Purpose: Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. We reported a bullet that resulted in two separate diaphragmatic lacerations and hernias: One by the penetrating bullet and the second by the associating blunt trauma. Observations: A 23 years old young man who sustained a bullet injury resulting in isolated diaphragmatic lacerations with minor lung impact. The diaphragmatic injuries resulted in omental herniations. Symptoms of diaphragmatic injuries were masked by associated injuries and missed in the Primary Care Unit. After referring the patient to our Unit in Abo-khalifa Hospital for Emergency and Fine Surgeries because of upper abdominal discomfort, computerized tomography showed two diaphragmatic tears and the herniated omentum. A lateral small tear in line with the inlet and exit of the bullet and adjacent to the minor lung lesion can be explained by direct bullet injury. The second larger medial radial diaphragmatic tear can be due to indirect trauma caused by markedly increased intrathoracic pressure with closed epiglottis; this pressure was immediately created on penetration of skin. This increasing pressure is going to be relieved by either bronchial or diaphragmatic rupture. Thoracoscopy confirmed the diagnosis and assisted complete management. Smooth reduction of the hernias, closure of the diaphragmatic defects and application of one clip onto the lung lesion. Conclusions: High suspicion of diaphragmatic injuries helps early diagnosis of these rare traumatic lesions. Computerized tomography of the chest with barium meal has a high sensitivity and specificity for diagnosis of traumatic diaphragmatic hernias. Uniporter thoracoscopy is a good safe diagnostic and therapeutic tool for traumatic diaphragmatic lacerations with hernias.
References
[1]
Mahamid, A., Peleg, K., Givon, A., Alfici, R., Olsha, O. and Ashkenazi, I. (2017) Blunt Traumatic Diaphragmatic Injury: A Diagnostic Enigma with Potential Surgical Pitfalls. The American Journal of Emergency Medicine, 35, 214-217. https://doi.org/10.1016/j.ajem.2016.10.046
[2]
Abdellatif, W., Chow, B., Hamid, S., Khorshed, D., Khosa, F., Nicolaou, S., et al. (2020) Unravelling the Mysteries of Traumatic Diaphragmatic Injury: An Up-To-Date Review. Canadian Association of Radiologists Journal, 71, 313-321. https://doi.org/10.1177/0846537120905133
[3]
Thiam, O., Konate, I., Gueye, M.L., Toure, A.O., Seck, M., Cisse, M., et al. (2016) Traumatic Diaphragmatic Injuries: Epidemiological, Diagnostic and Therapeutic Aspects. SpringerPlus, 5, Article No. 1614. https://doi.org/10.1186/s40064-016-3291-1
[4]
Morito, A., Nakagawa, S., Imai, K., Uemura, N., Okabe, H., Hayashi, H., et al. (2021) Successful Surgical Rescue of Delayed Onset Diaphragmatic Hernia Following Radiofrequency Ablation Using a Thoracoscopic Approach for Hepatocellular Carcinoma: A Case Report. Surgical Case Reports, 7, Article No. 130. https://doi.org/10.1186/s40792-021-01213-8
[5]
Uzzaman, M., Nair, M., Al-Zuhir, N., Jadeja, A. and Navaratnam, R. (2011) Changing Trends in the Pattern and Outcome of Stab Injuries at a North London Hospital. Journal of Emergencies, Trauma, and Shock, 4, 455-460. https://doi.org/10.4103/0974-2700.86628
[6]
Williams, M., Carlin, A.M., Tyburski, J.G., Blocksom, J.M., Harvey, E.H., Steffes, C.P., et al. (2004) Predictors of Mortality in Patients with Traumatic Diaphragmatic Rupture and Associated Thoracic And/or Abdominal Injuries. The American Surgeon, 70, 157-163. https://doi.org/10.1177/000313480407000212
[7]
Petrone, P., Leppäniemi, A., Inaba, K., Søreide, K. and Asensio, J.A. (2007) Diaphragmatic Injuries: Challenges in the Diagnosis and Management. Trauma, 9, 227-236. https://doi.org/10.1177/1460408607087716
[8]
Desser, T.S., Edwards, B., Hunt, S., Rosenberg, J., Purtill, M.A. and Jeffrey, R.B. (2009) The Dangling Diaphragm Sign: Sensitivity and Comparison with Existing CT Signs of Blunt Traumatic Diaphragmatic Rupture. Emergency Radiology, 17, 37-44. https://doi.org/10.1007/s10140-009-0819-5
[9]
Leppäniemi, A. and Haapiainen, R. (2003) Diagnostic Laparoscopy in Abdominal Stab Wounds: A Prospective, Randomized Study. The Journal of Trauma: Injury, Infection, and Critical Care, 55, 636-645. https://doi.org/10.1097/01.ta.0000063000.05274.a4
[10]
Simpson, J., Lobo, D. and Shah, A.B. (2000) Traumatic Diaphragmatic Rupture: Associated Injuries and Outcome. Annals of the Royal College of Surgeons of England, 82, 97-100.
[11]
Hanna, W.C., Ferri, L.E., Fata, P., Razek, T. and Mulder, D.S. (2008) The Current Status of Traumatic Diaphragmatic Injury: Lessons Learned from 105 Patients over 13 Years. The Annals of Thoracic Surgery, 85, 1044-1048. https://doi.org/10.1016/j.athoracsur.2007.10.084
[12]
Iadicola, D., Branca, M., Lupo, M., Grutta, E.M., Mandalà, S., Cocorullo, G., et al. (2019) Double Traumatic Diaphragmatic Injury: A Case Report. International Journal of Surgery Case Reports, 61, 82-85. https://doi.org/10.1016/j.ijscr.2019.07.030
[13]
McDonald, A.A., Robinson, B.R.H., Alarcon, L., Bosarge, P.L., Dorion, H., Haut, E.R., et al. (2018) Evaluation and Management of Traumatic Diaphragmatic Injuries: A Practice Management Guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery, 85, 198-207. https://doi.org/10.1097/ta.0000000000001924
[14]
Karmy-Jones, R. and Jurkovich, G.J. (2004) Blunt Chest Trauma. Current Problems in Surgery, 41, 223-380. https://doi.org/10.1016/j.cpsurg.2003.12.004
[15]
Blaivas, M., Brannam, L., Hawkins, M., Lyon, M. and Sriram, K. (2004) Bedside Emergency Ultrasonographic Diagnosis of Diaphragmatic Rupture in Blunt Abdominal Trauma. The American Journal of Emergency Medicine, 22, 601-604. https://doi.org/10.1016/j.ajem.2004.08.015
[16]
Rossetti, G., Brusciano, L., Maffettone, V., Napolitano, V., Sciaudone, G., Del Genio, G., et al. (2005) Giant Right Post-Traumatic Diaphragmatic Hernia: Laparoscopic Repair without a Mesh. Chirurgia Italiana, 57, 243-246.
