dr.

Chairul Sandro
Diaphragma Injury (AAST)
 Grade Injury Description

 I Contusion
 II Laceration <2 cm
 III Laceration 2-10 cm
 IV Laceration > 10 cm with tissue loss ≤ 25cm
 V Laceration with tissue loss > 25 cm

 (Advance one grade for bilateral injuries)

 American Association for the Surgery of Trauma
 The diaphragm separates the chest and the abdominal
cavities.
 A tear in the diaphragm allows abdominal viscera to
enter the chest. Such an event can lead to difficulty in
breathing and respiratory distress. The process is more
rapid with spontaneous or unsupported respirations. It
may also lead to bowel/visceral strangulation.
 Prompt identification is mandatory to avoid ischemia
to the viscera or respiratory failure.
 Initiate the ATLS protocol with each trauma patient
 Intubate the patient if the patient is in respiratory
distress.
 Obtain necessary adjuncts such as a chest radiograph,
however, a chest radiograph may be non-diagnostic.
 If the patient has sustained a blunt abdominal injury
with a tear in the diaphragm on the left or a
penetrating injury to the left diaphragm, a chest
radiograph may display viscera in the left chest cavity.
 If the chest radiograph is suspicious, a nasogastric
tube may be inserted into the patient’s stomach. If a
repeat chest radiograph is obtained, examine the
radiograph for evidence that the nasogastric tube
placement into the chest.
 Commonly obtained a thoracic computed tomography
scan will most likely be non-diagnostic for a
diaphragmatic injury.
 If necessary, a contrasted upper gastrointestinal
swallow may be obtained to assess the location of the
stomach. In addition, contrast may be used in the
nasogastric tube to help identify gastric herniation
into the chest.
 If the injury is to the right diaphragm, assess the chest
radiograph for an abnormal “hump” in the lateral
diaphragm which is suggestive of a large laceration of
the diaphragm with protrusion of the liver.
 Confirmation of diaphragmatic injuries by computed
tomography of the chest or by thorascopic or
laparoscopic evaluation of the right chest.
 While laparoscopy may be challenging to assess the
entire diaphragm, it may be useful, especially when
examining the abdomen for other concomitant
injuries.
 Once identified, diaphragmatic injuries must be
repaired promptly with reduction of abdominal viscera
back into the abdomen, inspection of those abdominal
viscera, and debridement of necrotic diaphragmatic
muscle if necessary.
 Repair all left-sided injuries even if it is small while
small injuries on the right side may not require repair
(intra-operative determination for repair is
recommended.)
 For those diaphragmatic injuries that are early on in
the patent’s clinical course, consider an open
abdominal approach, however, laparoscopic repair has
been described for such injuries.
 Diagnostic laparoscopy provides a vital tool for
detecting occult diaphragmatic injury among patients
who have no other indications for formal laparotomy.
 For those diaphragmatic injuries that are late in the
patient’s clinical course, consider a trans-thoracic
approach. The patient may require both abdominal
and thoracic approaches if the dissection is difficult,
yet could be facilitated with a dual cavity exploration.
 Mesh replacement is rarely needed but several options
are available, including both synthetic and non-
synthetic substitutes.
 Close all injuries using a non-absorbable suture in an
interrupted or running fashion.
 Place a 32 or 36 French chest tube into the thoracic
cavity on the side of injury prior to repairing the
diaphragm. This chest tube may be removed if there is
no injury to the lung parenchyma and no
pneumothorax where a chest tube would therefore not
be warranted.
REFERENCES
 Carter BN, Giuseffi J, Felson B. Traumatic diaphragmatic
hernia. Am J Roentgenol Radium Ther Nucl
Med. Jan 1951;65(1):56-72.
 Rizoli SB, Brenneman FD, Boulanger BR, Maggisano R. Blunt
diaphragmatic and thoracic aortic rupture: an emerging injury
complex. Ann Thorac Surg. Nov 1994;58(5):1404-8.
 Grimes OF. Traumatic injuries of the diaphragm. Diaphragmatic
hernia. Am J Surg. Aug 1974;128(2):175-81.
 Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt
diaphragmatic rupture. Eur J Cardiothorac
Surg. Apr 1999;15(4):469-74.
 Barbiera F, Nicastro N, Finazzo M, et al. The role of MRI in
traumatic rupture of the diaphragm. Our experience in three
cases and review of the literature. Radiol Med
(Torino). Mar 2003;105(3):188-94.
REFERENCES
 Barsness KA, Bensard DD, Ciesla D, et al. Blunt diaphragmatic
rupture in children. J Trauma. Jan 2004;56(1):80-2.
 Bergqvist D, Dahlgren S, Hedelin H. Rupture of the diaphragm
in patients wearing seatbelts. J Trauma. Nov 1978;18(11):781-3.
 Boulanger BR, Milzman DP, Rosati C, Rodriguez A. A
comparison of right and left blunt traumatic diaphragmatic
rupture. J Trauma. Aug 1993;35(2):255-60.
 Boulanger BR, Mirvis SE, Rodriguez A. Magnetic resonance
imaging in traumatic diaphragmatic rupture: case reports. J
Trauma. Jan 1992;32(1):89-93.
 Guth AA, Pachter HL, Kim U. Pitfalls in the diagnosis of blunt
diaphragmatic injury. Am J Surg. Jul 1995;170(1):5-9.
REFERENCES
 Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS. The current
status of traumatic diaphragmatic injury: lessons learned from
105 patients over 13 years. Ann Thorac Surg. Mar 2008;85(3):1044-
8.
 Jarrett F, Bernhardt LC. Right-sided diaphragmatic injury: rarity
or overlooked diagnosis?. Arch Surg. Jun 1978;113(6):737-9.
 Leaman PL. Rupture of the right hemidiaphragm due to blunt
trauma. Ann Emerg Med. Jun 1983;12(6):351-7.
 Leppaniemi A, Haapiainen R. Occult diaphragmatic injuries
caused by stab wounds. J Trauma. Oct 2003;55(4):646-50.
 Matsevych OY. Blunt diaphragmatic rupture: four year's
experience. Hernia. Feb 2008;12(1):73-8.
REFERENCES
 Mihos P, Potaris K, Gakidis J, et al. Traumatic rupture of the
diaphragm: experience with 65
patients. Injury. Mar 2003;34(3):169-72.
 Nau T, Seitz H, Mousavi M, Vecsei V. The diagnostic dilemma of
traumatic rupture of the diaphragm. Surg
Endosc. Sep 2001;15(9):992-6.
 Patselas TN, Gallagher EG. The diagnostic dilemma of
diaphragm injury. Am Surg. Jul 2002;68(7):633-9.
 Powell BS, Magnotti LJ, Schroeppel TJ, Finnell CW, Savage SA,
Fischer PE, et al. Diagnostic laparoscopy for the evaluation of
occult diaphragmatic injury following penetrating
thoracoabdominal trauma. Injury. May 2008;39(5):530-4.
 Ramos CT, Koplewitz BZ, Babyn PS, et al. What have we learned
about traumatic diaphragmatic hernias in children? J Pediatr
Surg. Apr 2000;35(4):601-4.
REFERENCES
 Rodriguez-Morales G, Rodriguez A, Shatney CH. Acute rupture
of the diaphragm in blunt trauma: analysis of 60 patients. J
Trauma. May 1986;26(5):438-44.
 Sangster G, Ventura VP, Carbo A, et al. Diaphragmatic rupture: a
frequently missed injury in blunt thoracoabdominal trauma
patients. Emerg Radiol. Nov 29 2006.
 Schneider CF. Traumatic diaphragmatic hernia. Am J
Surg. Feb 1956;91(2):290-7.
 Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic
injuries: spectrum of radiographic findings. Radiographics. Jan-
Feb 1998;18(1):49-59.
 Shatney CH, Sensaki K, Morgan L. The natural history of stab
wounds of the diaphragm: implications for a new management
scheme for patients with penetrating thoracoabdominal
trauma. Am Surg. Jun 2003;69(6):508-13.
REFERENCES
 Shatney CH, Sensaki K, Morgan L. The natural history of stab
wounds of the diaphragm: implications for a new management
scheme for patients with penetrating thoracoabdominal
trauma. Am Surg. Jun 2003;69(6):508-13.
 Shehata SM, Shabaan BS. Diaphragmatic injuries in children
after blunt abdominal trauma. J Pediatr
Surg. Oct 2006;41(10):1727-31.
 Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic
injury of the diaphragm. Injury. Jul 1991;22(4):303-6.
 Tansley P, Treasure T. Trauma care and the pitfalls of
diaphragmatic rupture. J R Soc Med. Mar 1999;92(3):134-5.
 Voeller GR, Reisser JR, Fabian TC, et al. Blunt diaphragm
injuries. A five-year experience. Am Surg. Jan 1990;56(1):28-31.
Thank You