Diaphragmatic Injuries Flashcards
Why is there a higher incidence of left-sided traumatic diaphragmatic injury (TDI) compared to right-sided
Due to the presence of a congenital weakness along the costal and lumbar portions of the diaphragm.
What is blunt TDI a marker for?
t is a marker for severe associated injuries, as the diaphragm is rarely injured in isolation
What is the most commonly associated injury with blunt TDI?
Pulmonary injury is the most commonly associated injury.
What does the caval hiatus (at the T8 level) contain?
It contains the inferior vena cava and the right phrenic nerve
What does the esophageal hiatus (at the T10 level) contain?
It contains the esophagus and the bilateral vagus nerves
What does the aortic hiatus (at the T12 level) contain?
It contains the aorta, thoracic duct, and azygous vein
Why is the right dome of the diaphragm higher than the left?
The right dome is 2 cm higher to accommodate the underlying liver
What arteries supply the diaphragm?
The superior and inferior phrenic arteries, which are direct branches off the thoracoabdominal aorta.
How is the diaphragm’s venous drainage provided?
By the phrenic veins, which drain directly into the inferior vena cava
What nerves innervate the diaphragm, and where do they originate?
The right and left phrenic nerves, originating from the C3–C5 nerve roots
Through which anatomical structures do the phrenic nerves pass?
They pass over the anterior scalene muscle and run along the pericardium
How common is it to diagnose isolated TDI?
It is unusual to have an isolated TDI, and it is often diagnosed during surgery for other injuries
What are the classic physical findings associated with TDI, and are they reliable?
Unilateral decreased breath sounds or bowel sounds in the chest have been described, but they are neither sensitive nor specific for TDI.
What type of collateral evidence might be seen on CT to suggest injury in penetrating thoracoabdominal trauma?
Evidence such as an entrance wound in the chest wall, a bullet tract through the lung, an injury to the spleen, or a retained bullet in the abdominal wall
What is recommended for patients with thoracoabdominal penetrating injury undergoing nonoperative management?
The recommendation is to use diagnostic laparoscopy for definitive diagnosis of TDI
How are left-sided thoracoabdominal injuries managed after an observation period?
If the patient passes the 24-hour observation period without signs of peritonitis, a diagnostic laparoscopy is performed to visualize the left diaphragm
What must be done cautiously during laparoscopic insufflation for left-sided injuries?
Insufflation must be done carefully to avoid building tension physiology, which can cause increased inspiratory or plateau pressures, hypoxia, or hypotension.
What should be done if tension physiology occurs during laparoscopic insufflation?
Immediate release of pressure and tube thoracostomy are required.
How are small diaphragmatic injuries repaired during laparoscopy?
Small injuries are repaired with primary repair using nonabsorbable sutures
For acute TDI, what is the recommended surgical approach, and why?
A midline laparotomy is recommended due to the high incidence of associated intraabdominal organ injuries
What type of suture is commonly used for the primary repair of TDI?
Nonabsorbable monofilament sutures, size 0 or 1.
What types of sutures can be used for the primary repair of a traumatic diaphragmatic injury (TDI)?
Interrupted figure-of-8, mattress, or simple sutures, as well as running repairs
What type of mesh is a practical option for repairing large diaphragmatic defects, based on congenital diaphragmatic hernia evidence?
Polytetrafluoroethylene (PTFE) mesh, used in a tension-free manner.
What is a surgical strategy if the diaphragm defect is too large for reattachment at its original location?
The attachment point can be moved several rib spaces up, using the diaphragm’s natural curvature to achieve a tension-free repair.
What is the recommended approach for chronic traumatic diaphragmatic hernia (TDH) repair in the latent phase?
A semi-elective repair after a preoperative workup including cardiopulmonary function
What are common complications following a diaphragm repair?
Complications include disruption of the repair site, phrenic nerve injury, and surgical site infections.
What can cause paralysis of the hemidiaphragm following diaphragm repair?
It may be caused by the traumatic injury itself or occur during the surgical repair due to phrenic nerve injury.
Where should extra care be taken to avoid phrenic nerve injury during diaphragm repair?
Near the esophageal or caval hiatus, as the phrenic nerves are in close proximity
What are the postoperative infectious complications associated with diaphragm repair?
Complications include subdiaphragmatic abscess and empyema.
