EC Clinical and Medical Case Reports

Introduction: Right-sided diaphragmatic injuries are associated with severe trauma to the abdomen, pelvis, and thorax. These injuries may also be accompanied by rib fractures, hemopneumothorax, and hepatic damage.

Objective: To present a clinical case at the General Hospital of Ticoman, under the Secretariat of Health of Mexico City, detailing a right diaphragmatic rupture secondary to blunt thoracic trauma to the surgical community.

Case Presentation: A 43-year-old male patient was admitted to the emergency department of the General Hospital of Ticoman, referred by emergency medical personnel due to blunt thoracoabdominal and pelvic polytrauma. An anteroposterior chest radiograph revealed a homogeneous radio-opacity in the entire right hemithorax, ipsilateral tracheal deviation, and multiple simple rib fractures. A right anterolateral thoracotomy and decortication were performed, achieving right lung expansion. A Grade V diaphragmatic injury with a defect measuring approximately 20x15 cm was identified, accompanied by total herniation of the liver and gallbladder into the thoracic cavity. The right hemidiaphragm was repaired using 1-0 Prolene sutures, and a polytetrafluoroethylene (PTFE) prosthesis was placed, with subsequent satisfactory patient evolution.

Discussion: Traumatic Diaphragmatic Hernia (TDH) is a potentially life-threatening condition. TDH occurs following thoracoabdominal trauma, primarily in areas of inherent weakness, such as embryological fusion sites, where a sudden increase in the pleuroperitoneal pressure gradient is the main pathophysiological mechanism.

Right-sided diaphragmatic hernias are mainly associated with severe thoracic, abdominal, and pelvic trauma. The most common type of injury results from blunt thoracoabdominal trauma, often due to motor vehicle accidents. Delays in diagnosis are more common in cases of right-sided TDH, as they are less frequent than left-sided hernias, more difficult to visualize on imaging studies, commonly associated with other life-threatening injuries, and tend to present with subtle clinical manifestations.

Laparotomy or thoracotomy are the traditional treatment approaches, with the choice largely depending on the surgeon’s expertise.

Conclusion: Traumatic Diaphragmatic Hernia is a severe condition requiring a high index of suspicion for timely diagnosis, particularly on the right side. Early detection and an appropriate surgical approach are essential to improving prognosis and reducing mortality.

 Keywords: Rupture; Diaphragm; Thoracic Trauma; Prosthetic Repair; Thoracotomy

1. Heras Gómez F., et al. “Hernia diafragmática traumática”. Anales de la Real Academia de Medicina y Cirugía de Valladolid 50 (2013): 55-69.
2. Testini M., et al. “Emergency surgery due to diaphragmatic hernia: case series and review”. World Journal of Emergency Surgery 12 (2017): 23.
3. Feyissa M., et al. “Right side traumatic diaphragmatic hernia presented after 20 years with shortness of breath: A rare case presentation, and literature review”. International Journal of Surgery Case Reports 121 (2024): 109973.
4. D Sadamitsu., et al. “[Right-sided traumatic diaphragmatic hernia following blunt trauma]”. Nihon Rinsho Geka Gakkai Zasshi 2 (1984): 182-187.
5. S Kesavaramanujam., et al. “Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma”. Surgical Case Reports 1 (2020): 178.
6. Carter BN., et al. “Traumatic diaphragmatic hernia”. American Journal of Roentgenology Radium Therapy and Nuclear Medicine 1 (1951): 56-72.
7. Panda A., et al. “Traumatic diaphragmatic injury: a review of CT signs and the difference between blunt and penetrating injury”. Diagnostic and Interventional Radiology 2 (2014): 121-128.
8. Kaur R., et al. “Blunt traumatic diaphragmatic hernia: pictorial review of CT signs”. Indian Journal of Radiology and Imaging 3 (2015): 226-232.
9. Agalar ˘ C., et al. “Adult Morgagni hernia: a single-center experience of five cases and a review of literature”. Turkish Journal of Surgery 4 (2018): 321-324.
10. M Giuffrida., et al. “Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper”. World Journal of Emergency Surgery 1 (2023): 43.
11. EK Jones., et al. “Surgical management of delayed-presentation diaphragm hernia: a single-institution experience”. JTCVS Techniques 13 (2022): 263-269.