Blunt Traumatic Rupture of the Right Hemidiaphragm: Experience in 12 Patients

In a 9-year period (1972 to 1981), 35 patients with blunt traumatic rupture of the diaphragm were seen in our institution; 12 had involvement of the right hemidiaphragm, an incidence of approximately 34%. In 9 of these 12 patients, the right-sided diaphragmatic injuries were seen soon after the accident (acute), and in 3, late after the accident (chronic). A large diaphragmatic rent, usually 10 cm or more, without any predilection to a specific area of the right hemidiaphragm, was a frequent operative finding. Expectedly, the most common viscus that was injured or herniated through the defect was the liver. Total or nearly total herniation of the liver was noted in 5 patients and partial herniation, in 1. Injury to the juxtahepatic vena cava or hepatic vein, or both, was also encountered in 5 patients. This highly lethal injury accounted for the 3 deaths in the series, all of which were directly related to an uncontrollable exsanguinating hemorrhage from the injured vena cava or hepatic vein. The surgical approach for repair of a ruptured right hemidiaphragm is best individualized. The right thoracotomy approach through a right posterolateral incision is preferred for chronic diaphragmatic injury. It is also our choice in patients in whom acute right-sided injuries are definitively diagnosed and who are hemodynamically stable. This approach not only provided the best exposure of the defect, but also made the repair of associated retrohepatic caval injury surprisingly easy in at least 2 of our patients. Patients with clinical evidence of other obvious associated abdominal injuries and those who are hemodynamically compromised are best approached through an upper midline abdominal incision, with immediate extension into a median sternotomy when associated retrohepatic caval injury is encountered. This approach provides better exposure and allows insertion of the temporary internal caval shunt, which is helpful in the control of hemorrhage.