Santo Tomás Hospital
Panamá, Republic of Panamá
Correspondence to: Rafael Andrade Alegre, MD, FCCP, Thoracic Surgery, Santo Tomás Hospital, PO Box 8748, Zone 5, Panamá, Republic of Panamá
To the Editor:
I read with interest the article published by Seelig et al
(January 1999).1Chronic diaphragmatic hernias have a high
rate of mortality and morbidity, as has been stressed by the authors.
They also represent a diagnostic and therapeutic challenge for
surgeons. There are two aspects of this report that I would like to
emphasize. First, the diagnosis of traumatic injuries of the diaphragm
should be performed ideally at an early stage (ie, in the
acute setting of the trauma). Diagnosis may be easy if diagnostic
ancillary studies are conclusive or if the patient requires an
emergency operation. Unfortunately, there are a significant number of
patients that have neither of these, and injuries to the diaphragm will
go undetected. Murray et al2 reported recently a
prospective study in which 24% of patients with penetrating trauma to
the left lower chest had occult diaphragmatic injuries. In order to
reduce this number of patients with occult diaphragmatic injuries, they
proposed performing a diagnostic laparoscopy or thoracoscopy. Minimally
invasive procedures are currently being assessed in several trauma
centers and may become the “gold standard” diagnostic modality for
ruptured diaphragms in the near future.
The second aspect I would like to point out is the surgical approach
for chronic diaphragmatic hernias. In my experience, and in that of
others,3–4 thoracotomy has a significant advantage over
laparotomy. There are two fundamental reasons for this. Diaphragmatic
hernias do not have a true hernia sac, and the reduction of larger
portions of viscera (spleen, stomach, and bowel) from the chest can be
hindered by adhesions between the abdominal and thoracic
structures,5and there can be an increased risk of causing
iatrogenic injuries due to the awkward exposure through the abdomen. On
the other hand, patients with complications such as gangrenous or
perforated viscera will rapidly develop empyema, which requires
complete drainage and complete reexpansion of the lung. The latter is
achieved by taking down adhesions and decorticating the lung. This is
best accomplished through the chest, as occurs with other traumatic
I congratulate Dr. Seelig and colleagues for bringing attention to this
difficult surgical problem.
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