may lead to her-niation and obstruction of hollow organs complicating with strangulation and/or perforation of the herniated contents (16). Approximately 84% of all hernias were on the left side similar to the previous studies (16-18) possi-bly due to relative weakness of left hemi-diaphragm and protective effect of liver on right diaphragm. Diaphrag-matic herniation with blunt trauma was more common in left hemi-diaphragm (12). In the present study, the only patient with right-sided diaphragmatic hernia was a 43-year-old female with a history of blunt trauma 5 years before admission. The patient was manifested by symp-toms of chronic dyspnea and epigastric pain. During the operation, a diaphragmatic defect of 15 cm was detected through which right lobe of liver was herniated. Primary repair of diaphragm was performed to restore the defect. The mean interval between the trauma and operation was almost similar to that in previous studies. It was 6.5 years in our study, 5.9 years in Okan et al. (16) and 4.1 years in Reber et al. (17) studies. In Feliciano et al. (18) study, this 
time was 1 year, but it is noteworthy that their study was performed on diaphragmatic hernia after penetrat-ing injuries. Except for a patient who showed chronic symptoms due to liver herniation through right hemi-diaphragm, other patients were admitted to the hospital with acute problems such acute abdomen and respira-tory insufficiency that mandated urgent operative inter-vention. The initial chest X-ray was diagnostic only in 25% of patients where hemopneumothorax was visible in the thoracic cavity in acute setting of the injury (12). Similar to Reber et al. (17) and Worthy et al. (19), chest X-ray, as an initial imaging, was diagnostic in 50 percent of the pa-tients. Although Okan et al. reported a higher percentage of diagnostic value for chest X-ray (up to 80%), they used the additional diagnostic tests because most of their patients had chronic and long–term complaints (16). In recent studies CT scan and MRI were used for additional imaging (16, 20, 21), while upper gastrointestinal (GI) con-trast studies were used in earlier case reports (22). In the acute phase of diaphragmatic injury, CT scan is able to add 10% to the preoperative diagnostic value of chest X-ray (12). In delayed presentation, each of the CT scan and barium study was 100% diagnostic for diaphragmatic her-nia detection in our study. Orkan et al., as well, reported that CT scan and MRI findings were 100% diagnostic in both penetrating and blunt mechanisms (16). Bodana-pally et al. with the use of multi-detector CT scanning re-ported promising results in penetrating diaphragmatic injuries, with sensitivity, specificity, and accuracy rates of 87%, 72%, and 77%, respectively (23). Therefore, computed tomography is the diagnostic test of choice in suspected patients with diaphragmatic hernia. Similar to the previ-ous case series (17, 18, 22), the preferred method of defect closure in our series was primary repair using interrupt-ed non-absorbable sutures. Although in Orkan et al. study (16) the mean diameter of defect size and mean interval time between trauma and operation were less than those in our study. Orkan et al. used prosthetic material as a preferred method of defect closure. They explained that the mesh was used because defect size and the duration might cause loss of elasticity of the diaphragm. Stomach was the most common herniated organ in the present study. Since the most diaphragmatic injury occurred in left diaphragm, stomach could be considered as the most common herniated organ. Gastric volvulus associ-ated with traumatic diaphragmatic hernia was relatively rare and made the diagnosis even more difficult (24-26). Stomach resection was performed in 2 patients due to mi-cro-perforation and necrosis. During recent decades, ad-vanced diagnostic modalities and postoperative manage-ment lead to decreasing mortality rates due to delayed diagnosis of diaphragmatic herniation from 25% to 10% (17, 22). However, the presence of strangulation with gan-grene and perforation was related to increased morbid-ity and mortality. Mortality rate of undergone emergency repairs in this condition was up to 32% (27). There was one 
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postoperative death in our study due to gastric torsion and gangrene (16.7%). Although most authors granted trans-abdominal approach to repair defects in acute in-juries due to high incidence of associated abdominal injuries in this setting (12, 28), the definite treatment of blunt traumatic hernia of diaphragm was surgical repair with standard posterlateral thoracotomy and reduction of herniated organs into abdominal cavity first, and then repair of injured diaphragm. This approach allowed the surgeon to release strong adhesions between herniated viscera and pleura, and achieve complete clearance of pleural cavity and repair of diaphragmatic defect. While this approach may require additional laparotomy if small or large bowel has to be resected, nevertheless in our study, no patient needed to undergo laparotomy. Ex-cept for one patient who died after the operation due to critical situation (sepsis and stomach gangrene), others were discharged without any complication. In conclu-sion, delayed diagnosis and treatment of ruptured dia-phragm are associated with increased rates of morbidity and mortality and necessitates early aggressive surgical intervention. Despite the fact that the incidence of dia-phragmatic hernia is uncommon, it should be suspected in patients with gastro-intestinal complains and history of recent chest blunt trauma.
AcknowledgmentsThe authors would like to thank the operating room personnel in Kashan Shahid Beheshti hospital for their assistance in data collection.
Authors’ ContributionAbdolhossein Davoodabadi (study manager and study designer), Esmaeil Fakharian (article writing), Mahdi Mohammadzadeh (study design and article writing), Es-maeil Abdorrahim Kashi (data collection ), Azadeh Sadat Mirzadeh (data analysis ).
Financial DisclosureNone declared.
Funding/SupportNone declared.
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Blunt Traumatic Hernia of Diaphragm With Late Presentation

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Blunt Traumatic Hernia of Diaphragm With Late Presentation

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