Laparotomy Vs Thoracotomy to Repair Traumatic Diaphragmatic Hernia after Blunt Trauma

Background: Blunt injuries of the diaphragm are becoming more common with higher automotive speeds and increased use of seat belt restraints. In some cases, the decision about whether to perform thoracotomy or laparotomy to repair the injured diaphragm is difficult. It is the most commonly missed injury after blunt thoracic injuries. There is a wide range of clinical presentations and a wide range of complications. Successful diagnosis and treatment require a high level of suspicion and early surgical repair. Objectives: We reviewed our experience in managing these injuries over the last 5 years to choose the proper approach in these injuries. Material and Methods: Retrograde study included patients admitted into Suez Canal University Hospitals or Ben Sinai Teaching Hospitals in Hadhramout over the past five years, from 1st April 2003 to 31st March 2008 that had been diagnosed and treated as having traumatic rupture of the diaphragm and traumatic diaphragmatic hernia. Clinical presentation, diagnosis, associated lesions and management were reviewed. Results: We studied 48 patients, 32 male patients (66.6%) and 16 female patients (33.4%). The age ranged between 8 and 67 years. There were 8 isolated lesions (16.7%), 20 cases associated with intra-abdominal lesions (41.6%), 8 patients with intra-thoracic injuries (16.7%) and 12 patients with abdominal and thoracic injuries (25%). Intra-abdominal associating lesions diagnosed or suspected after ultrasonography in 20 patients indicated laparotomy as the chosen approach to deal with the lesion and reduce the hernia and repair the diaphragm. Intra-thoracic associating lesions indicated thoracotomy in 8 patients to deal with the intra-thoracic lesions, reduce the hernia and repair the diaphragm. In presence of abdominal and thoracic injuries, laparotomy was the chosen approach as long as the thoracic injuries do not indicate intervention e.g, fractured ribs in 4 patients. Lung laceration and fractured ribs were found in 3 cases and lung contusion and fractured ribs in 5 patients. The isolated lesions of traumatic diaphragmatic hernia; In 5 cases, the lesion was suspected after chest X-ray and confirmed after insertion of Ryle’s tube and were operated upon through thoracotomy, reduction of the hernia indicated widening of the diaphragmatic tear in 3 cases, injury to small bowel happened in two cases and this indicated later laparotomy. In the other 3 patients the lesion was missed and all the three were operated upon through a laparotomy without any intra- abdominal complications. Conclusion: Presence of evident intra-thoracic lesion which indicates direct intervention is the only indication for thoracotomy in such patients; otherwise, laparotomy is the approach with easy repair and minimal post-operative complications.