Case history This is the case of an 82-year-old patient with past medical history significant for a bicycle accident two years earlier.
Clinical findings The patient presented at the ER with increasing epigastric pain, vomiting, and no bowel movement from the previous day.
Investigation/Results CT-scan showed a voluminous left diaphragmatic hernia measuring 4.6 cm in diameter and containing small bowel.
Diagnosis The diagnosis was small bowel obstruction due to diaphragmatic hernia.
Therapy and Progressions The patient underwent emergency surgery, and a laparoscopic direct hernia repair was performed. After ICG angiography, no perfusion defects were identified, and no bowel resection was required. A thoracic drain was placed in the left chest. Gastric tube was removed on POD 1, when the patient started the solid food diet. The thoracic drain was removed on POD 5 and the patient was discharged on POD 6. At one-month follow-up no complication occurred.
Comments Diaphragmatic hernia following blunt abdominal injuries occurs in 0.8–1.6% of cases. Patients may stay asymptomatic for long time, presenting symptoms after 24h up to 50 years. The nature of symptoms can vary and is often more severe in case of left or bilateral herniation. They typically present with abrupt, severe epigastric pain often associated with nausea and vomiting. The laparoscopic approach is preferred for either primary closure or mesh placement, depending on the defect size. In our report, the patient experienced small bowel obstruction two years after injury and underwent a successful laparoscopic intervention. The use of ICG can be a valuable added tool for identifying ischemic bowel, preventing unnecessary bowel resections.
References
Uribe AF, Cantú HO, Pérez LPC, Rock de la Peña GR, Ornelas EC, Gallardo RAS, et al. Post-Traumatic Left Diaphragmatic Hernia of Late Presentation: Case Report. World J Surg Surgical Res. 2023; 6: 1448.
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