Rare presentation of right side traumatic diaphragmatic herniation in female : A Rare

Case

: A CASE REPORT

1
Dr. Bhavesh vaishnani, 2Dr.Mayank Vekariya,3Dr.Vikrant Patel

1-Dr Bhavesh Vaishnani

MS (General Surgery) FMAS, FIAGES
Associate Professor
Department of Surgery
P. D. U. Medical College & Hospital
Rajkot
Address:
Mo.-9824207281
Email:drbvaishnani@gmail.com

2-Dr Mayank Vekariya

MS, (General Surgery)
Assistant Professor,
Department of Surgery
P.D.U. Medical College
Rajkot, Gujarat India.
Mo. 9429728947
Email: dr.mayankvekariya@ymail.com

3-Dr Vikrant Patel

3rd year resident doctor
PDUMC,Rajkot.
ABSTRACT:

The diaphragmatic hernia is defined as a defect in the continuity of muscular fibers

which allow communication among abdominal and thoracic cavities. Diaphragmatic hernias
can have a congenital origin as a result of the alteration in the fusion of pleuroperitoneal
membranes or in the formation of the transverse septum during development, which origin
can be traumatic as a consequence of a muscle tear due to penetrating, iatrogenic injuries or
due to blunt abdominal trauma. The traumatic diaphragmatic hernia diagnosis is based on
images studies. Conventional chest x-rays remains as the initial evaluation method in patients
with a suspicion of a traumatic tear of the diaphragm. Sensitivity between 27 and 73% has
been described. Multiple detector computed tomography (MDCT) has become the diagnosis
method for patients with traumatic diaphragmatic hernia suspicion. Studies have proven that
the sensitivity of this method ranges between 71 - 90% and a specificity between 98 and
10.Diaphragmatic injuries related to trauma are rare and frequently missed. Acquired
diaphragmatic hernias occur after blunt or penetrating thoracic or abdominal trauma. Right
sided diaphragmatic hernia is rare because of protection by the liver. Moreover, right
hemidiaphragm is congenitally stronger. Right sided hernia occurs in 0.83.6% of blunt
trauma cases.Traumatic diaphragmatic hernia (TDH) is frequently missed in the acute trauma
setting because of non-specific features, lack of familiarity with the condition and initial
small size of hernia.

KEY WORDS: Diaphragmatic hernia, Blunt abdominal trauma

INTRODUCTION: CASE PROFILE:

A 55 year old female Hindu patient of low socio-economic class presented with the chief
complaint of right upper abdominal and right lower chest pain since 1day after blunt trauma.
H/O trauma while working in farm
No H/O vomiting
No H/O fever
No Burning micturition

PAST HISTORY: operation for 1st rib excision before 20 years

FAMILY HISTORY: - not significant

PERSONAL HISTORY :- not Significant

P/A: soft,generalised tenderness with garding with no rigidity

INVESTIGATIONS

Hb- 13.5 gm. %, TLC- 8,000/cumm,

S. Creatinine- 0.8 gm%, B.urea -22

USG- NAD

Xray chest PA bowel loop like opacity seen in right lower zone anterior aspect S/O
traumatic diaphragmatic rupture with anterior diaphragmatic hernia

CECT ABDOMEN WITH PELVIS:

About 4.5 to 5.5 cm defect in right dome of diaphragm anteriorly withherniation of large
bowel with mesocolon without any sign of obstruction. S/O Traumatic diaphragmatic hernia

MANAGEMENT
Laproscopic converted to open right side diaphragmatic hernia repair with
meshplasty(7.5*15cm) with right side ICD insertion

Post-operative outcome

Oral started on POD,

ICD and Drain removed on POD

Discharge on POD

DISCUSSION

Trauma is the leading cause for acquired diaphragmatic hernias. Incidence of traumatic
diaphragmatic injuries ranges from 5.217%, where in blunt injuries share 0.81.6%.
However,diaphragmatic rupture along with diaphragmatichernia occurs in 3% of abdominal
injuries.Traumatic diaphragmatic hernia is more commonin males than in females. Blunt
injury leads to74% of acquired hernias.Delayed presentation occurs in as many as 30%,
because most hernias are small to begin withbut enlarge due to pressure differences
betweenthoracic and abdominal cavities to allow herniation.CT scan is the diagnostic tool of
choice with a sensitivity of 73%.
Signs on CT SCAN
Direct signs Abrupt loss of diaphragm continuity associated with a thickening of the free
edge due to retraction or hemorrhage . More easily spotted when the defect is small or in
contact with the abdominal fat or the aerated lung. No visualization of the hemidiaphragm.
A sign commonly related to large hernial defects . Dangling diaphragm sign. A comma-
shaped curving of the free edge at the rupture site . Associated with the focal thickening of
the torn diaphragmatic edge.
Indirect signs Protrusion of abdominal organs or peritoneal fat into the pleural space .
Collar sign. A sign secondary to the compression of a herniated structure at the site of rupture.
Dependent viscera sign. A reference to the herniated abdominal organ in direct contact with
the posterior thoracic wall . This sign has no interposition of the lung parenchyma. Hump
sign. A consequence of hepatic herniation. Most of the times it is related to a hypodense band
in the hepatic parenchyma between the torn diaphragm edges, a consequence of a
compression-driven hypoperfusion condition. Elevated abdominal organs. The cephalic
displacement of abdominal organs causes the contralateral hemidiaphragm to be at a lower
level. A coronal reconstruction could suggest a rupture if a displacement of more than 5 cm in
the right side and 4 cm in the left side.
Diaphragmatic rupture and subsequent herniation pass through three phases: initial phase, at
the time of trauma; delayed phase, where defect enlarges or herniation occurs
(asymptomatic); and obstructive phase, where patient presents with complications of hernia
.e.g., obstruction,strangulation or posterior rupture.Most common organs that herniated
include stomach, spleen,colon, small bowel and liver. In cases of missed or delayed
diagnosis, mortality rises up to 30%.
Surgical management depends upon time of presentation. In the acute phase, a laparotomy is
indicated. When diagnosed later, a thoracotomy may be performed to address intrathoracic
adhesions Laparoscopy,thoracoscopy or video-assisted thracoscopic surgery (VATS) may be
considered instable patients. In our case, we considered upper midline laparotomy to assess
the bowel for viability.Primary surgical repair is reserved for small defects. For large defects,
mesh may be used. Since right-sided diaphragmatic hernia is rare and difficult to diagnose
initially, patients present with complications increasing risk of morbidity and mortality. A
thorough evaluation of patientscomplaints and past history, detailed examination with
involvement of radiologist will lead to initial accurate diagnosis.

Conclusions
Recognition of a traumatic diaphragmatic hernia in the immediate post-traumatic period is
difficult, due to associated injuries and to the fact that several radiological features suggestive
of hernia may mimic those of chest injuries. A careful history, examination, and awareness of
the possibility of the condition and its complications are essential if these patients are to be
managed successfully. despite significant advances in diagnostic technology, traumatic
diaphragmatic hernias remain challenging entities. Left-sided hernias are generally believed
to be more common, yet we know that the overall incidence of right traumatic diaphragmatic
hernias is likely underestimated. Factors resulting in increased intraabdominal pressure can,
in fact, reveal missed diaphragmatic defects. We accordingly hypothesize that right-sided
diaphragmatic hernias occur at a higher rate than is reported in the literature as the anatomic
lie of the liver impedes visceral incarceration and allows them to remain asymptomatic.
Factors predisposing to increased intraabdominal pressure may be the impetus required to
uncover these missed defects and should be entertained when one encounters a delayed
presentation of a traumatic diaphragmatic hernia.

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