Post-traumatic diaphragmatic hernia. The danger of a hidden enemy

Abstract text (incl. references and figure legends)

Case history: 75-year-old patient, airplane pilot. Car accident in 2007 with closed thoracic, abdominal and pelvic trauma. After trauma patient continued flying with non-pressurized airplanes. The patient was admitted to the emergency room due to abdominal pain for 4 days, with associated nausea, vomiting and constipation.

Clinical findings: The patient was hemodynamically stable. Slightly distended abdomen, tender on deep palpation in lower abdomen. No guarding.

Results: A Thoracoabdominal CT scan showed an hernial defect of the right hemidiaphragm with 2.7 cm neck and liver medialization, through which a volvulated sigmoid colon was incarcerated with suffering signs. Passive atelectasis of themiddle and lower right lung lobes.

Diagnosis: Complicated right diaphragmatic hernia with volvulated and incarcerated sigma.

Therapy and Progression: Urgent surgery was performed, starting with an exploratory laparoscopy. The hernia was then reduced, diaphragmatic closure with v-lock 3/0 and resection of perforated sigmoid colon through assistance laparotomy and mechanical L-L anastomosis was completed. Patient was admitted to ICU. Postoperative day 6 the patient presented tachypnea and respiratory distress secondary to condensation and right pleural effusion, resolved with aspiration and respiratory physiotherapy. Discharged home on the 10th postoperative day.

Comments: Post-traumatic diaphragmatic hernia occurs in 1-5% of cases. About 13% appear on the right side. Diaphragmatic injuries may be followed by immediate herniation of the abdominal viscera into the chest, or develop a late presentation. In our case, continuous exposure to environment pressure changes may have favored a progressive increase of the hernia volume. In many cases, its asymptomatic presentation delays diagnosis and may result in life-threatening complications. Laparoscopic repair of posttraumatic diaphragmatic hernias without mesh is safe and effective, and allows early postoperative recovery.

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