Surgical tactics in treatment of traumatic raptures of the diaphragm: our experience

Background

The aim of this retrospective study was to analyze our experience with operative approach of traumatic rapture of diaphragm (TRD).

Methods

38 patients with TRD (34 men and 4 women ranging from 13 to 70 years) were treated in 1993-2013. 29 patients (76%) had a left TRD and 9 patients (24%) - right TRD. Multiple-associated injures were observed in 31 patients (82%), and isolated TRD - in 7 patients (18%). Causes of trauma included vehicle crash for 33 patients and fall from height for 5.

Results

TRD was diagnosed preoperatively in 32 patients (84%) by contrast X-Ray of gastrointestinal tract, abdominal ultrasound, and CT scan of the chest and abdomen. In 6 (16%) patients TRD was diagnosed during surgery. We did not use pleural centesis to avoid injury of abdominal organs. 27 patients (71%) underwent surgery upon 1 month of trauma episode, and 13 (34%) – after 1 month to 13 years. Right lateral thoracotomy on the 6th interspace was performed in 9 (24%) patients with right TRD. In case of large raptures the diaphragm was repaired by simple interrupted suture to chest wall on 1-2 interspaces above anatomical juncture-line which allowed repairing the diaphragm out of high tension. 11 patients (29%) with old left TRD underwent left lateral thoracotomy on the 6th interspace. In both left and right TRDs the large diaphragmatic defects were repaired by polypropylene mesh. 18 (47%) patients with acute left TRD were treated by left lateral thoracotomy accompanied by upper-medial laparotomy (11 cases) and laparoscopy (7 cases) for better examination of abdomen and restoring lesions. We observed 3 deaths (8 %) – 2 from severe craniocerebral trauma and 1 from pulmonary thromboemboli.

Conclusions

Our experience showed superiority of repairing of diaphragm on 1-2 interspaces above anatomical juncture-line in right TRD to avoid hypertension of sutures and accompanying thoracotomy with laparoscopy in left TRD as a rational surgical approach.