Over the years I have seen a number of diaphragm injuries. Four come to mind as very interestingly different.
- While I was doing a lot of chest surgery, I received an urgent call to come to the OR, where a an obstetrician friend was doing a Caesarian Section. The patient had been in a car accident a couple of years before, and had gone through pregnancy well until when on the operating table, having been given a dose of scoline her left chest became dull and the anaesthetist had to struggle to keep her oxygenated. She had a rapid LSCS making it much easier for the anaesthetist. You could hear bowel sounds in the chest, so with her accident story, we diagnosed delayed rupture of the diaphragm, probably by the rupture of her incomplete tear with the twitches caused by the scoline. She was repositioned and her diaphragm repaired. She and her baby did well.
- A man had been caught between a backing utility and a bench several years before. He was referred to me with a large AAA and a ruptured diaphragm. At the time he had been investigated and no problems found. After work up, and postulating that his prior accident had probably damaged his aortic wall allowing his aneurysm to develop, and that its size had caused an incompletely ruptured diaphragm to completely tear, he was operated on. We repaired both problems at the same time. Obviously this time the diaphragm was repaired from below.
- A grossly obese woman unwisely sat on a glass table. She had a stab wound in her right back, and was operated on by a general surgeon who at laparotomy found a little blood but no other problem and closed the abdomen. She survived but was not well. They did a chest X-ray and found a mass in her right lower chest. I was asked to see her and after investigation explored her right chest finding a complete cut across her diaphragm with the liver totally in the chest. With it repaired she made a rapid recovery.
- The fourth case was seen when one day I made one of my weekly trips to Nazret Hospital when living in Addis Ababa. There was a man who had been stabbed in the back of his right chest. There was an UWSD in place to treat the pneumothorax. He had no abdominal signs or symptoms. But no one had noticed that there was bile coming out the drain! I explored his chest and found about a 5cm laceration in his diaphragm and a considerable laceration into the bare area on the top of his liver. I repaired both liver and diaphragm through the chest. He did well.
Being a surgeon is interesting!
Barry Hicks
Medical Memoirs 