INTRODUCTION: Diaphragmatic rupture is a relatively rare but reparable injury usually associated with penetrating or blunt trauma. Classical teaching holds that most of the cases of diaphragmatic rupture are left-sided due to the liver's position on the right, and its consequent dispersion of pressure over a wide area in cases of blunt trauma. The diagnosis of diaphragmatic rupture can be elusive. Herniation of abdominal contents through the ruptured diaphragm is a well-documented and life-threatening complication. We report a case of right-sided diaphragmatic rupture which presented several weeks after video-assisted thorascopic surgery (VATS).
CASE PRESENTATION: A 55-year-old female presented to the emergency department seven weeks after undergoing VATS for biopsy of small pulmonary nodules in the right upper and lower lobes. She complained of an insidious onset of dyspnea, right shoulder pain, and right upper quadrant abdominal pain. Her immediate perioperative course was uncomplicated. The nodules were benign. Until the two weeks prior to re-admission, she had been doing well at home, increasing activity as directed. During re-admission, the patient was in mild distress due to pain. Her vital signs were unremarkable. The remainder of the exam was significant for dullness and decreased breath sounds in the right base. Laboratory studies were unremarkable. A chest radiograph and computed tomography (CT) pulmonary angiogram were performed, which revealed apparent elevation of the right hemidiaphragm. No evidence of parenchymal disease or pulmonary embolus was demonstrated. A fluoroscopic “sniff” test demonstrated that the right diaphragm appeared to move properly with respiration. At this point, three-dimensional reconstruction of the admission CT was implemented and this was suggestive of a ruptured diaphragm with herniation of the liver. The patient was taken to the operating room and repair was uncomplicated. It was postulated that the patient had sustained some sort of minor diaphragmatic injury at the time of her initial surgery which compromised the integrity of the diaphragm. As the patient recovered from surgery, the resultant increase in activity and stress on the diaphragm caused complete rupture with subsequent herniation of the liver.
DISCUSSIONS: This case illustrates one of the key problems with diaphragmatic rupture, particularly when the injury is on the right side: making the diagnosis. Diaphragmatic rupture is a relatively uncommon injury, and despite advances in imaging technology, the majority cases of diaphragmatic rupture are diagnosed only during exploratory surgery or when surgery is being performed for other reasons. Delay in diagnosis can lead to increased morbidity and mortality. The diagnosis is frequently not considered in cases of an apparent elevated right hemidiaphragm, since most cases present with the injury occurring on the left side. Radiographic diagnosis of diaphragmatic rupture is also more difficult when the injury occurs on the right side. While abdominal contents can clearly be identified herniating through the diaphragm on the left, it is often difficult to determine if the liver is herniating though an injured diaphragm on the right. This scenario can be radiographically identical to a paralyzed hemidiaphragm, in which the diaphragm is elevated with the liver and abdominal contents still appropriately in an inferior position. Treatment for diaphragmatic rupture is surgical. Particulars on technique will vary depending on the clinical situation and the technical expertise of the surgeon.
CONCLUSION: We have reported a case of a ruptured right hemidiaphragm that initially appeared to be an elevated hemidiaphragm with normal motion. This appears to be the first report of a ruptured hemidiaphragm presenting as a possible late complication of VATS. Due to the lack of sensitivity and specificity of imaging studies in the diagnosis of diaphragmatic rupture, physicians should consider the diagnosis in the differential of an idiopathic elevated hemidiaphragm.
DISCLOSURE: Gregory Howell, None.