Diaphragmatic rupture repair

Penetrating injuries to the lower chest and upper abdomen, such as bullets or stab wounds, can cause diaphragmatic rupture and can simultaneously damage adjacent organs of the diaphragm. Non-penetrating severe chest blunt contusion, such as falling from a height, traffic accidents can also lead to diaphragmatic rupture, the incidence of about 3%, and most occur in the left semitendinosus center. At this time, the stomach, transverse colon, spleen and small intestine can be inserted into the chest. Some of the diaphragmatic rupture can be diagnosed early in the post-injury resuscitation and treatment, especially when the left diaphragm is ruptured with spleen rupture, causing intra-abdominal hemorrhage. Some have complicated or severe injuries that affect or cover the symptoms and signs of diaphragmatic rupture, or penetrating injuries. The symptoms of rupture of the right diaphragm are not as obvious as the left side, and are easily misdiagnosed and missed. This is because the liver can temporarily block the gap and the liver into the chest and give the wrong impression of the diaphragm on the X-ray or the contusion and consolidation of the right lower lobe. Patients in the acute phase are mainly characterized by severe pain, difficulty breathing, cyanosis and traumatic shock. On the X-ray film, the injured lateral diaphragm muscle was elevated, blurred and irregular. The rib angle is blunt and the mediastinum is displaced. If you see a gastrointestinal or solid organ image containing gas or fluid in the chest, the diagnosis can be determined. In addition, if the difficulty is encountered in the lower stomach tube or the X-ray film is taken after the lower stomach tube, the stomach tube is found in the chest cavity, the diagnosis can be further confirmed. If the diaphragm is not severely ruptured after trauma, or the omentum, the liver is closed, or there are not many organs that break into the chest, the diagnosis will be missed and the patient will enter the incubation period. In this period, the patient can be asymptomatic. Ultrasound, CT, MRI, gastrointestinal angiography, and heparin scanning can help diagnose in this period. 85% of patients with latent period enter the third stage or obstruction and strangling period within 3 years after trauma. The symptoms of the patients are obvious. In addition to intestinal obstruction, intestinal narrowing, perforation, severe breathing difficulties, massive effusion and gas accumulation in the chest may occur. Even toxic shock, such as diagnosis, treatment is not timely, can die quickly. A small number of patients, especially those with bullets or stab wounds, can have an incubation period of several to several decades. Treatment of diseases: diaphragmatic bulging Indication Diaphragm rupture repair is applicable to: Diaphragm rupture, whether it is penetrating or non-penetrating, should be treated promptly if the diagnosis is established. Patients with acute phase often have abdominal injury, so the diaphragmatic muscle repair and injury organs should be treated through the abdomen. When it is suspected that the internal organs of the chest are also damaged, a chest incision should be made and treated with the chest. Patients with latent period should undergo repair of the diaphragm through the chest. Patients with the third stage or obstruction or strangulation often require chest and abdomen combined with path surgery. Preoperative preparation 1. Patients in the acute phase should have a detailed understanding of the injury to determine the extent and extent of the combined injury and combined injury. 2. Active anti-shock treatment, restore breathing, circulatory function, the condition is slightly stable, it should be immediately operated. 3. Lower stomach tube, gastrointestinal decompression. 4. Apply antibiotics to prevent infection. 5. Patients with stage 3 or obstruction or strangulation should also be prepared according to intestinal obstruction, intestinal stenosis, and bowel preparation. Surgical procedure Incision Transabdominal, median incision in the left upper abdomen; transthoracic, posterior thoracic incision; chest and abdomen combined approach, chest and abdomen combined incision. 2. Reveal the diaphragmatic rupture and suture After the damaged abdominal organ was treated and the organ that broke into the chest was still returned, the left colon, spleen and stomach were pulled to the lower right to reveal the diaphragmatic rupture, and the suture was closed with a 6-wire suture. 3. Transthoracic approach When the diaphragm is repaired by the chest, the 6th or 7th ribbed bed enters the chest cavity, taking care not to injure the abdominal organs that break into the chest. 4. Separation of adhesions Organs that break into the chest often adhere to the lungs, chest wall, and diaphragm, and should be carefully separated. 5. Repair the diaphragmatic rupture After the organs of the abdominal cavity were freed and retracted, the gap was repaired by sutured sutures with a 6-gauge thread. 6. Place drainage Place a drainage tube in the 8th intercostal space, then close the abdomen or close the chest. complication The effect of diaphragmatic rupture repair is generally better, with little recurrence after successful repair, but there is still a high operative mortality, blunt trauma is 14% to 22%, penetrating injury is 2% to 3%, third Intestinal strangulation and intestinal necrosis, up to 80%. The reason is that the diaphragmatic rupture is often accompanied by severe combined injuries and shocks, as well as the failure to timely recognize and deal with the sacral injury.