Repair of right sided Traumatic Diaphragmatic Hernia with intrathoracic herniation of liver and a segment of ruptured jejunum—a case report and review of literature

Abstract

We present this rare case of a 24 year old male who was knocked down by a slowly backing truck when the rear wheels climbed on to the right side of the abdomen and on hearing the shouts of people rolled forwards causing a partial run over injury. He was resuscitated and treated conservatively. An X Ray Chest done 24 h later showed right sided chest wall fracture, right basilar opacity suggesting chest injury with localized haemothorax/pulmonary contusion and a chest tube was inserted through Rt. 5th intercostal space. Initially some blood came out. But on the third day bile was seen coming out of the intercostal drain prompting a diagnosis of traumatic rupture of diaphragm with liver injury. A Magnetic Resonance Imaging (MRI) scan was done when the diagnosis of ruptured right dome of diaphragm with Traumatic Diaphragmatic Hernia (TDH) with herniation of liver into the right hemithorax was made. Surgical exploration on the 4th day through right thoraco- abdominal approach confirmed TDH with herniated liver into the right hemithorax without any injury to the liver, hepatic blood vessels or the bile ducts but an unsuspected rupture in a herniated loop of jejunum wedged into the right hemithorax anterior to the liver with biliary discharge into the right hemithorax but without any peritoneal soiling. Repair was done by resection anastomosis of the ruptured jejunum, reduction of the liver into the abdomen, suturing of the torn diaphragm effectively obliterating the hernia orifice and reinforcing it with a polypropylene mesh anchored to the chest wall. There was a stormy post operative phase involving burst thorax which was corrected by re-exploration of the thoracic portion of the thoraco abdominal wound, wound toileting and resutured. The wound healed after 2 months. The patient is doing well after 20 months of follow up.