The incidence of traumatic diaphragmatic
rupture (TDR) is around 0.5% of all
trauma patients, located more frequently on the left side (80%), with penetrating
trauma being more predominantly the cause (63%) than
blunt injuries (37%). TDR typically develops during thoracoabdominal
injuries and outcome depends on the severity of the associated organ lesion. Diagnosis is sometimes very difficult: chest X-ray can verify TDR in only 25-70% of cases, although the specificity of a multidetector computed tomography (MDCT) is 100% and 83% for left and right-sided
ruptures, respectively. When TDR is a part of a
polytrauma, the management of the patient must follow the ATLS (
Advanced Trauma Life Support) protocol and surgery is rarely based on the primary survey. The usual scenario involves cases detected during the secondary survey. In acute cases approach is determined by the site of the life-threatening
injuries. In the daily surgical routine, in cases of acute TDR,
laparotomy provides the best approach to manage the associated
abdominal injuries and diaphragmatic
rupture. Alternatively a transthoracic approach offer access to reconstruction in cases of delayed. A transdiaphragmatic procedure is offered when during an exploration (
laparotomy or
thoracotomy), any sign of an injury (
bleeding, perforation) is verified through the
rupture of the diaphragm in the other cavity (abdomen or chest and vice versa): the injury via a transdiaphragmatic way can be managed. Usually, a simple and small
rupture up to 5-6 cm can be reconstructed with No. 0 or 1 monofilament non-absorbable or absorbable interrupted
sutures, while for larger defects, interrupted figure-of-eight or horizontal mattress
sutures are required. Mesh
prosthesis is rarely needed.