Diaphragmatic hernia Classification Classification Traumatic ...

Traumatic diaphragmatic herniaDiagnosis : HistoryType of herniation• StomachGastric dilatationCongenital hernia• At any ageTraumatic hernia• Trauma may be unrelatedDiaphragmatic rentDiagnosis : Clinical signsDiagnosis : Auscultation…Respiratory• Dyspnea and exercice intolerance = 38 %Gastro-intestinal• Vomiting, dysphagia…General• Depression, weight lossMuffled heart soundsChest hyporesonance (if effusion)Others• Borborygmae• Empty abdomenDiagnosis : ImagingRadiographsContrast radiographs ?Ultra-soundOthers…2

Radiographic signsRadiographic signsAbdominal organs in the chestOr cranial displacement of abdominalorgansRadiographic signsRadiographic signsOr loss of abdominal organsLoss of diaphragmatic contourDiagnosis : ImagingRadiographsContrast radiographs ?Ultra-soundOthers…3

Contrast radiographsContrast radiographsBarium studyBarium studyContrast studyUltra-soundPeritoneographyWhen to operate ?Surgery within 24 hours after trauma33% mortalityBoudrieau, Comp, 19874

When to operate ?Worsening of respiratory insufficiencyGastric dilation in the chestAnesthesiaSurgical approachPreoxygenationInduction• Fast, no fight• Propofol,IntubationManual ventilation or adequateventilatorMedian laparotomyMedian sternotomy• Pleuroperitoneal H.• Adhesion of liverSurgerySurgeryReduction• Gentle manipulation• Spleen and Omentum first• Liver lobes lastReduction• Gentle manipulation• Spleen and Omentum first• Liver lobes last5

SurgeryClosure of radial H.• Preplace U points• Simple continuousfrom hiatusSurgeryPost-operative issuesAfter closure• Emptythe chestStrangulated organs• Liver• Intestines6

Post-operative issuesIntensive care unitAcute lung edema• Reperfusion injury• BarotraumatismConclusionsDiagnosis : Trauma may be unrelatedTreatment : Not on emergencyLung edema is always possible7