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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 3  |  Page : 78-80

Traumatic diaphragmatic hernia in a pregnant woman


1 Department of General Surgery, León General Hospital, Guanajuato, México
2 Department of General Surgery, General Surgery Hospital, Mexican Institute of Social Security, México City, México
3 Department of General Surgery, Ixtapaluca High Specialty Regional Hospital, UNAM, México City, México

Date of Submission16-Mar-2017
Date of Acceptance29-Jun-2017
Date of Web Publication15-Sep-2017

Correspondence Address:
Luis Angel Medina Andrade
Department of General Surgery, General Surgery Hospital #30, Mexican Institute of Social Security, México City
México
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_8_17

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  Abstract 

Traumatic diaphragmatic hernia is always a challenge for diagnosis. The present case was a penetrating thoracoabdominal trauma in a pregnant woman that was not initially suspected but detected when adequate treatment was performed, and good results were obtained. Due to the high rate of associated complications, we should consider this diagnosis initially.

Keywords: Abdominal trauma, diaphragmatic hernia, trauma during pregnancy


How to cite this article:
Carmona OA, Andrade LA, Misael SG, Dartigues JC. Traumatic diaphragmatic hernia in a pregnant woman. Transl Surg 2017;2:78-80

How to cite this URL:
Carmona OA, Andrade LA, Misael SG, Dartigues JC. Traumatic diaphragmatic hernia in a pregnant woman. Transl Surg [serial online] 2017 [cited 2019 May 23];2:78-80. Available from: http://www.translsurg.com/text.asp?2017/2/3/78/214807


  Introduction Top


The diagnosis of diaphragmatic hernia is not easy. This pathology could be congenital or acquired, and penetrating thoracic and abdominal blunt trauma are the most common causes of origin. Unfortunately, acquired diaphragmatic hernias often occur asymptomatic initially, and if they are not diagnosed early, by imaging studies, the presentation in the acute setting is associated with severe complications and mortality (near 30%).[1],[2] In the present case, the diaphragmatic involvement was not suspected by the missile trajectory, but through other factors such as elevation of the diaphragmatic dome by the 39 weeks of gestation.


  Case Report Top


A 30-year-old female, at 39 weeks of pregnancy, was brought to emergency room secondary to an accidental gunshot in thorax, an hour before arrival. The patient reported no history of pathologies, chronic diseases, allergies, or surgeries. It was her first pregnancy. At physical examination, gunshot entrance hole was found in the left fourth intercostal space anterior axillar line, and exit hole in the eighth left intercostal space costovertebral angle, presenting subcutaneous emphysema in the ipsilateral thorax and with limited bilateral thoracic movements. The patient referred pain in the gunshot holes. Hemodynamically, she was stable with arterial tension 110/80 mmHg, cardiac rate 110 beats/min, 26 breaths/min, temperature 36.8°C, and with no cardiac arrhythmias. Owing to pregnancy, a regular globular enlargement of uterus was seen with bowel movements. The amniotic liquid index was normal, fetus was alive and in cephalic position with unaltered limbs, and fetal cardiac frequency was 145 beats/min. A 38-Fr pleural drain was placed in left thorax evacuating 200 cc of hematic liquid, without the need for a continuous drain. At this moment, as the hemoneumothorax was resolved, no further imaging studies were done as no other lesion was suspected.

Considering the high risk of complications suspected in the following hours, the obstetric team decided to perform a caesarean on the patient, 2 h after which a newborn was born weighing 3,165 g, crown to heal length of 50 cm, Apgar scale of 6–8 points, with fetal cardiac frequency of 140 beats/min, and total postpartum hemorrhage quantified at 500 cc. About 6 h after birth patient presented hemodynamic instability, requiring dobutamine infusion and ventilatory support, and was immediately shifted to Intensive Care Unit for a suspected hypovolemic shock. A chest radiograph, with oral contrast, was requested, showing a mass occupying about 50% of the left hemithorax, without adequate pulmonary expansion [Figure 1]. Pleural drain was mobilized evacuating 400 cc of hematic liquid and a thoracic computed tomography scan was acquired, revealing a diaphragmatic hernia with gastric disruption to thorax, occupying more than 50% of hemithorax and displacing heart and great vessels [Figure 2] and [Figure 3]. Considering the high risk of strangulation, cardiothoracic service recommended an immediate surgery, at 24 h after admission, a left anterolateral thoracotomy was performed on the patient, finding a posteromedial diaphragmatic hernia of 5 cm [Figure 4], with two-third of stomach in the thorax exhibiting about 2 cm of ischemic lesion, with no necrosis, in the anterior gastric surface that was only invaginated with a Lembert stitch. Stomach was reduced to abdomen and the diaphragmatic defect was closed with interrupted Smith Jones stitches. The patient did not present any electrocardiographic alteration during surgery. A thoracic drain was placed and secondary to the good progress in the next 48 h, ventilatory support and vasoactive agents were withdrawn, with thoracic tube removed at 72 h without complications. Four days after surgery patient was shifted to department of general surgery and after 2 days, with resuming oral intake of food, patient was discharged uneventfully.
Figure 1: Thorax-postero-anterior radiography with contrast, showing an air bubble with contrast content in left hemithorax

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Figure 2: Thoracoabdominal computed tomography scan reconstruction showing gastric bubble in the thorax, displacing the heart to the right

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Figure 3: Thoracic computed tomography scan coronal view showing gastric bubble in left hemithorax with contrast medium content

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Figure 4: Left diaphragm with a posteromedial disruption by the bullet

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  Discussion Top


Diaphragmatic hernia is a congenital or acquired defect in diaphragm. Most of the congenital diaphragmatic hernia manifests in newborns as acute respiratory failure secondary to pulmonary hypoplasia, with only a few cases remaining concealed until adulthood. Trauma is the most common cause of acquired diaphragmatic hernia, described by Senner in 1541, and presents after high energy blunt or penetrating trauma.[2],[3]

Considering the mechanism of disruption, traumatic diaphragmatic hernias can be secondary to blunt or penetrating trauma. Of the two possibilities, the blunt trauma is associated with higher morbidity and mortality owing to its high amount of energy and associated multi-organ lesions.[2]

The traumatic diaphragmatic hernia has been classified into acute, latent, and obstructive phase. The acute presentation is in the patient with polytrauma and immediate detection by suspect or symptomathology, and the latent phase is when herniation occurs through undetected diaphragmatic ruptures and rents. The obstructive phase is when the loop herniating obstructs, and the patient develops distension and strangulation.[3] In the current report, the patient presented at latent phase and developed dyspnea at 6 h after hospital presentation.

The statistics of penetrating trauma reveal diaphragmatic injury involvement in about 0.8% to 20% of the cases, of which almost 26% did not have any related recognizable symptom. Although the surgical management of any thoracic or abdominal penetrating trauma may allow the early identification of diaphragmatic hernia, many of them remain unrecognized owing to the tendency of conservative management of traumatic injuries, thus increasing the rate of misdiagnosis in the acute phase (33%–67%).[3] This is one of the reasons why in the present case we missed diaphragmatic hernia as concentration was on to resolve the hemoneumothorax. Further added by the absence of associated symptoms, we did not suspect the presence of diaphragmatic hernia or the need for further imaging studies.

The reported statistics of patients in obstructive phase reveal an increased rate of the morbidity (>60%) and mortality (25%–80%).[4],[5] This phase would be associated with symptoms secondary to the viscera occupying thorax region, such as dyspnea and orthopnea (20%), intestinal obstruction (28%), and chest pain (69%). The more frequent involved visceral structures are stomach, small intestine, colon, and spleen.[4],[5]

Chest X-ray is the usually requested initial investigation, but various studies report a low sensibility (25%–49%) of the procedure. On the other hand, thoracoscopy has been advocated in the acute setting with a reported sensitivity and specificity approaching 100%. Therapeutic approach depends on the phase of case presentation. For the latent phase an elective approach would be preferred, but in the obstructive phase, an emergency surgery must be performed for the high risk of visceral ischemia, necrosis, and perforation to abdominal and thoracic cavity, with the associated high morbidity and mortality.[2],[3]

The suggested treatment for diaphragmatic hernias of <10 cm is the primary closure with interrupted stitches using a nonabsorbable suture by laparoscopic or open approach, and in the case of bigger defects the use of a biological mesh or a dual mesh (polypropylene and polytetrafluoroethylene) is recommended. Both of them have reported good outcomes, especially in avoiding fistula formation.[2]

In the present case, as mentioned before, the diaphragmatic hernia was not suspected by the injury mechanism and missile trajectory, but the anatomic changes related with pregnancy must had contributed to diaphragm elevation and perforation during initial injury, with subsequent gastric herniation to thorax. Initially, further to thoracic tube placement no other image analysis was requested as we believed that the hemoneumothorax was resolved, like in more than 90% of thoracic penetrating traumas. However, considering the pregnancy status, it is essential to suspect other possible lesions such as diaphragmatic perforation. Fortunately, patient received surgical management in time, and the ischemic lesion not requiring gastrectomy or any other procedure, resulting in positive outcome.

In conclusion, during evaluation of thoracoabdominal trauma, blunt or open, diaphragmatic involvement must be considered. In case of suspected involvement by the location of injury and condition of the patient, such as pregnancy in the presented case, the correct evaluation by imaging studies or minimally invasive techniques is indicated to discard or confirm the diagnosis of diaphragmatic hernia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pakula A, Jones A, Syed J, Skinner R. A rare case of chronic traumatic diaphragmatic hernia requiring complex abdominal wall reconstruction. Int J Surg Case Rep 2015;7C:157-60.  Back to cited text no. 1
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2.
Angel MA, David CP, Laura MA, Abraham MA, Stephanie SC, Grecia OR. Bochdalek hernia and repetitive pancreatitis in a 33 year old woman. Int J Surg Case Rep 2014;5 (10):743-5.  Back to cited text no. 2
    
3.
Blitz M, Louie BE. Chronic traumatic diaphragmatic hernia. Thorac Surg Clin 2009;19 (4):491-500.  Back to cited text no. 3
    
4.
Petrone P, Asensio JA, Marini CP. Diaphragmatic injuries and post-traumatic diaphragmatic hernias. Curr Probl Surg 2017;54 (1):11-32.  Back to cited text no. 4
    
5.
Andrade LA, Collazos SS, Martinez Ferretiz MA, Perez Munñoz FY, Ruiz B, Gonzalez GI. Bochdalek hernia with gastric necrosis in a 54-year-old man, case report and review of the literature. MOJ Clin Med Case Rep 2016;4 (2):84.  Back to cited text no. 5
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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