Latent traumatic diaphragmatic hernia: a surgical challenge.

The article published in CHEST by Seelig and associates (January 1999)1 on a very rare complication of occult diaphragmatic hernia has an important theoretical and practical value. Like the authors, we found that the diagnosis of blunt traumatic rupture of the diaphragm may represent a challenge. In the majority of 13 patients managed at our clinic between 1989 and 2000, the fact of blunt thoracic trauma and/or abdominal trauma had been forgotten and the injury to the diaphragm was not suspected before admission to the clinic. In three other cases, rupture of the left diaphragm was missed during the prior laparotomy, a recurrent left-sided diaphragmatic hernia was interpreted as a posttraumatic phrenic nerve palsy (at another institution), and an erroneous diagnosis of a massive hiatal hernia was made. However, in all our patients the correct diagnosis was established preoperatively. In all instances, visceral herniation (ie, stomach, intestine, spleen, liver, and omentum) into the chest cavity was present, most commonly through the pericardiac area in the left and central tendon on the right side. A left posterolateral thoracotomy was the preferred approach, except in two cases in which a left thoracolaparotomy was required or on one occasion when a right thoracotomy was required for hernia repair with an interrupted suture buttressed with vicryl mesh. The delay of the diagnosis in latent blunt diaphragmatic ruptures may be attributed to several factors,2–4 but a careful history of abnormalities, plain chest roentgenograms, CT scans, and barium studies of the alimentary tract are the most useful diagnostic tools. Extensive adhesions between the herniated viscera and the lung or pericardium are difficult to remove through laparotomy, so a transthoracic approach and suturerepair of the diaphragm is the best choice of procedure.