Diaphragmatic rupture with splenic and gastric injury after blunt thoraco-abdominal injury: Management with damage control

Case history: 23-year-old man victim of a road accident with closed thoraco-abdominal trauma, transferred to our Level I trauma center

Clinical findings: received intubated and under invasive mechanical ventilation. In the assessment of B, symmetrical chest movements are present and a left thoracic drain had already been placed with 200cc of hematic content; peripheral O2 saturation of 100%. In terms of C, on vasopressor support, tachycardic but with mean arterial pressures of 75 mmHg. Neurologically, the pupils were isochoric and no motor lateralization was detected. There were no open fractures/deformities

Results: trauma protocol CT scan shows 7-10th rib fracture and rupture of the left hemidiaphragm with abdominal herniation; splenic laceration and pneumoperitoneum were identified

Diagnosis: diaphragmatic rupture with splenic laceration and hollow visceral perforation

Therapy and Progression: exploratory laparotomy confirms a grade IV (AAST) rupture of the left hemidiaphragm (herniation of the stomach, spleen and colon), grade IV (AAST) splenic laceration and grade II (AAST) stomach perforation. A damage control procedure was performed: splenectomy, atypical gastrectomy and primary diaphragmatic repair with vacuum-assisted abdominal closure. A 2nd look laparotomy confirmed an intact gastric suture and the definitive abdominal closure was performed on PO4. The postoperative period was complicated by thoracic empyema and surgical site infection, treated with antibiotic and negative pressure therapy (Dindo-Clavien II). He was discharged on the 38th day and the 3 months follow-up appointment showed a god recovery

Comment: traumatic diaphragm injuries are rare but potentially fatal situations. The approach should be early and directed at restoring herniated content to improve respiratory physiology and control bleeding and contamination. Immediate laparotomy in a damage control strategy is warranted for unstable patients and was the key to success in this case

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