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Home > Images > Thoraco-phreno-laparotomy for a delayed presentation of a left diaphragmatic hernia

Denis Allard, Trauma Surgeon, GF Jooste, Cape Town

This patient presented with bowel obstruction, a small scar from a left sided thoraco-abdominal chest wound treated by a chest drain two years previously, and a chest X ray showing a loop of bowel above his left diaphragm. He complained only of abdominal pain and pain on breathing. He was not hypotensive and had a mild acidosis with a mildly raised lactate on ABG. He went to theatre the same day that he presented to our ED without further delay.

We do our best to exclude a diaphragmatic laceration on all our thoraco-abdominal stab wounds, but without doing a laproscopic evaluation - scarcity of resources and volume of patients makes this impractical. In cases where there is a strong suspicion or some omentum eviscerating over the ribs, we do a midline laparotomy to repair the diaphragm and to wash out the chest.

I approach the delayed obstruction cases such as this always by starting with a mid-midline laparotomy to assess the diaphragm from below and to see if the bowel loop can be mobilised. Next I open the antero-lateral chest to see the dead bowel in the pleural cavity. If the bowel is very necrotic, I teach my registrars to not push or pull on the bowel but to deliver it safely after having joined the thoracotomy and the laparotomy incisions and cut the healthy diaphragm.

This is an extensive 'thoraco-phreno-laparotomy' through which the bowel gets delivered safely and prevents perforation. In cases where the bowel has already perforated, the patient is usually in septic shock and damage control principles apply. After controlling the arterio-venous supply, this patient had a transverse colon resection with a primary end-to-end anastomosis and a diaphragm and costal suture repair (the diaphragm is best repaired with non-absorbable interrupted sutures). He was admitted to the ICU, extubated the first night and left the hospital after five days without complication.

Associated Images

Post skin closure

Anastomosis of the colon and closure

Scalp injury mainly overlying frontal bone seen at time of examination

CT scout view of injury to scalp overlying frontal bone

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