Diaphragmatic Injuries

Question 1

Why is there a higher incidence of left-sided traumatic diaphragmatic injury (TDI) compared to right-sided

Answer 1

Due to the presence of a congenital weakness along the costal and lumbar portions of the diaphragm.

Question 2

What is blunt TDI a marker for?

Answer 2

t is a marker for severe associated injuries, as the diaphragm is rarely injured in isolation

Question 3

What is the most commonly associated injury with blunt TDI?

Answer 3

Pulmonary injury is the most commonly associated injury.

Question 4

What does the caval hiatus (at the T8 level) contain?

Answer 4

It contains the inferior vena cava and the right phrenic nerve

Question 5

What does the esophageal hiatus (at the T10 level) contain?

Answer 5

It contains the esophagus and the bilateral vagus nerves

Question 6

What does the aortic hiatus (at the T12 level) contain?

Answer 6

It contains the aorta, thoracic duct, and azygous vein

Question 7

Why is the right dome of the diaphragm higher than the left?

Answer 7

The right dome is 2 cm higher to accommodate the underlying liver

Question 8

What arteries supply the diaphragm?

Answer 8

The superior and inferior phrenic arteries, which are direct branches off the thoracoabdominal aorta.

Question 9

How is the diaphragm’s venous drainage provided?

Answer 9

By the phrenic veins, which drain directly into the inferior vena cava

Question 10

What nerves innervate the diaphragm, and where do they originate?

Answer 10

The right and left phrenic nerves, originating from the C3–C5 nerve roots

Question 11

Through which anatomical structures do the phrenic nerves pass?

Answer 11

They pass over the anterior scalene muscle and run along the pericardium

Question 12

How common is it to diagnose isolated TDI?

Answer 12

It is unusual to have an isolated TDI, and it is often diagnosed during surgery for other injuries

Question 13

What are the classic physical findings associated with TDI, and are they reliable?

Answer 13

Unilateral decreased breath sounds or bowel sounds in the chest have been described, but they are neither sensitive nor specific for TDI.

Question 14

What type of collateral evidence might be seen on CT to suggest injury in penetrating thoracoabdominal trauma?

Answer 14

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

Question 15

What is recommended for patients with thoracoabdominal penetrating injury undergoing nonoperative management?

Answer 15

The recommendation is to use diagnostic laparoscopy for definitive diagnosis of TDI

Question 16

How are left-sided thoracoabdominal injuries managed after an observation period?

Answer 16

If the patient passes the 24-hour observation period without signs of peritonitis, a diagnostic laparoscopy is performed to visualize the left diaphragm

Question 17

What must be done cautiously during laparoscopic insufflation for left-sided injuries?

Answer 17

Insufflation must be done carefully to avoid building tension physiology, which can cause increased inspiratory or plateau pressures, hypoxia, or hypotension.

Question 18

What should be done if tension physiology occurs during laparoscopic insufflation?

Answer 18

Immediate release of pressure and tube thoracostomy are required.

Question 19

How are small diaphragmatic injuries repaired during laparoscopy?

Answer 19

Small injuries are repaired with primary repair using nonabsorbable sutures

Question 20

For acute TDI, what is the recommended surgical approach, and why?

Answer 20

A midline laparotomy is recommended due to the high incidence of associated intraabdominal organ injuries

Question 21

What type of suture is commonly used for the primary repair of TDI?

Answer 21

Nonabsorbable monofilament sutures, size 0 or 1.

Question 22

What types of sutures can be used for the primary repair of a traumatic diaphragmatic injury (TDI)?

Answer 22

Interrupted figure-of-8, mattress, or simple sutures, as well as running repairs

Question 23

What type of mesh is a practical option for repairing large diaphragmatic defects, based on congenital diaphragmatic hernia evidence?

Answer 23

Polytetrafluoroethylene (PTFE) mesh, used in a tension-free manner.

Question 24

What is a surgical strategy if the diaphragm defect is too large for reattachment at its original location?

Answer 24

The attachment point can be moved several rib spaces up, using the diaphragm’s natural curvature to achieve a tension-free repair.

Question 25

What is the recommended approach for chronic traumatic diaphragmatic hernia (TDH) repair in the latent phase?

Answer 25

A semi-elective repair after a preoperative workup including cardiopulmonary function

Question 26

What are common complications following a diaphragm repair?

Answer 26

Complications include disruption of the repair site, phrenic nerve injury, and surgical site infections.

Question 27

What can cause paralysis of the hemidiaphragm following diaphragm repair?

Answer 27

It may be caused by the traumatic injury itself or occur during the surgical repair due to phrenic nerve injury.

Question 28

Where should extra care be taken to avoid phrenic nerve injury during diaphragm repair?

Answer 28

Near the esophageal or caval hiatus, as the phrenic nerves are in close proximity

Question 29

What are the postoperative infectious complications associated with diaphragm repair?

Answer 29

Complications include subdiaphragmatic abscess and empyema.