Laparoscopic repair of a penetrating injury of the diaphragm

Abstract text (incl. references and figure legends)
CASE HISTORY

A 32-year-old male patient, with no known past medical history, was admitted to the emergency room after being stabbed multiple times by a cold weapon, during a conflict occurred in the previous hour.

CLINICAL FINDINGS

The victim presented with hypotension and tachypnea. He was agitated and noncompliant, requiring sedation. eFAST was negative for pericardial effusion, as well as for free fluid in the abdominal compartments, but positive for a left pneumothorax. A chest tube was placed, and he was intubated with improvement of his hemodynamic profile. He sustained multiple stab wounds: one in the epigastric region with peritoneal violation; two in the precordial area, near xiphoid process; and two around left scapula.

INVESTIGATION

CT scan revealed a pneumomediastinum with possible pericardial compromise; a small left pleural effusion with a partial collapse of the left lower lobe; and a perihepatic pneumoperitoneum without any free fluid in the abdominal cavity.

DIAGNOSIS

An exploratory laparoscopy was performed. The optical trocar was inserted through the epigastric wound and two additional ports were placed in both flanks. A 3.5 cm laceration, with herniated omentum, was found in the center of the diaphragm. Through the defect, a 1 cm pericardial laceration with no active bleeding was seen. There was no evidence of other organ injury.

THERAPY AND PROGRESSIONS

A tension-free repair was performed with a barbed suture 2/0. There was no indication for pericardial repair, after observation by a thoracic surgeon. He was discharged on day 5, after an uneventful course. He missed the follow up appointment.

COMMENTS

Any thoracoabdominal wound can cause a diaphragmatic injury, but the diagnosis can be challenging since the physical examination may be unremarkable, and up to 50% of diaphragmatic ruptures are missed on initial imaging. In stable patients, the laparoscopic repair of these injuries is safe and feasible with the appropriate skill set.

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