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Abstract

Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

Traumatic Diaphragmatic Hernia: An Uncommon Entity 
Ellina Dangol1, Aditya Prakash Yadav1, Umesh Kumar Yadav1, Binod Kumar Rai1, Vipul Vivek 
Pathak2

1Department of Surgery, National Medical 
College and Teaching Hospital Birgunj, 
Nepal.

2Department of Anaesthesia, National 
Medical College and Teaching Hospital 
Birgunj, Nepal.

Dr. Ellina Dangol, 
Department of Surgery, National Medical 
College and Teaching Hospital, Birgunj, 
Nepal. 

Email: dangol.lna@gmail.com

Traumatic diaphragmatic hernia is secondary to penetrating injuries 
and blunt abdominal and thoracic trauma. It is an uncommon entity. 
Early diagnosis is necessary to decrease morbidity and mortality. Here 
we report a case of 22-year-old male with the diagnosis of traumatic 

tenderness was present and bowel sounds were not appreciated and 

defect with intrathoracic herniation of abdominal viscera. Laparotomy 

through the diaphragmatic tear.

Keywords: CT scan; Laparotomy; Traumatic diaphragmatic hernia. 

Introduction
Traumatic diaphragmatic injury is an uncommon and rare 
injury. It occurs as a result of high velocity blunt trauma 
to abdomen, penetrating injury to chest or abdomen, with 

varies, as it may be asymptomatic or may have acute 
presentation with features of breathlessness or may present 
late with complications like obstruction, strangulation or 
perforation.3

be obtained in all cases of thoraco-abdominal injuries as it 
is useful in ruling out rupture diaphragm in asymptomatic 
cases as well as visualizing solid organs injuries and hollow 
viscus perforation in cases of multiple injuries.5

Treatment of diaphragm rupture mainly consists of repair 
of diaphragm and can be performed through a thoracotomy 

can visualize all intra-abdominal injuries. The mortality is 
mainly related to associated injuries.

Case history
A 22-years-old male came to the emergency of National 
medical college and teaching hospital with a history of stab 
injury by sharp knife with sustained injury of abdomen and 

Grade Findings 
I Contusion 
II
III Laceration 2-10cm

2

Laceration and tissue loss>25cm2

2,4:

Case Report

an uncommon entity. J Sosc Surg Nep. 



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

s 2

lumbar region above the iliac crest with retroperitoneal fat 

injury was over the right lateral subcostal region with ribs 

one was longitudinal over L3-L4 vertebra with muscle 
tear and active bleed. Fourth was longitudinal over right 
lateral to T8-T10 vertebra with muscle tear and active bleed 

tenderness and guarding were present and  bowel sound 

air entry over left side with normal breath sound over right. 

were normal. 

showed hyperlucent shadow in left lower zone and was 

Figure 1

scan was done which showed left sided diaphragmatic defect 
Figure 

2

distal pancreas through diaphragmatic tear was found. The 
anterior wall of stomach, mainly the body of stomach, 

was collection of blood about 150ml in the left pleural 
cavity. Primary closure of diaphragm was done with Prolene 

20cm distal to the Duodenal-jejunal junction. Abdominal 
drain of size 28fr kept over pelvic region. Abdominal wall 

tube of 28Fr was kept over left chest.  

Postoperatively patient was kept in intensive care unit 

report on 2nd post operative day and was hemodynamically 

month. 

Discussion

diaphragmatic injury.  It is mainly associated with multiple 
injuries8 and are diagnosed either with respiratory distress 
or as in intestinal obstruction.9 Mechanism of injury mainly 
involves the shearing of stretched diaphragm at the point of 
diaphragmatic attachment due to sudden force transmission 
through viscera in abdomen. Most common site of rupture 

of its origin from pleuro-peritoneal membrane which is 
structurally weak.10 Left side rupture are more common as 

liver11

in the current reviews.12 The presented case also showed 
left sided traumatic diaphragm injury with herniation of 
abdominal content.

Figure 1. Chest X-ray at the time of admission

tomography scan of the patient.

Dangol E et al



Journal of Society of Surgeons of Nepal
J Soc Surg Nep. 2022;25(2)

www.jssn.org.np

tears can be initially missed or incorrect interpretation of 
radiograph is a frequent reason for incorrect diagnosis of 
diaphragmatic rupture.13,14

actually due to stomach herniated into the chest. Such a 
mistake can lead to placement of unnecessary chest tubes 

in the presented case was confused with the left sided 

the suspicion of diaphragmatic eventration took the step 
of CECT chest and abdomen and showed diaphragmatic 
herniation of bowel contents.

when nasogastric tube is seen in chest but often masked 

right side.15

laparoscopy is another diagnostic method when in doubt or 
when other measures fail.

References

1. 
in abdominal stab wounds: a prospective, randomized 
study. Journal of Trauma and Acute Care Surgery. 2003 

2. Asensio JA, Petrone P. Diaphragmatic injury. In: 
Cameron JL ed. Current surgical therapy, 8th ed. 

3. 
traumatic diaphragmatic hernia: Pictorial review of CT 

4. Department of Surgery/Songkhla Hospital. 

5. Hordiychuk A, Elston T. Traumatic diaphragmatic 

DeBarros M, Martin MJ. Penetrating traumatic 

8. 
presentation of a patient with a ruptured diaphragm 
complicated by gastric incarceration and perforation 
after apparently minor blunt trauma. Canadian Journal 

9. 
Traumatic rupture of diaphragm. The Annals of 

For diaphragmatic repair there are many approaches, 
the choice depends on the circumstances of each case. 
Laparotomy is considered by some authors as gold 
standard but others preferred thoracotomy. Laparotomy 

laparoscopic repair is also becoming popular. In case of 
small defect simple suture is done whereas in case of large 
defect synthetic mesh is required.  As this patient had 
peritoneal breach in other parts along with diaphragmatic 
injury laparotomy was considered as better option and 
since defect was wide enough for the primary repair there 
was no need for the mesh. The important thing in using 

rate of necrosis seen in emergency surgeries.18

Conclusion
Traumatic diaphragmatic hernia is an uncommon entity that 
carries serious morbidity and mortality. A high degree of 
suscpicion is warranted in cases of abdominal and thoracic 
trauma. 

10. 
J, D’Agostino H. Diaphragmatic rupture: a frequently 
missed injury in blunt thoracoabdominal trauma 

11. 

12. Carter BN. Traumatic diaphragmatic hernia. Am J 

13. 
A review on delayed presentation of diaphragmatic 

14. 
Napolitano C. Late posttraumatic diaphragmatic hernia. 
A clinical case report. Minerva chirurgica. 1994 May 

15. 

long-term sequelae. Journal of Trauma and Acute Care 

Blaivas M, Brannam L, Hawkins M, Lyon M, Sriram 
K. Bedside emergency ultrasonographic diagnosis of 
diaphragmatic rupture in blunt abdominal trauma. The 
American journal of emergency medicine. 2004 Nov 

current status of traumatic diaphragmatic injury: lessons 
learned from 105 patients over 13 years. The Annals of 

18. Jee Y. Laparoscopic diaphragmatic hernia repair using 


