Surg Endosc DOI 10.1007/s00464-014-3710-8

and Other Interventional Techniques


Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma Laparoscopy in trauma Monde Mjoli • George Oosthuizen • Damian Clarke • Thandinkosi Madiba

Received: 25 November 2013 / Accepted: 1 July 2014 Ó Springer Science+Business Media New York 2014

Abstract Background Diaphragmatic injuries from penetrating thoracoabdominal trauma are notoriously difficult to detect with clinical and radiological evaluation. The aim of this study was to establish the incidence of diaphragmatic injury from penetrating thoracoabdominal trauma, clinical and radiological features predictive of a diaphragmatic injury and the feasibility of laparoscopic repair. Methods This is a prospective consecutive case series conducted in a metropolitan hospital complex. Fifty five patients were enrolled into the study and underwent a standardized laparoscopic procedure. Only stable patients were selected and right-sided penetrating thoracoabdominal injuries were excluded. The patients’ clinical details, radiological findings, operative procedure, treatment of the diaphragmatic injury and complications were collected and analysed. Results There were a total of 55 patients, of whom, 22 (40 %) had diaphragmatic injuries. The mean age was 26.3 ± 7.8 years (range 15–44) with a male:female ratio of 10:1. The causes of injury were stab in 54 (98.2 %) patients and firearm in one (1.8 %). Twenty six (47.3 %) patients had positive radiological findings, of which 10 (38.5 %) had a diaphragmatic injury. There were 6 (27.3 %) associated intraabdominal injuries. Twenty one (95.5 %) of 22 patients with diaphragmatic injuries were successfully repaired laparoscopically. Mean duration of procedure with diaphragmatic

M. Mjoli (&)  G. Oosthuizen  D. Clarke Department of Surgery, Pietermaritzburg Hospital Complex, University of KwaZulu Natal, Pietermaritzburg, South Africa e-mail: [email protected] M. Mjoli  T. Madiba Department of Surgery, University of KwaZulu Natal, Durban, South Africa

repair was 74.9 ± 22.5 min compared to 38.3 ± 16.9 min without diaphragmatic repair. Six patients (10.9 %) had minor intra-operative complications. There were no deaths. Hospital stay was 2.9 ± 3.4 days. Conclusions Diaphragmatic injury was present in 40 % of patients with left-sided thoracoabdominal injury. Radiological findings were not reliable in predicting diaphragmatic injury. The majority of these injuries can be safely repaired laparoscopically. Keywords Traumatic  Diaphragmatic  Hernia  Thoracoabdominal  Laparoscopy

The thoracoabdominal area is defined as the region bounded superiorly by the nipple line or a line that runs across the 4th intercostal space in the midclavicular line, the 6th intercostal space in the mid axillary line and the 8th intercostal space in the mid scapular line. The inferior border of the thoracoabdominal area is formed by the subcostal margin. The anterior and posterior medial borders are the mid sternal line and the vertebral line, respectively [1, 2]. Diaphragmatic injuries from penetrating trauma to the thoracoabdominal area are usually small linear lacerations less than 2 cm in size [3]. These injuries may either be a breach (full thickness laceration) or an acute hernia (abdominal viscera protruding through the diaphragmatic injury). Diagnosis of this injury is difficult especially in the asymptomatic patient. The accuracy of the available noninvasive diagnostic tests is low [1]. The only reliable diagnostic tests are invasive and consist of either a diagnostic laparoscopy or thoracoscopy [4, 5]. The local incidence of diaphragmatic injuries due to penetrating thoracoabdominal wounds is 38 % [6]. Other studies have reported incidences of 7–48 % [1, 7], with


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injuries occurring predominantly in young male patients [3]. Missed diaphragmatic injuries may gradually enlarge over time and present later with a chronic diaphragmatic hernia [8]. These hernias have a high propensity for complications with bowel obstruction and/or strangulation of the herniated viscera, leading to high morbidity and mortality rates [1]. The management of the asymptomatic patient with a penetrating injury to the thoracoabdominal region should be directed towards preventing this sequela. One option is to explore all asymptomatic patients, an approach that is associated with a high incidence of negative procedures that expose patients to complications. The other option is to leave them alone and only treat them when they develop a diaphragmatic hernia. The risk of this approach is the development of a chronic diaphragmatic hernia with associated high morbidity and mortality rates [2, 9]. There are currently no evidence-based management guidelines to treat these patients. The primary aim of this study was to determine the incidence of diaphragmatic injuries, and to identify any factors that may be used to improve the diagnostic yield of diaphragmatic injuries. The secondary aim was to test whether these diaphragmatic injuries can be repaired safely using minimally invasive methods.

Methods The study was conducted in an academic hospital complex that comprises three hospitals, one district, one regional and one tertiary hospital. The diagnostic procedures were performed at the regional and tertiary hospitals. All the patients seen at the district hospital were referred to either the regional or tertiary hospitals according to the discretion of the attending medical officers at the district hospital. All patients with penetrating thoracoabdominal injury presenting to the Pietermaritzburg Hospital Complex were recruited into the study. The thoracoabdominal area was further divided into anterior, lateral and posterior using the anterior and posterior axillary lines in order to accurately define the site of the penetrating wound. Patients were first assessed by a surgical registrar or medical officer on duty at the casualty department to establish their hemodynamic status and the presence of symptoms. Symptomatic patients and those with compelling signs requiring immediate surgical intervention (peritonitis, evisceration, free peritoneal gas, etc.) were excluded from the study. Asymptomatic patients not requiring any surgical intervention were admitted to the surgical ward for serial abdominal examination for a 24-hour period as is consistent with our trauma protocols. Patients who developed symptoms


(hemodynamic instability, peritonism or required an operative intervention) were further excluded from the study. Patients that remained asymptomatic after this period were then submitted into the study and underwent diagnostic laparoscopy. The patients’ clinical details, radiological findings (hemothorax, pneumothorax, diaphragm elevation, diaphragmatic contour and opacities that suggested bowel within the chest cavity), operative procedure, its duration, operative findings, intra-operative treatment of the diaphragmatic injury when found, operative and post-operative complications were collected prospectively using a predesigned data form. The data were tabulated in a spread sheet and analysed. Operative procedure The patient is placed in a supine position with a slight reverse trendelenburg and tilted towards his/her right-hand side. Three ports are used and a fourth one may be placed when additional retraction is required, but generally three are adequate. A 10-mm port is inserted in the periumbilical region for the camera, 5-mm port in the midline just inferior to the inferior margin of the liver and another 5- or 10-mm port in the left midclavicular line at or just above the umbilical level. The midclavicular port may be exchanged for a 10-mm port when repair of the diaphragm is required, where a 5-mm port was used initially. Diaphragmatic injuries are repaired laparoscopically with interrupted intra-corporeal knotting, using ethibond 2.0. At the end of the procedure, the pneumothorax is sucked out using a veress needle through the 2nd intercostal space in the midclavicular line. A chest x-ray is then obtained in the recovery room and a chest drain is inserted only if there is a significant residual pneumothorax. Post-operatively the patients are observed in the general ward, where their vital signs are monitored. The principles of the enhanced recovery after surgery are employed regarding analgesia, oral feeding and mobilization. The patient is discharged when they are tolerating a normal ward diet, pain controlled with simple analgesia and no clinical evidence of pneumothorax.

Results A total of fifty five patients were studied. Fifty were males (91 %) with a male: female ratio of 10:1. The mean age was 26.3 ± 7.8 years (range 16–44 years). The mean ages for male and female patients were 25 ± 6.52 and 38.8 ± 7.52 years, respectively (Table 1). Twenty two patients (40 %) had diaphragmatic injuries, of which 12 (54.5 %) had acute diaphragmatic hernias and

Surg Endosc Table 1 Clinical characteristics and operative findings Variable External wound N (%)

Chest X-ray N (%) [missing]

Site of diaphragmatic injury

Associated injuries


N (%) [missing]


11 (20.0)


20 (36.4)


23 (41.8)


1 (1.8)

Size (cm)

3.3 ± 1.5 (range 1–8)


10 (18.2) [2]

Hemothorax Diaphragmatic elevation

7 (12.7) [1] 6 (10.9) [2]

Abnormal contour

2 (3.6) [2]

Bowel in chest

1 (1.8) [2]


16 (29.1) [1]


13 (59.1)


4 (18.2)

Central tendon

3 (13.6)

Posterior size (cm)

1 (4.5) 2.5 ± 1.5 (0.5–7)

Splenic laceration

4 (18.2)

Liver laceration

1 (4.5)

Stomach laceration

1 (4.5)

Table 2 Relationship of diaphragmatic injury to site of penetrating trauma Operative findings

Site of injury Anterior (11)

Lateral (23)

Posterior (20)

No injury

4 (36.4 %)

11 (47.8 %)

18 (90.0 %)

Acute diaphragmatic hernia

4 (36.4 %)

6 (26.1 %)

1 (5.0 %)

Acute diaphragmatic breach

3 (27.3 %)

6 (26.1 %)

1 (5.0 %)

10 (45.5 %) were diaphragmatic breaches. All the acute diaphragmatic hernias contained omentum and the contents included the stomach and colon in one patient. The injury mechanisms were stabs (54) and firearm (1). Seven patients with stab wounds sustained multiple wounds within the thoracoabdominal area. The mean size of the external wounds on the thoracoabdominal area was 3.3 ± 1.5 cm. The site of injury on the thoracoabdominal area was lateral (23, 41.8 %), posterior (20, 36.4 %) and anterior (11, 20 %). The anterior penetrating wounds had the highest incidence of diaphragmatic injuries (Tables 1 and 2). Twenty six (47.3 %) patients had abnormal radiological findings on plain chest radiography, of whom 20 warranted insertion of an intercostal chest drain (19 on radiological

grounds and one because of a blowing wound). Ten (38.5 %) of the 26 patients had a diaphragmatic injury. Twenty eight out of 55 patients (50.9 %) had a normal chest X-ray. Twelve of the 28 patients with normal chest radiography (42.9 %) had a diaphragmatic injury. The radiological findings are shown in Tables 1 and 3. The diaphragmatic injury was repaired laparoscopically in 21 patients (95.5 %) using intra-corporeal suturing. Conversion in one patient was necessitated by equipment failure. Six patients (27.3 %) had other associated visceral injuries, namely splenic laceration (4), liver laceration (1) and serosal laceration of the stomach (1), all of which were minor and did not warrant any additional intervention. (Table 1) The mean duration of the procedure was 53.4 ± 26.2 min. Laparoscopy without diaphragmatic repair lasted an average of 38.3 ± 16.9 min compared to 74.9 ± 22.6 min in the presence of a diaphragmatic injury with repair (Table 4). The mean hospital stay was 3 ± 3.4: 3.6 ± 3.5 days for patients with diaphragmatic injury compared to 2.6 ± 3.3 days for those without diaphragmatic injury (Table 4). There were 6 (10.9 %) intra-operative complications, namely splenic injuries (3), partial lung collapse with cardio-respiratory compromise (2) and injury to transverse mesocolon (1). These complications were minor and did not require any intervention other than releasing the pneumoperitoneum to release the tension pneumothorax. There were no post-operative complications and no inhospital deaths (Table 4).

Discussion Diaphragmatic injuries in the asymptomatic patient without an indication for a surgical intervention remain a difficult diagnosis without the use of diagnostic laparoscopy. Patients presenting with this injury remain a poorly studied group. The proportion of patients with diaphragmatic injuries is reported at 7–48 % of thoracoabdominal injuries in the literature [1, 7]. The 40 % noted in the present series falls within this figure. The 27 % of associated intra-abdominal injuries was lower than the 46.2 % reported in other series [10]. The associated injuries themselves were however minimal and did not require surgical intervention. Definite preoperative diagnosis of diaphragmatic injury is not possible with the currently used imaging modalities in penetrating trauma. As in other series, plain chest radiography was not predictive of the presence of diaphragmatic injuries in this series. Radiological signs suggestive of intra-thoracic injury were not helpful in the diagnosis of diaphragmatic injuries. Even in the case of the single chest x-ray which was reported to have features suggestive of


Surg Endosc Table 3 Radiological findings in relation to diaphragmatic injury Operative findings

Hemothorax n=7

Pneumothorax n = 10

Diaphragm elevation n = 6

Abnormal diaphragm n = 2

Bowel in chest n=1

Normal chest X-ray n = 28

No injury (33)

4 (57.1 %)

5 (50.0 %)

1 (16.7 %)

1 (50.0 %)

1 (100.0 %)

16 (57.1 %)

Acute diaphragmatic Hernia (12)

1 (14.3 %)

3 (30.0 %)

4 (66.7 %)

1 (50.0 %)

0 (0.0 %)

6 (21.4 %)

Acute diaphragmatic Breach (10)

2 (28.6 %)

2 (20.0 %)

1 (16.7 %)

0 (0.0 %)

0 (0.0 %)

6 (21.4 %)

Table 4 Characteristics of operative Intervention


No injury n = 33

Diaphragmatic breach n = 10

Diaphragmatic hernia n = 12

Duration of procedure (min)

38.3 ± 16.9 (20–90)

69 ± 20 (40–92)

79.3 ± 24.2 (49–120)





Associated injuries




Size of driaphragmatic injury (cm)

1.9 ± 0.9 (0.5–3)

3.1 ± 1.8 (1–5.5)

Length of stay (days)

2.6 ± 3.4 (1–15)

3.6 ± 4.7 (1–15)

3.6 ± 1.9 (1–7)

bowel in the chest laparoscopy did not reveal a diaphragmatic injury. The chest x-ray findings were retrospectively explained as being due to a previous pulmonary infection. The sensitivity and specificity of CT scan to detect diaphragmatic injuries is disappointing and varies from 0 to [90 % [11]. The use of multidetector CT (MDCT) scan holds some promise with a reported accuracy of 95.8 % in detecting diaphragmatic injuries [11]. The most accurate sign on a CT scan is reported to be the presence of a contiguous injury on either side of the diaphragm in a single-entry penetrating trauma with a sensitivity of 88 % and specificity of 82 % [12]. We do not routinely use CT scan to investigate for a diaphragmatic injury, a view shared by other authors [13]. The majority of these patients are young males consistent with other studies with males ten times as frequent as females [13]. The fact that the lateral and anterior penetrating trauma were the most common cause of diaphragmatic injuries may be explained by the nature of the confrontation between the assailant and the victim. We speculate that the anterior and lateral stab wounds would be inflicted with more force during direct confrontation, whereas the posterior wounds would have been inflicted whilst the victim was retreating and thus with less force. Some authors would convert to a laparotomy to repair the diaphragmatic injury [13, 14]. Ninety six percent of the patients in this series underwent laparoscopic repair of the diaphragmatic injury, thus avoiding laparotomy. Laparoscopic repair is likely to be more beneficial compared to open repair. Shorter hospital stay is a reported benefit of laparoscopy in diaphragmatic injury [15, 16]. Other


expected benefits of laparoscopy, though not previously tested for penetrating abdominal trauma, are faster recovery and return to normal activities, less analgesic requirements, less wound complications and decreased long-term complications such as adhesions and incisional hernias. Cooper and Brewer [15] and Yahya et al. [16] contend that laparoscopy should be used routinely instead of exploratory laparotomy in asymptomatic patients with penetrating lower chest injuries. There is still a paucity of literature on laparoscopic repair of diaphragmatic injuries as this procedure is not yet widely accepted in trauma. Another reason for converting to a laparotomy by many authors is the high incidence of associated injuries, up to 55 % [17–19]. The associated injuries in this series were 27 % and did not require operative treatment or conversion. We believe that the reason for this is our initial selective conservatism with serial abdominal examination at which time most patients with significant visceral injury would be detected. Patients who remain stable can then safely undergo diagnostic laparoscopy and laparoscopic repair. The mean duration of the diagnostic laparoscopy was 38 min and that in patients with diaphragmatic injury was understandably longer at 75 min. There are no comparative data in the literature since previous series have not reported operative times. Comparing our series to that of Mahajna et al. [13], it can be seen that converting to an open procedure lengthens the operative time (75 min in our laparoscopic series vs. 102 min in the converted series) and increased the morbidity (10.9 % in our series vs. 20 % in the converted series). The complication rate in this series was 10.9 %, and comprised mainly of minor injuries to closely related

Surg Endosc Fig. 1 Management algorithm for penetrating thoracoabdominal trauma

organs. None of these minor injuries required any intervention. The complication rate among patients undergoing diagnostic laparoscopy and repair of the diaphragm is not well reported in the literature. Therefore, we cannot compare our complication rates. A number of publications report on their successful laparoscopic repair of diaphragmatic injuries, but do not report their operative complications [15, 16, 20]. Partial lung collapse with cardiorespiratory compromise may occur when the gas enters the pleural cavity through the diaphragmatic injury. We approach the management of this complication with a stepwise algorithm. First is immediate deflation of the abdomen which allows the anaesthesiologist to catch up with the stabilization of the patient. This first step is usually sufficient. This is followed by re-establishment of the pneumoperitoneum at lower pressure such as 8 mmHg and increasing slowly if required up to maximum of 15 mmHg. If the first step does not work, the second step in our preference is the insertion of needle thoracostomy using a veress needle. Lastly is the insertion of a tube thoracostomy in addition to stopping the insufflation as described by Murray et al. [10]. Our method of initial selective conservatism with serial abdominal examination is shown in Figure 1 and we recommend this algorithm for the management of thoracoabdominal injuries. This serves to select out those patients who require an operative intervention and at the same time those that remain stable are unlikely to have a severe

visceral injury that would warrant operative intervention. Thus, these patients can be managed exclusively laparoscopically with little risk of missing other intra-abdominal injuries. In conclusion, laparoscopy after a 24-hour period of serial abdominal examinations is a viable option to investigate and repair diaphragmatic injuries with minimal morbidity and no mortality in the asymptomatic patient with penetrating thoracoabdominal trauma. Plain chest radiography should not be relied upon to determine the probability of a diaphragmatic injury. Diagnostic laparoscopy after selective conservatism for patients sustaining thoracoabdominal injury is safe and effective and is now standard treatment in our unit. Disclosures Drs. Monde Mjoli, George Oosthuizen, Damian Clarke and Prof. Thandinkosi Madiba have no conflicts of interest or financial ties to disclose.

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12. Bodanapally UK, Shanmuganathan K, Mirvis SE et al (2009) MDCT diagnosis of penetrating diaphragm injury. Eur Radiol 19:1875–1881 13. Mahajna A, Mitkal S, Bahuth H, Krausz MM (2004) Diagnostic laparoscopy for penetrating injuries in the thoracoabdominal region. Surg Endosc 18:1485–1487 14. Nel JH, Warren BL (1994) Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest. Br J Surg 81:713–714 15. Cooper C, Brewer J (2012) Laparoscopic repair of acute penetrating diaphragm injury. Am Surg 78:E490–E492 16. Yahya A, Shuweiref H, Thoboot A et al (2008) Laparoscopic repair of penetrating injury of the diaphragm: an experience from a district hospital. Libyan J Med 3:138–139 17. Hanna WC, Ferri LE (2009) Acute traumatic diaphragmatic injury. Thorac Surg Clin 19:485–489 18. Turhan K, Makay O, Cakan A et al (2008) Traumatic diaphragmatic rupture: look to see. Eur J Cardiothorac Surg 33:1082–1085 19. Hanna WC, Ferri LE, Fata P, Razek T, Mulder DS (2008) The current status of traumatic diaphragmatic injury: lessions leaned from 105 patients over 13 years. Ann Thoracic Surg 85: 1044–1048 20. Zantut LF, Ivatury RR, Smith RS et al (1997) Diagnostic and therapeutic laparoscopy for penetrating abdominal trauma: a multicentre experience. J Trauma 42:825–831

Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma: laparoscopy in trauma.

Diaphragmatic injuries from penetrating thoracoabdominal trauma are notoriously difficult to detect with clinical and radiological evaluation. The aim...
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