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Communications to the Editor |

Chronic Diaphragmatic Hernia FREE TO VIEW

Rafael Andrade-Alegre, MD, FCCP
Author and Funding Information

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



Chest. 1999;116(6):1838-1839. doi:10.1378/chest.116.6.1838-a
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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,34 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 empyemas.6

I congratulate Dr. Seelig and colleagues for bringing attention to this difficult surgical problem.

References

Seelig, MH, Kingler, PJ, Schonleben, K (1999) Tension fecopneumothorax due to colonic perforation in a diaphragmatic hernia.Chest115,288-291. [CrossRef]
 
Murray, JA, Demetriades, D, Asensio, JA, et al Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.J Am Coll Surg1998;187,626-630. [CrossRef]
 
Mansour, KA Trauma to the diaphragm.Chest Surg Clin North Am1997;7,373-383
 
Sharma, OP Traumatic diaphragmatic rupture: not an uncommon entity; personal experience with collective review of the 1980’s.J Trauma1989;29,678-682. [CrossRef]
 
Naumheim, KS Adult presentation of unusual diaphragmatic hernias.Chest Surg Clin North Am1998;8,359-369
 
Andrade-Alegre, R T-tube intubation in the management of late traumatic esophageal perforations: case report.J Trauma1994;7,131-132
 

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References

Seelig, MH, Kingler, PJ, Schonleben, K (1999) Tension fecopneumothorax due to colonic perforation in a diaphragmatic hernia.Chest115,288-291. [CrossRef]
 
Murray, JA, Demetriades, D, Asensio, JA, et al Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.J Am Coll Surg1998;187,626-630. [CrossRef]
 
Mansour, KA Trauma to the diaphragm.Chest Surg Clin North Am1997;7,373-383
 
Sharma, OP Traumatic diaphragmatic rupture: not an uncommon entity; personal experience with collective review of the 1980’s.J Trauma1989;29,678-682. [CrossRef]
 
Naumheim, KS Adult presentation of unusual diaphragmatic hernias.Chest Surg Clin North Am1998;8,359-369
 
Andrade-Alegre, R T-tube intubation in the management of late traumatic esophageal perforations: case report.J Trauma1994;7,131-132
 
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