Management of Chronic Neglected Traumatic Diaphragmatic Hernia

A 45-year-old man came to the emergency department complaining of progressive shortness of breath for 10 days. He also complained of vomiting and absolute constipation for four days. He had a past history of left stab to the chest for 1.5 years. Examination revealed the patient was hemodynamically unstable, with severe respiratory distress, cyanosis, fever, and absent air entry on the left side of the chest. The patient had a chest x-ray suggestive of tension pneumothorax, however a chest computed tomography scan was suggestive of diaphragmatic hernia.An emergency left posterolateral thoracotomy was performed. There was a gangrenous perforated transverse colon inside the chest. The authors widened the diaphragmatic defect, and they performed a transthoracic transverse colectomy and reanastomosis, as well as a right iliac ileostomy. The authors repaired the diaphragmatic defect. The patient was discharged at postoperative day 30 in a good general condition.ConclusionHistory-taking and high index of suspicion is important for the diagnosis of neglected traumatic diaphragmatic injuries. In this case, the authors performed the repair totally transthoracically, with no need for an abdominal incision.

一位45岁的男性患者因连续10天的呼吸困难来急诊科就诊，同时伴有持续四天的呕吐和完全性便秘。患者既往有1.5年前左侧胸部刺伤史。体检发现患者处于血流动力学不稳定状态，表现为严重呼吸窘迫、发绀、发热，胸部左侧听诊区呼吸音消失。胸部X光片提示张力性气胸，但胸部CT扫描则提示膈肌裂孔疝。随即进行了紧急的左侧后外侧胸腔切开术。在胸腔内发现一例坏疽性穿孔横结肠。作者扩大了膈肌缺损，并实施了经胸横结肠切除术及吻合术，以及右侧髂骨结肠造口术。之后修复了膈肌缺损。患者术后第30天康复良好，出院。结论：病史采集和对疑似病例的高度警觉对于诊断被忽视的创伤性膈肌损伤至关重要。在本例中，作者完全经胸腔进行修复，无需腹部切口。