JSSN_vol25i2-cut.pdf 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