Damage to the diaphragm, causes, clinical picture, diagnosis, treatment. How to treat a pectoral muscle strain

Diaphragm ruptures due to blunt chest trauma are rare but serious complications. Their frequency is 0.8-2.2% (V.A. Akbarov, 1960; Konrad, Millinckrodt, 1963). We observed diaphragm ruptures in 6 patients (0.1%). The rarity of rupture of the thoraco-abdominal barrier with a closed chest injury is explained by the fact that when the chest is compressed, the diaphragm easily bends down and remains motionless.
Drews (1967) believes that when the chest is compressed in the anteroposterior direction, a rupture of the dome of the diaphragm most often occurs, going from front to back; with lateral injuries, the rupture has a transverse direction. Direct injury to the diaphragm by broken ribs is even less common (B.V. Petrovsky, N.N. Kanshin, N.O. Nikolaev, 1966). Of the 6 patients we observed with a diaphragmatic hernia, in 5 it was formed as a result of severe road or railway trauma, accompanied by damage to internal organs and second-degree shock. In 1 patient this happened due to a chest contusion from a fall. 3 victims had multiple fractures of the ribs, the remaining 3 had a closed blunt chest injury without breaking the integrity of the chest bones.
The severity of the condition of patients with damage to the diaphragm is largely explained by the fact that this pathology often occurs with combined trauma, that is, polytrauma (Yu.V. Progressov, 1973; Popovici, Bricin, 1974).
Most often, with a closed injury, the rupture is localized in the left half of the diaphragm (E.A. Wagner, 1964; 1969; I.I. Shmulevich, 1965; A.P. Lebedev, 1971). All our patients had a left-sided hernia. Right-sided ruptures of the diaphragm are rarely observed, since the liver covers from below the entire right half of the thoraco-abdominal obstruction. It is extremely rare for both domes of the diaphragm to rupture (A.I. Guzeev, 1976; Konrad, Millinckrodt, 1963).
The stomach, omentum, loops of the small and large intestines prolapse into the pleural cavity through a hole in the diaphragm, and occasionally the liver prolapses. Prolapse of breast organs into the abdominal cavity is extremely rare. I.D. Korabelnikov (1951) observed partial prolapse of the heart through a rupture of the left dome of the diaphragm, which he discovered during surgery. A similar case was described by T.Ya. Ariev and O.A. Mikhailov (1953).
Prolapse of internal organs can occur either immediately after injury or much later. In 2 of our patients, the initial X-ray examination immediately after the injury did not reveal any pathology, but 6-8 months later, during an examination associated with the appearance of pain in the left hypochondrium, radiating to the back, a diaphragmatic hernia was discovered.
A defect in the diaphragm can lead to infringement of internal organs.
The severity of this pathology is also due to the fact that it is often detected late or not diagnosed at all.
In 2 of the patients we observed, during the initial clinical and radiological examination, a diagnosis of left-sided pneumothorax was made, and only a month after the injury, in one of them, during examination in a specialized thoracic department, and in the other, 10 months later during surgery undertaken for acute obstruction. intestines, a diaphragmatic hernia was discovered. This is due to the fact that sometimes the symptoms of chest trauma prevail over the signs characteristic of a diaphragm rupture.
This category of patients may have symptoms of shock, pain in the corresponding half of the chest with irradiation to the supraclavicular region, neck, and arm. The last moments as important signs of diaphragm rupture were given importance by N.A. Shchegolev (1902) and V.F. Voino-Yasenetsky (1927). Patients are restless, complaining of dry mouth, shortness of breath, cyanosis. When percussing in lower parts In the affected half of the chest, areas of tympanic sound may alternate with areas of dullness. When listening, breathing over these areas is weakened or completely absent. Unusual noises are often heard (intestinal peristalsis, splashing noise when the stomach is distended with gases). Sometimes the phrenicus symptom is pronounced. The heart is displaced to the right (with a left-sided hernia), tachycardia and impaired heart rate. All this is associated with compression of the lung and pushing the mediastinal organs to the healthy side. Nausea, vomiting, and partial or complete intestinal obstruction are often observed.
X-ray data are of decisive importance in establishing a diagnosis of diaphragm rupture. When it ruptures, not complicated by prolapse, limited mobility and an increase in the level of its standing are observed. The resulting hemothorax gives either significant shading or signs of a small accumulation of fluid in the costophrenic sinus. If an organ prolapses, you can find a hollow organ with a level of fluid in the pleural cavity above the dome of the diaphragm, compression of the lung, and displacement of the cardiovascular bundle to the healthy side.
If there is the slightest doubt, one cannot limit oneself to survey fluoroscopy. It is also necessary to carry out a contrast X-ray examination stomach, small and large intestines. In some cases, pneumoperitoneum is used, especially if, with a narrow opening in the diaphragm, the barium suspension cannot enter the prolapsed part of the organ.
It should be noted that despite the many techniques for diagnosing diaphragm ruptures, errors still occur. This is primarily due to the rare use of special examination methods. There are times when due attention is not given clinical picture, are limited only to plain fluoroscopy of the chest. As a result, a diagnosis of pneumothorax, hemothorax, and exudative pleurisy is made, after which a puncture is performed. L. Levshin (1909, 1912) reported on a patient whose injury due to compression of the chest by the buffers of railway cars was classified as pneumothorax, which was the reason for thoracentesis.
At the last point, the tip of the trocar stylet perforated the transverse colon displaced into the chest cavity and the patient died. To illustrate incorrect diagnosis, we present an extract from the medical history.
Patient B., 34 years old, was taken to the hospital on April 22, 1968 after a railway injury. The circumstances of the injury could not be determined due to the patient’s alcohol intoxication.
A chest contusion, a rupture of the right kidney, a retroperitoneal hematoma in the left lumbar region, a compression fracture of the 3-4 lumbar vertebrae, and stage II shock were diagnosed. The right kidney was urgently removed, the left perinephric tissue was drained. The patient's condition began to improve. On 05/02/68, a sharp pain suddenly appeared in the left half of the chest. Upon percussion over the left lung, a tympanic sound was detected; upon auscultation, breathing was not audible. An X-ray examination revealed a gas bubble occupying almost the entire left pulmonary field (Fig. 22). Based on the data obtained, a diagnosis of left-sided pneumothorax was made. During puncture, 400 ml of yellowish liquid was obtained. On 05/08/68, thoracentesis was performed and a drainage tube was inserted. The drainage functioned poorly and on May 17, 1968, resection of the 5th rib and thoracotomy were performed, gauze drainage was inserted into the wound, and when removed the next day, about 1.5 liters of gastric contents were released. On 05/23/68 the patient was transferred to the thoracic department.
On examination: the patient’s condition is severe, low nutrition, skin pale. Pulse-120 per minute, arterial pressure 149/104 hPa. The chest is symmetrical, the left half of it lags behind in the act of breathing, here breathing is not audible during auscultation, a tympanic sound is determined by percussion. X-ray contrast examination of the intestines revealed: the esophagus is freely passable; the stomach is deformed, deployed, located in the left pleural cavity (Fig. 23). Immediately after administration, the contrast agent flows through the thoracic fistula in the 7th intercostal space. After 2 hours, a small amount of contrast agent appeared in the loops of the small and large intestines, which were partially displaced into the pleural cavity.
A diagnosis of traumatic left-sided diaphragmatic hernia with displacement of the stomach, partially small and large intestines into the pleural cavity was made; gastropleural external fistula, pleural empyema.
On 05/29/68, under endotracheal anesthesia, a left-sided thoracotomy was performed through the posterior periosteum of the resected sixth rib. The pleural cavity contained the stomach, spleen, loops of the small intestine, transverse colon, and omentum. The lung is collapsed. The parietal pleura is thickened and covered with a fibrinous coating of a dirty gray color. The organs of the abdominal cavity, located in the pleural cavity, are loosely fused together. Along the greater curvature of the stomach there is a wound 12 cm long, through which the contents of the stomach are poured into the pleural cavity and then out through the thoracic fistula. There is a wound of 3*1.5 cm on the lateral surface of the stomach. The wounds of the stomach are sutured with a double-row suture. The abdominal organs have been reduced. A large defect in the diaphragm is sutured. Two drains were introduced into the pleural cavity through the II and VIII intercostal spaces. The chest wound is stitched tightly. In the postoperative period, pleural empyema developed, as a result of which the patient died on 06/08/68.
From the above observation it follows that for the correct diagnosis of diaphragmatic rupture in a closed chest injury, a thorough clinical and radiological examination is necessary. If there is the slightest doubt, one cannot limit oneself to survey fluoroscopy only; one must also resort to contrast X-ray examination of the stomach, small and large intestines, and use pneumoperitoneum.

Closed injuries to the diaphragm in children are relatively rare and are the result of severe trauma. Among the children operated on in our clinic, 1 was admitted after a fall from high altitude and 5 were hit or crushed by a car. The mechanism of diaphragm rupture is usually caused by a sudden and sharp increase in intra-abdominal pressure. In this regard, cases of abdominal compression with a pelvic fracture should especially alert the surgeon to a possible rupture of the diaphragm. Damage is localized mainly on the left, mostly in the area of ​​the tendon center or along the gaps between individual muscle groups, sometimes spreading to the pericardium. Through the formed wound defect they move into the pleural cavity. abdominal organs(stomach, intestines, spleen, etc.), squeezing the lung, displacing the mediastinum in the opposite direction. This condition is commonly called acute traumatic diaphragmatic hernia. Diaphragmatic rupture is usually one of the components of combined abdominal trauma. Less commonly, isolated damage to the diaphragm occurs. In such cases, the rupture may go unrecognized. Subsequently, the abdominal organs are periodically displaced through the defect of the diaphragm into the chest cavity. A “chronic” traumatic diaphragmatic hernia occurs. With this disease, the need for urgent surgical intervention arises only in cases of complications that are similar in nature to the complications observed with false congenital diaphragmatic hernias.

Clinical picture. Isolated damage to the diaphragm is not accompanied by characteristic signs. The child complains of pain in the abdomen and chest, difficulty breathing. Irradiation of pain to the shoulder or shoulder girdle has some diagnostic value. Palpation of the abdomen is painful in the upper parts. The general condition of the child worsens sharply when it is displaced into the chest cavity and the abdominal organs are pinched. A picture of severe shock develops. Respiratory and cardiac disorders are evident. Physical findings during chest examination depend on the degree of movement of the abdominal organs. As a rule, there is a shift in the boundaries of the mediastinum. If there is an invasion of the stomach or intestines into the chest cavity, then tympanitis is detected by percussion, and a splashing noise is detected by auscultation. Displacement of the liver or spleen into the chest cavity is accompanied by dullness of percussion sound in the corresponding places, and when listening, respiratory sounds are not detected.

Diagnosis of rupture in combined abdominal trauma is most difficult. Typically, the more striking symptoms of abdominal organ injury, accompanied by intra-abdominal hemorrhage and severe shock, completely mask the diaphragmatic injury. Only in cases of significant displacement of the abdominal organs into the chest cavity, causing significant respiratory distress, can the presence of an acute traumatic diaphragmatic hernia be suspected. Physical data help

They talk about diagnostics. The final judgment about the presence of displacement of the abdominal organs into the thoracic cavity can be made after an X-ray examination. Images in the chest cavity clearly show gas bubbles in the stomach or typical haustration of intestinal loops. The displacement of the spleen is less clearly defined.

Differential diagnosis of diaphragm rupture is carried out with lung damage(in the presence of hemopneumothorax). Special difficulty clinical picture and the severity of these injuries create significant difficulties for diagnosis. Only x-ray examination allows us to clarify the nature of the damage.

Treatment- surgical. A detected diaphragm rupture is an indication for immediate surgery.

Preoperative preparation should be short-term and intense, aimed at eliminating shock. The operation is performed under endotracheal anesthesia and protective blood transfusion.

Technique for suturing a ruptured diaphragm. A median laparotomy and a thorough examination of the abdominal organs are performed. The detected diaphragm defect after hemostasis is sutured with one row of separate silk sutures. In case of marginal tears, the diaphragm is sutured to the chest wall, passing the threads around the rib. The operation is completed by layer-by-layer suturing of the abdominal wall wound. Pneumothorax is eliminated by puncturing the pleural cavity and suctioning air with a Janet syringe while simultaneously straightening the lung with an anesthesia apparatus.

With a combined injury, in addition to severe shock, the child usually experiences an increase in internal hemorrhage. Surgical intervention in such cases cannot be delayed. The child is immediately taken to the operating room, blood is given a stream transfusion (into 2-3 veins at a time), anesthesia and surgical intervention begin. The doctor’s tactics when choosing the order of elimination of the consequences of an injury depend on the surgical findings. First of all, the bleeding is stopped, then the damaged hollow organs are sutured (resected), and lastly, the rupture of the diaphragm is eliminated. This sequence may be disrupted due to the characteristics of the identified damage.

Postoperative treatment. In case of isolated rupture of the diaphragm in the postoperative period, therapeutic measures should be aimed at preventing surgical infection and pulmonary complications. The child is prescribed antibiotics, oxygen therapy, and placed in an elevated position. The next day after surgery, active breathing exercises are prescribed. A control radiograph is taken after 2-3 days. Identified hemothorax is an indication for puncture of the pleural cavity. For concomitant and combined trauma, it is prescribed (except for the above) therapeutic measures recommended in the postoperative period for children with damage to the relevant organs of the thoracic and abdominal cavities.

Damage to the diaphragm

The diaphragm can be damaged both from wounds and from blunt closed trauma. Back in 1910, M. M. Magula identified two main types of this pathology: 1) subcutaneous injuries and 2) wounds with damage to the skin. The latter, in turn, were divided into firearms and stabs. In addition, there is a division of traumatic injuries of the diaphragm into direct and indirect, which in the first group combines open injuries and rare injuries of the diaphragm with a broken rib during a closed injury.

Based on the peculiarities of the mechanism of diaphragm damage, we adhere to the following scheme:

It should be noted that almost all open injuries are direct. With the exception of rare cases of rupture of the diaphragm due to gunshot wounds of parenchymal organs.

Open (percutaneous) diaphragm injuries

Frequency and pathological anatomy

Open injuries to the diaphragm, which are an essential component of any thoracoabdominal injury, occur in both peacetime and wartime. During periods of military events, their number, as well as damage to other organs, naturally increases sharply, which was especially evident during the years of the First and Second World Wars.

One of the largest statistics of open damage to the diaphragm during the First World War is provided by Yeyn and Sauerbruch (1922), who had 48 personal observations.

And in 1945, A. Yu. Sozon-Yaroshevich’s monograph “Thoracoabdominal Wounds” was published, based on 73 observations of the author during the Great Patriotic War, comprehensively covering issues of pathological anatomy, clinical presentation, diagnosis and surgical treatment of diaphragm injuries. E. S. Egorova (1945) reported on the experience of one of the military hospitals in treating 82 wounded with thoracoabdominal wounds.

I. F. Krupachev (1946) indicates that the number of victims with thoracoabdominal wounds is 5.1% in relation to all penetrating chest wounds and 16.7% in relation to abdominal wounds.

In peacetime, injury to the diaphragm is observed relatively rarely. V.I. Mushkatin (1929) noted damage to the diaphragm in 12% of those wounded in the chest. V. A. Perov (1953) damage to the diaphragm in 0.2% of those wounded in the stomach. The N.V. Sklifosovsky Research Institute of Emergency Medicine annually receives 5-6 patients with thoracoabdominal wounds. According to V.S., Shapkin (1962), out of 204 penetrating chest wounds, thoracoabdominal lesions were noted 20 times. E. A. Wagner (1955) reported 16 cases of diaphragm wounds encountered in 194 chest wounds.

The size, nature and characteristics of the diaphragm wound, in addition to the characteristics of the wounding projectile, are greatly influenced by the direction of the wounding channel, since with a tangential wound affecting a significant part of the diaphragm, the wound will be more extensive than with a wound channel directed perpendicular to the surface of the diaphragm. At the same time, with tangential wounds, damage to only the diaphragmatic pleura and the diaphragm muscle is possible without compromising the integrity of the peritoneum (observations by M. M. Magula, 1910; I. M. Derevyanko, 1961, etc.).

At the same time, there are cases when the integrity of the diaphragm is violated, but the organs adjacent to it remain intact. Such isolated wounds of the diaphragm were described by M. M. Magula (1910) in 25 people, V. I. Mushkatin (1925) - in 9 wounded, E. S. Egorova (1945) - in 4, I. F. Krupachev (1946) – at 16, by B. A. Stekolnikov (1953) – at 6, by E. A. Wagner (1956) – at 6, by I. M. Derevyanko (1961) – at 3, by V. S. Shapkin (1962) – at 3, Konrad, Tarbiat (1961) – 1 wounded. Noteworthy is the very large number of isolated wounds of the diaphragm, which were described by M. M. Magula. However, upon reviewing the case histories given by him, it turned out that in three cases there was concomitant damage to the stomach and intestines, which did not allow these observations to be attributed to isolated wounds of the diaphragm, and in a number of cases, revision of the diaphragm wound was carried out only by palpating with a finger without examining the internal organs, i.e. Injury to adjacent organs was not completely excluded.

Penetrating wounds of the diaphragm in the area of ​​the prediaphragmatic space without damage or with damage to the pleural sinus, but without injury to the lung, are rarely observed, which most often occurs when injury is caused at the time of exit. The consequence of these injuries is the development of an intercostal diaphragmatic hernia.

The thoracoabdominal wounds we observed (mainly during the Great Patriotic War) (409 in total) were stab wounds in 8 cases (2%), and gunshot wounds in 401 (98%). Among the latter, 95 (23.7%) were bullet wounds and 306 (76.3%) were shrapnel wounds. There were 108 (26.4%) through (mostly bullet) and 301 (73.6%) blind. There were 286 (70%) right-sided wounds, 121 (29.5%) left-sided wounds and 2 (0.5%) bilateral wounds. According to “The Experience of Soviet Medicine in the Great Patriotic War of 1941-1945.” “Right-sided wounds of the diaphragm were noted in 59.7%, left-sided - in 39.6% and bilateral - in 0.7% of the wounded. In case of gunshot thoracoabdominal wounds, the entrance hole was most often located in the lower parts of the chest at the level of 8 and 10 ribs (80% of cases), much less often - on the anterior abdominal wall and in the lumbar region.

I.F. Krupachev (1946), in addition to thoracoabdominal wounds, identified “thoraco-retroperitoneal” wounds, which he observed in 4.4% of cases. The wound channel for these injuries passes through the chest and retroperitoneal space, without penetrating into the abdominal cavity.

In addition, the diaphragm during a gunshot wound can be damaged outside the wound channel. B.V. Krukovsky (1946) observed during autopsies ruptures of the diaphragm in the area of ​​Bogdalek's triangle, which sometimes complicated wounds of the kidney, and pointed out the possibility of such ruptures in injuries of other parenchymal organs adjacent to the diaphragm.

The size of diaphragm wounds can vary widely: from small linear wounds to extensive defects irregular shape with crushed, torn edges, resulting from shrapnel and, less commonly, bullet wounds.

The size and shape of the wounds are influenced by the height of the diaphragm and the degree of curvature of its domes, depending on the phase of breathing and the filling of the abdominal organs.

R. S. Shpizel (1962) described a patient who fell from a height of 3 meters onto a picket fence. The sharp end of the board pierced the left hypochondrium of the victim and, injuring the transverse colon, led to a complete separation of the costal and partial lumbar parts of the diaphragm.

With multiple shrapnel wounds, multiple wounds of the diaphragm are possible, which can also occur with a single segmental wound passing through both slopes or through the slope and dome of the diaphragm. Multiple wounds to the diaphragm associated with several blows with a knife or bayonet have also been described (I.K. Isaev).

A completely special group of injuries to the diaphragm consists of damage caused by surgical operations. They can be accidental (for example, when separating the lung from the diaphragm in conditions of a closed pleural cavity) and intentional (transdiaphragmatic operations, excision of the diaphragm during oncological operations and so on.).

Prolapse of abdominal organs through the diaphragm in those killed on the battlefield was noted in 13.0% of cases of thoracoabdominal wounds (V.L. Byalik, 1955). It's comparative high frequency eventration can probably be explained by the extensiveness of the diaphragm defect in severe thoracoabdominal trauma, which led to the death of this group of wounded. Indeed, the frequency of prolapses in thoracoabdominal wounds, according to autopsies in advanced medical institutions, was much less common and amounted to only 3.1% (Yu. V. Gulkevich, 1955). We observed prolapse of the abdominal organs into the chest cavity in 23 wounded (5.6%).

Most often, prolapse of the omentum was observed, less often - the small and large intestines, stomach and spleen. Prolapse of the liver dome usually occurs only with extensive defects of the diaphragm.

The movement of the abdominal organs into the chest cavity through a defect in the diaphragm during thoracoabdominal wounds can be explained by the suction effect of the negative pressure of the pleural cavity with positive intra-abdominal pressure. Promotion intra-abdominal pressure contributes to the lowering of the diaphragm at entry, as well as a cut in the gastrointestinal tract, usually occurring with thoracoabdominal wounds. Movement of the chest organs into the abdominal cavity through a wound defect in the diaphragm usually does not occur, but individual similar observations are occasionally described in the literature. It should also be noted that sometimes, soon after injury, compression of prolapsed organs occurs, and this possibility is especially great when the size of the defect is small. We, however, did not observe such early infringements.

Clinic and diagnosis of open injuries of the diaphragm

The severity of the thoracoabdominal injury is determined by the combined damage to the organs of the abdominal and thoracic cavities.

Dwelling on the symptoms of damage to the diaphragm, we will not describe in detail the diversity of the clinical picture associated with damage to the internal organs, which usually occurs with a thoracoabdominal injury and mainly determines its symptoms. We will only point out that it is generally accepted to distinguish the following three main types of clinical picture of thoracoabdominal injuries: 1) the predominance of symptoms from the abdominal organs; 2) the predominance of symptoms of damage to the chest organs and 3) the presence of the same severity of both symptoms.

Accordingly, in the first option, a picture of an acute abdomen is observed (peritonitis, or intra-abdominal bleeding, or a combination of both). The second type is characterized by symptoms associated with pleuropulmonary shock, hemo- or pyopneumothorax and the development of respiratory and cardiovascular failure. It is clear that with the third type, a variety of combinations of the above symptoms are observed.

The clinical picture that occurs when the diaphragm itself is damaged develops with relatively rare isolated injuries. However, in these cases, symptoms of damage to the diaphragm in some patients may be completely absent, and the wound to the diaphragm remains, as a rule, unrecognized. In other cases, the clinical picture of an isolated wound of the diaphragm coincides with the diaphragmatic symptom complex described by M. M. Vikker.

A characteristic sign of diaphragm injury is pain in the area of ​​the xiphoid process (a symptom described by G. N. Keves, 1934). At the same time, abdominal pain, tension in the abdominal muscles, and a positive Blumberg-Shchetkin sign do not always indicate damage to the diaphragm during a thoracic injury, since they can often occur as a reflex. The same applies to the phrenicus symptom and hiccups, since they can manifest themselves when the diaphragmatic pleura is irritated by escaping blood.

A well-developed vascular network of the diaphragm is often the cause of very abundant internal bleeding, even with minor injuries to this organ. Fatal bleeding from the vessels of the diaphragm that occurred after pleural puncture has been described (N. A. Mityaeva, 1962).

When the abdominal organs prolapse into the chest cavity, symptoms associated with compression of the lung on the affected side and displacement of the mediastinum (shortness of breath, cyanosis, hiccups, palpitations, arrhythmias, etc.) are observed. Compression in the wound of the diaphragm of hollow organs when they prolapse causes signs of complete or partial intestinal obstruction. Most severe symptoms develop when prolapsed loops of intestines and stomach are pinched.

The clinical picture of this catastrophe depends mainly on which organ is infringed and on the time that has passed since the infringement. We consider this issue in more detail in a special chapter.

Diagnosis of open damage to the diaphragm is not always simple. Irrefutable evidence of damage is the prolapse of abdominal organs into the chest wound, the leakage of intestinal contents, bile or urine from it, as well as the accumulation of thoracic fluid or gas in the free abdominal cavity. Equally conclusive is the detection of hemo- and pneumothorax, confirmed by puncture or x-ray examination for abdominal wounds

An important auxiliary sign that allows one to think about a thoracoabdominal wound can be the direction of the wound canal. Thus, the location of the entrance hole on the chest, and the exit hole on the abdominal wall, in the lumbar region, or the reverse relationship for penetrating wounds, allows in most cases to diagnose a wound of the diaphragm.

However, the diaphragm can be damaged in blind wounds with very different localization of the entrance hole. Injuries to the diaphragm are described as casuistic cases when the entrance hole is located on the shoulder, in the gluteal and lumbar regions, etc. In these cases, clinical symptoms and especially x-ray examination become of great importance for the diagnosis.

X-ray diagnosis of open injuries of the diaphragm is often difficult. Only the presence of the stomach or intestines in the chest cavity can be recognized as a reliable radiological sign of such an injury. In some cases it is necessary to resort to X-ray contrast study. Right-sided thoracoabdominal wounds are even more difficult for radiodiagnosis, as well as for clinical recognition. An X-ray examination in these cases may reveal prolapse of the thoracic cavity of the liver through a wide wound in the diaphragm.

Thus, injury to the diaphragm with open injuries to the chest and abdomen cannot always be diagnosed. This is most often due to the severity of the patient’s condition and the inability to carry out a detailed examination. For isolated injuries of the diaphragm, the only reliable diagnostic method is revision of the diaphragm during thoracotomy. It goes without saying that in war conditions, preoperative diagnosis of diaphragmatic injuries is even more difficult.

Treatment of open injuries (diaphragm wounds)

Surgeon's tactics for established diagnosis thoracoabdominal wound must be active, and the plan of surgical intervention is determined mainly by the nature of damage to the organs of the abdominal and thoracic cavities. In case of injuries, the surgeon always faces the need to suture the wound of the diaphragm. It also exists in more rarely observed isolated wounds of the thoraco-abdominal obstruction.

The issue of indications for suturing wounds of the diaphragm has been the subject of a long discussion and continues to be studied both experimentally and in the clinic to this day. Back in 1902 B.K. Finkelstein, based on his experience of treatment in the surgical department of the Obukhov Hospital for the period from 1890-1901. 98 patients with penetrating stab wounds of the chest cavity indicated the need for suturing all wounds of the diaphragm, making exceptions only for wounds of the right dome.

When deciding whether to suture wounds of the diaphragm, their direction, size and location are of great importance.

The very specific features of the constantly contracting and relaxing diaphragm during breathing predetermine unfavorable conditions for the healing of its wounds. After the experiments of Repetto (1894), who noted that wounds of the diaphragm up to 1.5 cm long, inflicted perpendicular to the muscle fibers, do not heal, while wounds of the same size, located along the muscle bundles, scar well, a certain importance began to be attached to the influence of the direction of the wound diaphragm for healing. In the area of ​​the tendon center, where tension occurs in all directions, the direction of the wound is not so important. By the way, it should be noted that wounds in this section heal worse, which is partly due to poorly developed vascularization of the tendon part of the diaphragm.

The value equal to the aperture has a greater significance than the direction. I.G. Kadyrov (1932) established that incised wounds of the diaphragm up to 2-3 cm in size self-scarred, and with wounds large sizes hernias formed. The shape of the wound, according to this author, did not influence the nature of healing. D.G. comes to similar conclusions based on experimental studies. Dvali (1963). However, he noted that only wounds up to 1 cm heal on their own, and when they are larger than 1.5 cm, dogs usually develop a hernia, and the diameter of the hernial gate significantly exceeds the size of the wound.

More favorable conditions for the healing of wounds of the diaphragm are observed in the area of ​​its right dome, since here the liver lies below, and therefore traumatic hernias occur in these cases, as it turned out above, much less frequently.

The role of the omentum in the healing of diaphragm wounds is assessed differently. Thus, Iselin (1916) believed that the omentum, falling into the wound of the diaphragm, prevents its healing, and B.K. Finkelstein (1902), on the contrary, considered prolapse of the omentum and its fusion with the edges of the diaphragm wound as one of the conditions for its spontaneous healing. Based on experimental studies by I.D. Korabelnikov (1951) also confirms the participation of the omentum in the healing of wounds of the thoraco-abdominal barrier and considers the opinion about the introduction of the omentum as a factor preventing healing to be incorrect.

A.Yu. Sozon-Yaroshevich (1945) and B.A. Stekolnikov (1949) found suturing of wounds of the diaphragm in thoracoabdominal wounds indicated in order to prevent the spread of infection from one serous cavity to another. I.D.’s recommendation seems completely unjustified in our time. Maslova (1926) “avoid suture of the diaphragm so as not to cause peritonitis” in case of “contaminated omentum”. Resection of the omentum and antibiotics in these cases avoid the development of infection.

According to A.Yu. Sozon-Yaroshevich (1945) and E.S. Egorova (1945), only in cases of those “transdiaphragmatic wounds” that they call “lucky”, conservative treatment is possible. Naturally, with a short period of time that has passed since the injury, it is very difficult or almost impossible to reliably decide whether a given case can be classified in this group, and waiting increases the possibility of developing severe complications. Therefore, only after long periods after pinpoint thoracoabdominal wounds in the absence of clinical manifestations from the thoracic and especially abdominal organs, such tactics can be justified to some extent.

Thus, for almost all diagnosed injuries of the diaphragm, emergency surgical intervention is indicated.

Naturally, the need for a wide examination of the organs of the abdominal and thoracic cavities allows us to consider endotracheal anesthesia with the use of muscle relaxants as the method of choice in these cases.

The question of the most rational access for injuries of the diaphragm is widely discussed to this day. ON THE. Shchegolev's monograph on damage and surgical diseases chest, pleura and lungs indicated that all surgeons consider transpleural access to be the most convenient for suturing wounds of the diaphragm, and only if it is impossible to eliminate damage to the abdominal organs through this incision is it necessary to perform transection. V. M. Mints (1904) emphasized the advisability of transpleural suturing of wounds of the diaphragm, but he himself was forced to perform a laparotomy in addition to thoracotomy. M. M. Magula (1910), substantiated the need for surgical treatment of all thoracoabdominal wounds, pointed out the advantage of transpleural access for them. According to M. M. Magula, expansion of the diaphragm wound after thoracotomy allows for a sufficient revision of the abdominal organs and elimination of their damage.

V.I. Mushkatin (1929), who observed damage to the diaphragm in 27 wounded in the chest, also believed that with a diagnosed injury to the diaphragm, the troansthoracic route is indicated. On the contrary, V.F. Voino-Yayasenetsky (1927), who observed 12 patients with thoracoabdominal wounds, emphasized that, despite the anatomical feasibility of the transthoracic approach to the wound of the diaphragm, it is difficult to inspect the abdominal organs, and, based on these considerations, believed transabdominal access is more preferable. Regarding the difficulties associated with the need for revision of the abdominal organs, V.F. Voino-Yasenetsky wrote that “. . If it is possible to carry out such a study transpleurally, then only under the condition of a huge expansion of the diaphragm wound (up to 10-12 cm). No one, of course, will lightly spoil the diaphragm.” Transpleural access, according to V.F. Voino-Yasenetsky, is suitable only in cases of minor injuries. A. Zholondz (1926), who reported 7 cases of injury to the diaphragm, also preferred the transabdominal approach.

M. S. Grigoriev (1938), who performed laparotomy on 20 patients with stab thoracoabdominal wounds, believed that it was impossible to manipulate the abdominal organs with sufficient convenience from the transpleural approach. Obviously, the transthoracic approach did not become sufficiently widespread during this period due to the opinion about the dangers associated with transpleural intervention, which was quite justified for the level of development of surgery at that time, and surgeons were forced to temporarily abandon it.

The current state of development of surgery has made it possible to reconsider this issue. Thus, E. A. Wagner (1955) of 16 patients with thoracoabdominal wounds operated on 14 transthoracically and only one - transabdominally (one patient was not operated on).

For the development of the diaphragm and manipulations in its various parts, the transthoracic approach undoubtedly has all the advantages over the transabdominal one. This is confirmed by our wartime experience, as well as our experience in treating diaphragmatic injuries in peacetime. Our anatomical and surgical studies (N. O. Nikolaev, 1962) of objective indicators characterizing the quality of access to the diaphragm indicate the advantage of the transthoracic approach to the diaphragm. However, since isolated wounds of the diaphragm are observed relatively rarely and are usually only diagnosed during surgery, the issue of access for thoracoabdominal wounds must be decided only on the basis of the clinical picture of the injury in a given patient.

The predominance of signs of intra-abdominal damage (peritonitis, intra-abdominal bleeding) dictates the need for laparotomy and, conversely, severe symptoms of damage to the abdominal organs (bleeding, tension pneumothorax, etc.) force transthoracic surgery.

The location of the entrance hole plays a certain role in the choice of access for blind thoracoabdominal and abdominothoracic wounds, since there is usually a need for primary surgical treatment of the latter. However, in these cases, the predominance of signs of damage to the organs of the thoracic or abdominal cavities is of primary importance. With the same severity of clinical symptoms, it is obviously most correct to operate from the entrance hole.

In those cases when laparotomy makes it impossible to intervene on the damaged organs of the chest cavity, an additional thoracotomy has to be performed. For similar indications, it is sometimes necessary to resort to laparotomy after transpleural suturing of the diaphragm wound. Continuation of the thoracotomy incision into the abdominal wall according to the type of extended thoracolaparotomy according to Zeidler seems to us unjustified, since it is more advantageous to first eliminate the wide open pneumothorax and then operate on the abdominal cavity.

One way or another, with any access, after eliminating damage to the organs of the abdominal or thoracic cavities, it becomes necessary to eliminate the wound of the diaphragm itself. In practice, suturing a diaphragm wound is also possible from a transabdominal approach, since prolapse of the abdominal organs into the chest cavity through a defect to the diaphragm in the coming days after an acute injury is not yet accompanied by the development of strong adhesions. Reducing them from the abdominal side is usually relatively easy, especially after some expansion of the diaphragm wound.

If the stomach has prolapsed into the pleural cavity, then the best thing to do is first try to empty it with an eonic inserted through the nose or mouth. In cases where this cannot be done, the wound of the diaphragm has to be expanded. It is less advisable to resort to gastric puncture to empty it. When organs that have prolapsed into the wound are pinched, dissection of the diaphragm and expansion of the opening in it to bring them down is absolutely necessary.

Wolma and Moore (1965), who operated on 24 patients with open wounds of the diaphragm, believe that most wounds of the left dome should be sutured from the abdominal cavity. A. Yu. Sozon-Yaroshevich (1945) points out the great technical difficulties that often arise when attempting transabdominal suturing of wounds of the diaphragm. In one of his observations, the damage to the diaphragm was located at a depth of 18 cm and it was not possible to reach it without additional expansion of the surgical wound. We observed a similar case.

It is much more convenient to suture wounds of the right dome of the diaphragm from a transthoracic incision, since during laparotomy this can be difficult, often even impossible (A. Yu. Sozon-Yaroshevich, 1945; V. P. Otkhmezuri, 1957). However, if the wound is localized in the anterior part of the right dome, suturing it can be easily performed from the abdominal cavity. In this case, the approach to the diaphragm is greatly facilitated by crossing the falciform ligament and retracting the liver downwards.

Patient K., 34 years old, 6/IX 1963, in a state of alcoholic intoxication, fell on an iron crowbar stuck in the ground, which he immediately removed from the wound in the right hypochondrium and independently came to the first aid station. Delivered to the clinic by ambulance in satisfactory condition. Arterial pressure 125/70, pulse 88 beats per minute.

A moderately bleeding wound 5 by 4 cm, with smooth edges, was found in the right hypochondrium along the midclavicular line. Tension of the anterior abdominal muscles, pain on palpation and a positive Shchetkin-Blumberg sign in the right upper quadrant of the abdomen are noted. The patient underwent emergency surgery. The abdominal cavity was opened with an oblique right-sided subcostal incision with excision of the edges of the wound. A wound of the anterior edge of the liver 6 by 3 by 4 cm was discovered, running towards the diaphragm, in which a defect of 5 by 3 cm with smooth edges was visible. After dissection of the falciform ligament and retraction of the liver downwards, access to the diaphragm became quite spacious. The liver wound with tamponade was sutured with an omentum on the pedicle. The edges of the diaphragm defect are captured with long hemostatic clamps, after detection of which separate knotted silk sutures are applied to the diaphragm.

If, when the right dome of the diaphragm is injured, it is impossible to suture it during transabdominal surgery, and an additional thoracotomy should be performed in case serious condition wounded is dangerous, then to prevent the development of a diaphragmatic hernia, it is advisable to perform hepatopexeny. Hepatopexy is performed by suturing the anterior edge of the liver with separate sutures to the pariental peritoneum along the costal arch. However, with a large wound of the right dome, into which the liver itself can prolapse, this method should not be used. In these cases, it is necessary to suture the diaphragmatic defect through a transthoracic incision. This operation can be performed only after appropriate conservative measures to remove the patient from a serious condition.

In case of severe injuries, when the wound of the diaphragm discovered during laparotomy cannot be sutured through this access, A. Yu. Sozon-Yaroshevich (1945) recommends using the Kerte method, which consists of tamponade of the defect with an omentum, which is fixed to the diaphragm with at least one suture. It is quite obvious that this technique can be used only for small defects in the thoraco-abdominal barrier.

For stab and cut wounds of the diaphragm with relatively smooth edges, there is no need to excise them before suturing. On the contrary, in case of gunshot wounds, especially shrapnel wounds, it should be carried out according to the type of primary surgical treatment, sparingly removing non-viable tissue.

Regarding the diaphragm seam technique. We would not again specifically emphasize the need to use non-absorbable suture material if we had not found descriptions in the literature of suturing diaphragm wounds with catgut. If with a small, up to 1 cm, bleeding wound of the diaphragm in a patient with puncture wound heart, described by S.P. Protopopov (1937), the application of two catgut sutures to the diaphragm. Probably, with a hemostatic purpose, it could not have negative consequences in terms of the development of a hernia, since wounds of this size usually heal on their own, the method of suturing the diaphragm given in the work of E. S. Egorova (1945) is objectionable. Observing even very large wounds, when “the pectoral muscle is, as it were, torn into two parts,” E. S. Egorova emphasizes that the wounds of the diaphragm “were easily sutured with separate catgut sutures.” Naturally, if a similar technique was used in all 82 wounded with damage to the diaphragm, then, probably, a significant part of them could subsequently develop diaphragmatic hernia.

Our experience, numbering over 1000 transdiaphragmatic operations, has shown that the application of one row of separate knotted silk sutures to the diaphragm wound at a distance of 1 cm from each other reliably prevents the development of a diaphragmatic hernia. There is no need to use a double-row suture for injuries to the diaphragm. Such a suture can be recommended only in cases where a significant increase in intra-abdominal pressure can be expected in the near future after surgery. Gupta (1961) placed a double-row suture on a knife wound of the diaphragm in a woman with a 6-month pregnancy, which ended in normal term labor without the development of a diaphragmatic hernia.

It is very important to carefully ligate the bleeding vessels before suturing the defect in the diaphragm. Since ordinary ligatures easily slip off under these conditions, we resort to suturing the vessels with a z-shaped catgut suture.

As a rule, the wound of the diaphragm can be sutured after simply bringing its edges together. However, if the defect is large in size after initial surgical treatment, we recommend using the following technique: catgut sutures placed on the edges of the diaphragm wound for hemostatic purposes are not cut off, but are used as holders. By crossing them, the edges of the wound are brought together and separate silk sutures are applied, sequentially cutting off the catgut threads.

A. A. Olshanetsky and I. M. Margitai (1957), based on their experimental studies, suggest placing a purse-string catgut suture around the wound to reduce tension, and then suturing the wound with silk. The authors believe that in this case, until the moment of resorption, the catgut will heal without tension in the area of ​​the main silk sutures. However, this technique is not feasible at all for large defects, and is not necessary for small wounds.

For suturing marginal wounds and mainly injuries accompanied by separation of the diaphragm from the place of its attachment, it is advisable to apply percutaneous removable silk sutures according to the method of V.F. Voino-Yasenetsky or to apply a modification of this method, which consists in the fact that the suture is not brought out, but Having surrounded the rib with it, they tie it from the inside.

A very difficult situation arises in those relatively in rare cases when, after excision of damaged tissue, a large defect of the diaphragm is formed, which cannot be sutured in the usual way. The use of alloplastic materials to close such defects is possible only in the immediate hours after injury and the absence and absence of damage to the hollow organs of the abdominal cavity, especially the large intestine. To close wounds of the diaphragm, special prostheses made of rare nylon or mylar fabric impregnated with an antibiotic solution seem to be most suitable. The prosthesis is sutured to the edges of the diaphragm with separate knotted or U-shaped silk or nylon sutures so that the edges of the prosthesis overlap the edges of the diaphragm by 2-3 cm

After careful hemostasis and drying, drainage should be carried out to the prosthetic area to administer antibiotics and aspirate the effusion. Such an operation, of course, is much more convenient to perform from the pleural cavity.

When suppuration has already developed, the use of alloplastic prostheses is unacceptable, since under these conditions, engraftment will not occur and the prosthesis will inevitably be rejected. It should be taken into account that to remove the rejected prosthesis, it is necessary to undertake a second operation. Partial rejection of the prosthesis is dangerous due to the possibility of prolapse of the abdominal organs through the resulting narrow gap between the prosthesis and the diaphragm and the threat of strangulation.

In these cases, it is most advisable to use various methods of plastic surgery using nearby tissues and organs (cutting pedunculated muscle-periosteal-pleural flaps). At the same time, pneumopexy, gastric fixation, and omentoplasty do not always provide reliable strengthening of the diaphragm. However, these methods, especially hepatopexy for right-sided wounds, may be recommended in difficult conditions.

Suturing of large defects of the diaphragm can be facilitated by the use of thoracoplasty with subperiosteal resection of the ribs, but this usually results in permanent deformation of the chest.

In conclusion, we emphasize that when a purulent infection has developed, one no longer has to think about plastic surgery of the diaphragm, but mainly about eliminating damage to internal organs and creating complete drainage to save the life of the wounded.

Of the complications of open injuries to the diaphragm, we most often observed subphrenic abscesses. More rare is the formation of a gastropleural fistula. We recently observed the latter complication in one of our patients.

Lutterotti and de Costa (1960) reported the occurrence of persistent post-wound gastropleural and then gastropleurobronchial fistula in a 48-year-old woman.

Foreign bodies of the diaphragm

In blind gunshot wounds to the chest or abdomen, especially multiple shrapnel or pellet wounds, individual fragments or pellets may become lodged in the diaphragm and go undetected during surgery.

S. G. Konokotin (1926) described a case of a chest wound with two pellets, one of which was in the left ventricle of the heart, and the other in the diaphragm. N.K. Dietz (1946) reported on a patient with a blind shrapnel wound who experienced hemoptysis and chest pain when breathing. Fluoroscopy revealed a foreign body located in the chest wall in the area anterior section left costophrenic sinus. During the operation, performed 3 months after the injury, a fragment of 1.3 by 0.5 by 0.7 cm was removed, located, as it turned out, not in the chest, but in the left dome of the diaphragm. We also observed two similar wounded people. Removal of the fragments located in the diaphragm completely eliminated in these patients all the unpleasant sensations that arose during deep inhalation and coughing.

Foreign bodies of the diaphragm are observed not only after gunshots, but also stab wounds chest or upper abdomen. Thus, L.G. Zavgorodniy (1962) reported about a girl 1 year 7 months old who fell on a needle embedded in the chest in the ninth intercostal space on the right along the posterior axillary line. 18 days after this, the needle was removed, lying on the diaphragmatic surface of the liver and with its sharp end embedded in the diaphragm.

Clinical symptoms for foreign bodies of the diaphragm are often absent. Sometimes there is vague pain in the chest, aggravated by movement. When an abscess develops around a foreign body, symptoms characteristic of this disease occur.

It must be emphasized that the diagnosis of a foreign body of the diaphragm can only be made on the basis x-ray examination. N. K. Dietz (1946) believes that a characteristic of a foreign body of the diaphragm is the movement of its shadow when breathing along with the diaphragm. The absence of this sign did not allow us to diagnose correct diagnosis, but led to the mistaken assumption that the foreign body was located in the chest wall. However, even in the case of displacement of a foreign body during breathing, which can also be confirmed by x-ray kymography, it can be very difficult to accurately determine whether it is located in the diaphragm or in an organ adjacent to it or in the peddiaphragmatic space.

To establish a diagnosis, it is recommended to resort to the application of pneumoperitoneum, which makes it possible to clarify the location of the foreign body. Diagnostic pneumothorax may also have a certain auxiliary value. However, a reliable diagnosis of a foreign body of the diaphragm is usually established only during surgery.

The question of indications for surgery for foreign bodies of the diaphragm is decided on the basis of the severity of certain symptoms. In case of acute small foreign bodies, especially in the early stages after injury, the indication for surgery may be the threat of perforation of adjacent organs, especially the heart, aorta, inferior vena cava or perforation of the esophagus, stomach and intestines.

Large fragments located in the diaphragm, especially with uneven edges, can cause the development of bedsores of nearby organs. In longer periods after injury, when the foreign body is encapsulated, real threat, and therefore, the indication for surgery is the possibility of an abscess.

In Russia, an attempt to remove a foreign body from the diaphragm was made for the first time

V. M. Mints in 1915. In 1942, B. E. Pankratiev reported the removal of mine fragments from the diaphragm of 7 wounded people. Later, N.N. Bogoslovskaya et al reported on the removal of foreign bodies from this organ.

The transthoracic approach has advantages for accessing foreign bodies of the diaphragm, and, depending on the location of the foreign body, it can be posterior, lateral, anterior or wide universal. If a foreign body is located in the parietal zone of the diaphragm, it can be removed extrapleurally. In some cases, this intervention may be facilitated by fusion of the diaphragm with the chest wall, which often occurs in the area of ​​the wound and the location of the foreign body. The success of such an operation is especially real in cases where the foreign body is located in the extrapleural part of the diaphragm and access to it can be performed without opening the pleural sinus through the prediaphragmatic space.

The use of a laparotomy incision is justified when a foreign body is localized in the area of ​​the crura of the diaphragm. However, preoperative topical diagnosis in these cases is extremely difficult. Thus, for almost all foreign bodies of the diaphragm, transthoracic access is advisable, although in the clinic of A.G. Savinykh preference was given to the laparotomic approach.

During an operation performed soon after a wound, when the foreign body is not yet encapsulated, its simple removal is indicated. Foreign body surrounded by a strong fibrous capsule, taking into account the danger of a dormant infection, it is necessary to excise the area of ​​the diaphragm within the unchanged tissue. In these cases, antitetanus serum must be administered before surgery. The wound formed after excision of the diaphragm is sutured according to the general rules indicated in the previous section.

CLOSED DAMAGE TO THE DIAPHRAGM

TRAUMATIC CLOSED INJURIES (SUBCUTANEOUS RUPTURES) OF THE DIAPHRAGM

Frequency and pathological anatomy

Closed injuries to the diaphragm, which occur in peacetime, are mainly the result of transport, as well as industrial trauma. Of the 16 cases of diaphragmatic rupture described by Desforges et al (1957), 13 were associated with motor vehicle trauma. Of the 21 observations by Gage et al (1959), 20 relate to transport trauma.

Carlson et al (1958), based on summary statistics given in the English and American literature, indicate that auto trauma was the cause of diaphragm rupture in 77 cases, industrial and agricultural injuries in 7, falls from a height in 5 out of 99.

Wichowski and Holmes (1960) consider motor vehicle injury to be the cause of 80% of diaphragm injuries.

Konrad and Mallinckrodt (19b3) provide the following aggregate statistics on the frequency of diaphragmatic ruptures in blunt abdominal trauma (Table 1).

Tabliya 1

Diaphragm rupture rate according to Konrad and Mallinckrodt (1963)

Thus, out of 893 blunt abdominal injuries, diaphragm rupture was noted 36 times (47%).

In cases of chest trauma, damage to the diaphragm is less common. Of the 485 such patients admitted to the Düsseldorf surgical clinic Derra from 1949 to 1955. (Konrad, Mallinckrodt, 1963), diaphragm rupture was found in only 4 (0.8%).

According to V.A. Akbarov (1960) during forensic autopsies (1954 - 1958) for 575 cases closed injury In the chest, diaphragm rupture occurred 13 times (2.2%).

The significant difference in the incidence of diaphragm injury in abdominal and thoracic trauma is easily explained. With a blunt injury that causes a sudden increase in intra-abdominal pressure, the diaphragm, as the most pliable and thin wall of the abdominal cavity, often cannot withstand the increased load and ruptures. When the chest is compressed, the diaphragm easily bends down and remains intact. Only a large deformation of the chest from front to back or in the frontal direction leads to overextension and rupture of the diaphragm. Even Iselin (1907) pointed out that the walls of the chest are like a frame for the diaphragm on which it is stretched, and that with significant compression of this “frame” in one direction or another, the diaphragm can rupture.

The degree of filling of the hollow abdominal organs has a significant influence on the rupture of the diaphragm in blunt trauma. With increasing filling, more favorable conditions are created for the transmission of hydraulic shock.

As for the localization of diaphragmatic rupture during blunt trauma, the left half is most often affected. In the statistics of Iselin (1907), the gap was localized 31 times on the left and only 2 times on the right. Ramstrom and Alsen (1954) of 183 cases of diaphragmatic rupture collected in the literature noted right-sided localization in only 9 patients (4.8b%). Kummrle and Kloss (1957) observed it in 3 patients out of 13, Brunner (1956) - in 1 out of 10. According to the summary statistics of Haubrich (1956), numbering about 1000 observations of closed ruptures of the diaphragm, in 95% of cases the damage was localized on the left and in 5 % - on right.

There is no doubt that the comparative rarity of right-sided ruptures of the diaphragm depends on the protective role of the liver, covering from below the entire right half of the thoraco-abdominal barrier.

It is extremely rare for both domes of the diaphragm to rupture, as observed by Manlove and Baronofsky (1955) and Konrad and Mallinckrodt (1963). Moreaux (1957) found descriptions of 4 similar cases in the French literature.

A number of authors note that rupture of the diaphragm often occurs at the border between its muscular and tendon parts (Sinha, 1955). Koss and Reitter (1959), Landois (1943) believe that the most characteristic is damage to the tendon center of the diaphragm.

There are often cases where, simultaneously with damage to the dome, ruptures of the lumbar part of the diaphragm occur with damage to the esophageal opening (Sutherland, 1958).

Sometimes, when the lower parts of the chest are compressed, the diaphragm can separate from its attachment site (I. D. Korabelnikov, 1951). S.I. Shumakov (1957) reported on a patient in whom, during laparotomy, a separation of the left half of the diaphragm was discovered along the line of its attachment to the ribs from the xiphoid process to the posterior axillary line (the length of the separation is 28 cm). A similar observation was described by A.F. Platonov (1951). The shape of the tear is often very bizarre, and its edges are uneven and crushed. Unlike wounds, significant bleeding is usually not observed.

Direct closed injuries to the diaphragm (tears caused by a broken rib) are extremely rare. Blum and Ombredanne reported 7 similar injuries in 1882. One observation was described by A. Almazov (1935). Most authors (Landois, 1943; I. D. Korabelnikov, 1951; I. I. Sosnovik, 1951; Frangini, 1961) only indicate the possibility of rupture of the diaphragm by a broken rib, but do not provide their own observations.

It should be pointed out that ruptures of the diaphragm are most often only combined with damage to the ribs (as well as with fractures of other skeletal bones); in this case, the diaphragm ruptures independently, and is not injured by a bone fragment. Desforges, Strieder, Lynch and Madoff (1957) found concomitant rib fractures in 8 of 16 patients with closed diaphragmatic ruptures, Konrad and Mallinckrodt (1963) - in 11 of 33.

Frequent combination with rupture of the diaphragm of fractures of the pelvic bones was noted by Desforges and colleagues in 8 of 16 patients, Grage, Mclean and Campbell (1959) - in 12 of 21, Bartley and Wicklom (1960), Fitzgerald, Crawford, De Bakey (19b0), etc. Carlson, Diveley, Gobbel and Daniel (1958) noted a concomitant fracture of the pelvic bones in 29 out of 99 cases of closed diaphragm injury (collective statistics). According to their data, a combination of a closed rupture of the diaphragm with spinal fractures is quite often observed. Mann and Eckmann (19b2) even consider the combination of rupture of the diaphragm and symphysis to be classical. The combination of rupture of the diaphragm with a fracture of the pelvic bones is described in the domestic literature by F. M. Danovich and A. I. Mariev (1956), A. F. Platonov (1951), S. N. Ivanov (1961).

With blunt trauma leading to rupture of the diaphragm, parenchymal and hollow organs are also often injured. Carlson et al (1958) noted combined damage to internal organs and the diaphragm in 22 of 99 patients. Grage et al (1959) observed damage to internal organs in most of their patients.

Occasionally the pericardium is damaged. Vernhet (19b1) reported a case of transverse rupture of the diaphragm extending to the pericardium, and also cited 4 similar observations that he found in the French literature. Pentti (19b1) described a patient with rupture of the diaphragm and pericardium. In the domestic literature, such observations were reported by T. Ya. Ariev and O. A. Mikhailova (1953), E. F. Zobnin (1962). Periodically, reports of such gaps appear in almost all countries.

In 1958, we operated on patient Ya., 15 years old, 9 years after a closed abdominal injury received in a car accident. The rupture of the diaphragm extended to the pericardium, into the cavity of which the greater omentum penetrated through a defect measuring 5 cm.

Thus, isolated closed injuries of the diaphragm are observed much less frequently than combined ones. I. I. Sosnovik (1951), together with one of his own observations, summarized in the literature only 58 cases of “undoubted traumatic isolated rupture of the diaphragm.” Although these data are far from complete, they still clearly illustrate the relative rarity of isolated closed injuries to the thoracoabdominal obstruction.

The stomach, omentum, loops of the large and small intestines can prolapse into the pleural cavity through a hole in the diaphragm, both with closed and open injuries, and occasionally (with right-sided ruptures) the liver prolapses. It is also possible to move the entire

liver into the right pleural cavity, as observed by Mann and Eckmann (1962).

Prolapse of most of the liver along with the gallbladder in a patient with a diaphragmatic hernia that developed after a closed injury, as reported by M. T. Volkova (1955), was discovered during surgery by E. L. Berezov. Liver prolapse with a closed rupture of the diaphragm was also observed by Kummerle (1959) and a number of other authors. Prolapse of internal organs through a hole in the diaphragm can sometimes occur already at the time of rupture, in other cases it occurs much later, often even after several months or years after the injury. Some authors explain the late occurrence of prolapse by a two-stage rupture of the diaphragm. From this point of view, Langgenhager (1960) considers the medical history of a 35-year-old doctor who fell from a height of 8 m; during the first X-ray examination, only a high position of the left dome of the diaphragm was noted, and upon examination after 6 weeks (due to the appearance of pain in the left half chest) prolapse of small and large intestinal loops into the pleural cavity was revealed. Mann and Eckmann (1962) similarly interpret prolapse into the right pleural cavity of the liver, which occurred 24 hours after injury.

However, apparently, it is more correct to consider that in both cases there was not a two-stage rupture of the diaphragm, but the usual late occurrence of prolapse. Konrad and Mallinckrodt (19b3) are also skeptical about the explanation of the causes of late visceral prolapse by two-stage rupture of the diaphragm.

The formation of a hernia in the opposite direction, i.e. prolapse through the hole in the diaphragm of the chest organs into the abdominal cavity, is extremely rare. T. Ya. Ariev and O. A. Mikhailova (1953) during an operation performed for blunt trauma abdominal cavity in a 9-year-old boy, they discovered that through a rupture of the left dome of the diaphragm, “half of the heart, devoid of the pericardium, fell out.”

Diagnosis, clinical manifestations

and treatment of closed injuries

aperture

Diagnosis of closed ruptures of the diaphragm, combined with damage to other organs, is difficult, since the clinical manifestations of damage to the diaphragm are masked and, as it were, relegated to the background. In addition, the severity of the patient’s condition in some cases does not allow for a full X-ray examination for a long time. It should always be taken into account that

undiagnosed rupture of the diaphragm can lead to the development of extremely severe complications; its possibility should never be forgotten in all cases of severe trauma accompanied by compression of the abdomen or chest, as well as in cases of fractures of the pelvic bones.

At the same time, the diagnosis of diaphragm rupture is somewhat easier in cases requiring emergency laparotomy due to damage to internal organs. In this case, the following rule must be observed: with each laparotomy undertaken for closed traumatic damage to internal organs, the diaphragm must be examined. This will save patients in the future from the need for repeated surgery for traumatic diaphragmatic hernia. An example of such a repeated operation is observation F. M. Danovich and A. I. Marieva (1956), who describe a 29-year-old patient who was hit by a truck and suffered a fracture of the pelvic bones with a rupture Bladder. The latter was sutured, but the diaphragm was not examined during the operation. After 29 days, the patient had to be operated on again due to a traumatic diaphragmatic hernia discovered in him. Many similar observations have been described.

Timely diagnosis of an isolated rupture of the diaphragm can be difficult due to the fact that prolapse of the abdominal organs into the pleural cavity often does not occur immediately, but after a long period of time after the injury. In this regard, as clinical observations show, very often symptoms characteristic of a diaphragmatic hernia also appear very late. Brunner (1956), for example, emphasizes that only in isolated cases these symptoms occur immediately after the injury.

Thus, patients who have received severe abdominal trauma must be examined radiographically not only upon admission to the hospital. medical institution, but also upon discharge from it.

The satisfactory general condition of the victim and the absence of distinct symptoms from the organs of the chest and abdominal cavities should not remove suspicion of the possibility of damage to the diaphragm.

N.P. Khramtsova (1954) describes a 5-year-old boy who was taken to the clinic immediately after an injury in satisfactory condition with complaints of pain in the legs and minor pain in the abdomen. However, during a contrast fluoroscopy performed the next day, it was discovered that the stomach was in the left pleural cavity.

The possibility of diaphragmatic rupture not accompanied by any clear clinical symptoms is illustrated by our following observation.

Patient A., at the age of 7 years, fell under the wheel of a tractor plow, which ran over his chest. After that he continued to ride a tractor. At home, he did not say anything about what happened and was not examined by a doctor. He noted only slight pain in the right half of the chest, which then completely disappeared. The injury left a moderate deformation of the right half of the chest associated with a rib fracture. From that time on, the boy began to lag behind his peers in development, experiencing shortness of breath when running and rumbling in his chest. Only 20 years later, a diaphragmatic hernia was first diagnosed, which was confirmed during surgery.

Many other authors have made similar observations.

Sometimes a diaphragm rupture is not diagnosed only because surgeons forget about its possibility and misinterpret the existing symptoms.

Boy S., 3 1/2 years old, was crushed by a heavy log (4 m long and 0.5 m thick) that fell on the lower half of the body and thighs. After being removed from under the log, he remained unconscious for several minutes. 40 minutes after the injury he was taken to surgery department city ​​hospital, where fluoroscopy revealed fluid in the left pleural cavity, reaching the level of the III Ribs. No damage was noted.

The patient's condition was satisfactory. On the 5th day the boy was allowed to walk. On the 8th day, due to remaining darkening in the left half of the chest, a pleural puncture, but only a small amount of blood was obtained. On the 11th day the patient was discharged home. 1 1/2 years after this, the boy was operated on in our clinic for a traumatic diaphragmatic hernia with a large defect of the left dome and displacement of loops of the large and small intestine and spleen into the left pleural cavity of the stomach.

In this case, the presence of hemothorax in the absence of immediate

A serious chest injury suggested a rupture of the diaphragm. No importance was also attached to the discrepancy between the extent of the darkening and the too small amount of blood obtained by puncture.

At the same time, in a number of patients the clinical picture of a diaphragm rupture may be so characteristic that diagnosing it is not difficult. This happens, as a rule, with extensive ruptures with immediate prolapse of the abdominal organs into the pleural cavity. In addition to the possible phenomena of pleuropulmonary shock and pain in the abdomen and the corresponding half of the chest with irradiation to the supraclavicular region, neck and arm, victims experience shortness of breath, cyanosis, tachycardia, heart rhythm disturbances associated with compression of the lung and pushing of the mediastinal organs to the healthy side . Symptoms from the gastrointestinal tract (nausea, vomiting, partial intestinal obstruction) are also often associated.

The studies carried out in these cases make it possible to establish a shift of the mediastinum to the healthy side, the appearance of tympanitis within pulmonary field, sometimes in combination with dullness due to concomitant hemothorax, the presence of fluid in the prolapsed hollow organ or prolapse of the liver and spleen. Splashing sounds and peristaltic sounds may be heard in the chest. The phenomenon of variability in percussion and auscultation data, associated with periodically changing degrees of filling of prolapsed organs, is also very typical.

When strangulation occurs, an even more severe clinical picture develops, and the above phenomena are usually accompanied by symptoms of acute intestinal obstruction. Similar signs also occur when the stomach has moved into the pleural cavity.

Mistakes caused by rupture of the diaphragm are very common. Moreover, this pathology in most cases is not detected in a timely manner. Thus, out of 33 patients who were treated for a closed rupture of the diaphragm and its consequences in the Düsseldorf surgical clinic of Professor Derra, only 8 were diagnosed within the first month after the injury, while most of these patients had a traumatic diaphragmatic hernia in remained undetected for a number of years (Konrad, Mallinckrodt, 1963).

X-ray examination, if closed damage to the diaphragm is suspected, should begin with multi-axis survey fluoroscopy. In this case, the picture will be different depending on the presence or absence of prolapse of the abdominal organs into the pleural cavity.

In case of a rupture not complicated by prolapse, there is a restriction in the mobility of the diaphragm and an increase in its level of standing. The more or less pronounced hemothorax that inevitably arises in this case gives either significant darkening or signs of a small accumulation of fluid in the costophrenic sinus.

As for high standing and limited mobility of the diaphragm, as well as its paradoxical movements, they can occasionally appear with traumatic paresis of this organ, which is not accompanied by its rupture (for more details, see the chapter on relaxation of the diaphragm).

A sign of rupture is also sometimes detected deformation of the diaphragm contour. In some cases, it is even possible to see its defect (Haubrich, 1956).

It must be remembered that rupture of the diaphragm often leads to an incorrect diagnosis of traumatic pleurisy or pneumothorax. The error in this case can be twofold: either traumatic pleurisy or hemothorax actually exists and masks damage to the diaphragm, or the radiologically detectable shadow of an organ that has prolapsed into the pleural cavity is mistaken for pleurisy.

The last type of error is especially dangerous, since with it therapeutic and diagnostic punctures are often complicated by a puncture of the stomach or intestines.

Desforges et al (1957) describe a patient in whom, with a diaphragm rupture, not only puncture was performed, but even drainage of the pleural cavity was performed, which, of course, did not bring relief to the patient. Most often, such punctures for erroneous indications, sometimes even leading to the death of the patient, are performed when a rupture of the diaphragm is combined with a fracture of the ribs, which is taken for immediate cause hemothorax or pneumothorax.

Puncture of organs that have been displaced into the pleural cavity by rupture of the diaphragm is often reported in the literature.

Thus, if darkening or clearing is detected above the diaphragm when making a diagnosis of “traumatic pleurisy” or “traumatic pneumothorax,” one cannot limit oneself to plain fluoroscopy alone, but must also resort to a contrast X-ray examination of the stomach, as well as the small and large intestines.

The location of the stomach in the pleural cavity can be confirmed by inserting a probe into it during fluoroscopy. However, this technique can only partially replace conventional contrast studies using barium sulfate.

Thus, an X-ray examination of a patient with suspected rupture of the diaphragm has many similarities with the diagnosis of diaphragmatic hernias (described in the relevant sections).

It should be recalled that occasionally, with a narrow opening in the diaphragm, the barium suspension may not penetrate into the prolapsing part of the stomach. This makes it very difficult to resolve the question of the nature of the formation identified above the diaphragm. In such cases, pneumoperitoneum can confirm diaphragmatic rupture. This diagnostic method is also applicable if there is a suspected rupture of the diaphragm without prolapse of the viscera.

The extremely rare use of diagnostic pneumoperitoneum by practical surgeons and radiologists for the pathology being examined is explained by the fear of compression of the lung due to the penetration of a large amount of air into the pleural cavity. However, the risk of significant pneumothorax is eliminated by dosed injection of gas directly in the X-ray room through a thin plastic catheter inserted into the abdominal cavity through the lumen of the puncture needle.

To clarify the diagnosis of rupture of the right dome of the diaphragm with liver prolapse, Desforges, Strieder, Lynch and Madoff (1957) recommend cholangiography.

For differential diagnosis We used splenoportography for partial right-sided relaxation of the diaphragm with liver tumors and cysts. Based on this experience, we believe possible use this method and in individual patients with unclear signs of rupture of the right dome of the diaphragm. However, it is better not to use this method acute cases, and later, when there is no longer any suspicion of concomitant damage to the abdominal organs.

As stated above, all diagnosed penetrating injuries to the diaphragm are subject to emergency surgical treatment. If the patient’s condition allows, surgery should be performed as soon as possible. It is significant that out of 12 patients Grage, McLean, Campbell (1959), operated on within 48 hours to 3 months from the moment of injury, three died from strangulation, and out of 10 patients operated on within the first two days, only one died.

The principles of surgical treatment of closed injuries of the diaphragm are the same as for its wounds. It should only be emphasized that since ruptures are rarely accompanied by injuries to the chest organs, in most cases a transabdominal approach is indicated.

TRAUMATIC DIAPHRAGMAL HERNIA

HISTORY OF THE STUDY AND PATHOLOGICAL ANATOMY

The first detailed description of a traumatic diaphragmatic hernia belongs to Ambroise Paré. Most authors (Hedblom, 1925; B. M. Kudisch, 1929; N. R. Kopystyansky, 1949; Yu. Yu. Dzhanelidze and G. A. Zedgenidze, 1950, etc.) cite Pare’s work, published in 1610. while V.I. Petrov (1949) established that there is an earlier edition, published in 1594 (4 years after the death of Pare), containing a description of two observations of traumatic diaphragmatic hernia, one of which developed after a gunshot thoracoabdominal wound .

In 1646, a traumatic diaphragmatic hernia that occurred after a stab wound was described by Hildamus. Diaphragmatic hernia after closed damage to the thoraco-abdominal obstruction was described in 1798 by Cooreg and Preiss.

In Russia, the first report known to us about a traumatic diaphragmatic hernia was published in 1852 by I. V. Buyalsky.

It was about a 14-year-old girl who died two days after the onset of the attack, characterized by sharp chest pain and vomiting. At the age of two in the Caucasus, she received 7 stab wounds. During the autopsy, a traumatic hernia of the left dome of the diaphragm with constriction of the colon was discovered.

In 1866, N.I. Pirogov, in his book “The Beginnings of Military Field Surgery,” gives an almost similar observation. During the autopsy of the corpse of a 16-year-old girl, also in early childhood in the Caucasus, who had suffered stab wounds, he discovered a strangulated traumatic hernia of the left dome of the diaphrate.

An acute diaphragmatic hernia resulting from closed damage to the diaphragm (fall from a great height) was described in 1861 by I. G. Karpinsky. The patient died 2 weeks after the injury; the hernia was discovered at autopsy.

Almost all observations of traumatic diaphragmatic hernias until the end of the 19th century. were sectional finds. Only from the beginning of the 20th century did the number of hernias diagnosed intravitally begin to increase rapidly. By 1936, Hedblom presented a summary of 548 cases of traumatic hernia of the thoracoabdominal obstruction.

In the domestic literature, I. D. Korabelnikov, up to 1950 inclusive, found a description of 268 traumatic diaphragmatic hernias. The summary statistics of M. M. Bass (1957), who, in addition to literary data, had a significant amount of personal data, provides information about 755 patients with diaphragmatic hernia.

Currently, summing up a large number of published observations of traumatic diaphragmatic hernias, as well as describing each individual case, is no longer significant. Of incomparably greater interest are reports on the improvement of diagnostics and treatment methods for this pathology.

Monographs by V. I. Petrov (1949), I. D. Korabelnikov (1951) and a chapter in “The Experience of Soviet Medicine in the Great Patriotic War of 1941 – 1945” are specifically devoted to traumatic diaphragmatic hernias. Yu. Yu. Janelidze and G. A. Zedgenidze (1950). This topic is also discussed in the book by S. Ya. Doletsky “Diaphragmatic Hernias in Children” (1960).

The etiology of traumatic diaphragmatic hernias, in fact, has already been outlined by us in the chapter on injuries to the diaphragm. The source of their development can be any open or closed injury to the abdominal obstruction. Eventration of the abdominal organs through the hole in the diaphragm occurs either at the time of injury, or after one or another period of time after it, sometimes even after many months and years.

Eppinger (1911) divided traumatic diaphragmatic hernias into acute and chronic. An acute traumatic diaphragmatic hernia is said to occur when the abdominal organs prolapse immediately after injury.

Yu. Yu. Dzhanelidze and G. A. Zedgenidze (1950) call acute eventration a primary diaphragmatic hernia, and cases with later organ prolapse are classified as secondary diaphragmatic hernias. We consider such a division less appropriate, since with a chronic hernia it does not matter much whether it is “primary” or “secondary”. In addition, in a number of patients with chronic diaphragmatic hernia, it is not at all possible to accurately determine when the prolapse occurred (the moment of the onset of complaints often does not coincide with the moment of the onset of organ prolapse).

timely diagnosis and early suturing of diaphragm injuries eliminate the conditions for the formation of a hernia. Thus, a chronic traumatic diaphragmatic hernia can develop either after an undiagnosed injury to the diaphragm, or after non-radical or incorrect suturing of its defect (for example, when applying catgut sutures to the diaphragm).

The main issues relating to the diagnosis and treatment of acute traumatic diaphragmatic hernias in the 23 wounded we observed during the last world war are discussed in the chapter on diaphragm injuries. We observed chronic traumatic diaphragmatic hernia in 20 patients. In 7 of them, the hernia developed after closed, and in 13 after open injuries to the diaphragm, 4 of which were associated with dissection of the diaphragm during transthoracic operations.

All 17 chronic hernias we surgically treated were false, i.e. there was a through defect of the diaphragm and there was no hernial sac. In the literature, in the form of rare casuistry, true traumatic hernias of the thoraco-abdominal barrier are also described, which develop after tangential wounds of the dome of the diaphragm with damage only to the pleura and muscle layer. The remaining intact diaphragmatic peritoneum gradually stretches to form a hernial sac. A feature of such traumatic hernias is the absence of significant fusion of the hernial contents with the sac.

A number of authors also classify part of the true hernias of weak zones and natural openings of the diaphragm as traumatic hernias only on the basis that the patients’ history indicates an indication of trauma. Thus, Marchand (1962) describes “traumatic” hiatal hernias, G.P. Kosmakov and E.K. Neshel (1960) describe “traumatic” hernia of Larrey’s hiatus. Although trauma can contribute to the development of acquired true hernias, it is incorrect to call them traumatic, since they are not associated with rupture of the diaphragm.

In the most common false traumatic diaphragmatic hernia, the gates are usually localized in the left half of the diaphragm. This is equally typical for hernias developing after open and after closed damage to the abdominal barrier.

We operated on one patient with a right-sided traumatic diaphragmatic hernia (the hernia occurred after a gunshot wound). The significant rarity of right-sided traumatic hernias of the diaphragm, due to the protective effect of the liver, is noted by all authors. Neal in 1953 found only 10 reports of such hernias in the American literature. The first description of a right-sided traumatic diaphragmatic hernia of gunshot origin in the domestic literature belongs to the private associate professor of the hospital surgical clinic of Moscow University D.I. Tatarinov (1906). I. D. Korabelnikov (1951), when analyzing data from Russian literature (242 observations), noted 12 right-sided traumatic hernias of the diaphragm.

Here is our observation.

On January 20, 1963, patient D., 39 years old, who received a right-sided thoracoabdominal wound in 1943, was operated on in the clinic. Thoracotomy revealed prolapse into the right pleural cavity through a rounded defect and the anterior outer part of the diaphragm with a diameter of about 8 cm of almost the entire small and large intestine. The edges of the defect are smooth, dense, and in some places fused with the intestinal loops by the greater omentum. After separation of the adhesions of the hernial contents with the chest wall, the hernial orifice is expanded, the intestinal loops are separated from them and relegated to the abdominal cavity. The hernial orifice was repaired using the diaphragm's own tissues. Recovery has come.

In left-sided hernias, the defects can have very diverse localizations. We have not identified any clear pattern in this regard. It is advisable to distinguish parietal defects associated mainly with the separation of the diaphragm, in which one of the edges of the hernial orifice is the inner surface of the chest wall and defects limited on all sides by the tissues of the diaphragm, since the technique of suturing these defects is different.

The size of the defect in a traumatic diaphragmatic hernia can vary: from a small hole that allows one finger to pass through, to complete pleuro-peritoneal communication. They depend mainly on the size primary wound diaphragm, but due to gradual stretching they always turn out to be larger than it.

The hernial orifice is especially wide when the diaphragm is torn off and its dome is ruptured. IN the latter case wide flaps of the torn dome can fuse their thoracic surface with the chest wall, creating the impression of the absence of the entire left half of the thoraco-abdominal obstruction. The possibility of such a diagnostic error is illustrated by our next observation.

Patient P., 51 years old, was admitted to the clinic on 2/IV 1962. In 1943 he received a closed abdominal injury (he was run over by a passenger car). In 1954, a left-sided diaphragmatic hernia was diagnosed radiologically. In the same year, a thoracotomy was performed in one of the republican hospitals, during which, according to an extract from the surgical journal, “no remains or traces of the existence of the left half of the diaphragm were found.” During the operation in the clinic (H. O. Nikolaev), it was established that there was a complete rupture of the entire left dome of the diaphragm from the pericardium to the 6th surface of the chest wall along the mid-axillary line. Indeed, the impression was created of the absence of a diaphragm, since the anterior-inner part of its ball is widely soldered to the anterior chest wall, and its posterior half turned out to be twisted in the form of a cord and covered on top by the tail of the pancreas and the spleen, also fused to the chest wall.

The shape of the hernial orifice in a traumatic hernia is always round or slit-like, with smoothed corners. This is the result of cicatricial changes in the edges of the defect, as well as their long-term stretching by eventrated organs.

Rarely, traumatic diaphragmatic hernias with two hernial orifices are described, resulting from multiple injuries to the diaphragm.

Very often, the edges of the hole grow together with the organs subject to the defect. If this does not happen, then a fusion of the upper and lower serous layers of the diaphragm occurs. In these cases, the hernial orifice takes on the same appearance as in birth defect, but upon histological examination it is possible to detect traces of hemosiderin in them.

Scarring of the edges of the defect often gives the hernial orifice the appearance of a fibrous ring, passing along the periphery without a sharp border into the unchanged tissue of the diaphragm.

In case of damage to the diaphragm, accompanied by rupture of the trunk and large branches passing through it n. phrenicus, pronounced atrophic changes may occur outside the defect. This thinning of the diaphragm muscle makes it difficult to securely close the hernial orifice during surgery.

The transverse colon is most often displaced into the pleural cavity, often in combination with the stomach, sometimes the spleen and other organs.

I. D. Korabelnikov (1951), when analyzing data from Russian literature in combination with 26 of his own observations, which totals 126 cases of traumatic diaphragmatic hernia, noted prolapse of the large intestine 118 times, stomach - 98 and greater omentum - 93 times. Harrington (1950) during 67 operations found movement into the pleural cavity of the stomach in 66 patients, the large intestine in 59, the small intestine in 38, the spleen in 30, the liver in 20, and the kidney in 2.

In a traumatic hernia, the cecum rarely penetrates the hernial orifice. We observed two patients in whom almost the entire thick and small intestine, with the exception of the initial part of the jejunum and the descending parts of the colon.

Depending on the location and size of the hernial orifice, as well as on the period of existence of the hernia, either a section of the fundus of the stomach or almost the entire organ prolapses into the pleural cavity. Displacement of the stomach, if the integrity of the hiatus oesophageus is not broken, occurs with its simultaneous rotation with the greater curvature upward. When presenting this issue, almost without exception, the authors present a diagram of the movement of the stomach according to Schlecht, Wells (1920), which we consider in the chapter on relaxation of the diaphragm.

In rare cases, the edge of the hiatus oesophageus is damaged. In this case, a false traumatic hiatal hernia may develop, as was observed by Stoianoff (1900), V. S. Levit (1929), Sutherland (1958), and others.

In addition to the fusion of the organs that have prolapsed into the defect with the diaphragm in the area of ​​the hernial orifice, a strong fusion of the hernial contents with the lung and the costal or mediastinal pleura often occurs. These adhesions are most pronounced in hernias that develop as a result gunshot wounds. Most often, the greater omentum is soldered, which is explained, of course, by the well-known property of this organ to easily form adhesions during any inflammatory process.

Unlike I.D. Korabelnikov (1951), as a rule, we did not observe strong adhesions of the stomach, but the transverse colon, splenic angle of the colon and spleen were often fixed in the chest cavity. Only one of our patients, G., 31 years old, whose hernia occurred after a left-sided pleuropulmonectomy, had pronounced fusions of the entire stomach with the chest wall. If adhesions with the stomach and intestines are usually easily stretched and the surgeon, “entering the layer,” can separate them without much difficulty, then the fusion of the spleen with the costal pleura is often intractable. When mobilizing the spleen, the capsule is easily injured, which sometimes requires splenectomy if there is significant bleeding. Yu. Yu. Dzhanelidze (1950) was forced to remove the spleen in 4 out of 6 patients with its prolapse, I. D. Korabelnikov (1951) - in 2 patients. We performed splenectomy for these indications in one patient.

If a hernia persists for a long time, the prolapsed organs can undergo significant changes. In the intestinal wall, in the area of ​​its compression by a narrow hernial orifice, a strangulation scar ring can develop, which “can maintain the phenomenon of partial intestinal obstruction, even after the hernia is eliminated. Ulcers sometimes appear in the stomach, corresponding to the strangulation groove, the perforation of which is often reported in the press. Recently it was reported by S. T. Zakharyan (1960), Gerold. Steiner (1959) and others. Venous stagnation sometimes occurs in the prolapsed part of the stomach, leading to internal bleeding.

As already indicated in the chapter on damage to the diaphragm, with closed ruptures of the right dome, the liver can be displaced into the pleural cavity. In some cases, even with a small defect, the liver area, being deformed, is able to be “sucked” into the pleural cavity, forming a protrusion, which sometimes takes on a mushroom shape. When the liver is realigned, this deformation most often smoothes out, but sometimes it becomes irreversible.

Occasionally, prolapse of the entire liver into the hernial orifice is described. V.I. Petrov (1949) emphasizes that of the abdominal organs only the rectum and genitourinary organs have not yet been discovered in the pleural cavity by anyone.

With large hernias, pathological changes also develop in the organs of the chest cavity. In a long-term atelectatic lung, pneumosclerosis often occurs, and it loses the ability to fully expand after the hernia is repaired. Displacement towards the healthy side of the mediastinum leads to hemodynamic disorders: when the displaced heart is rotated, the vena cava flowing into it is bent. Thus, not only compression of the lung, but also an increase in this inflection explains the appearance of cyanosis and shortness of breath in some patients after eating.

Frenopericardial traumatic hernia is a very rare pathology, since with a closed injury the part of the diaphragm adjacent to the pericardium is damaged infrequently, and its more or less extensive open wounds usually turn out to be incompatible with life due to concomitant damage to the heart.

In the domestic literature, the first report of simultaneous injury of the diaphragm and pericardium belongs to A. T. Sidorenko (1910), who noted the prolapse of the greater omentum into the cavity of the cardiac membrane. We have already mentioned the observations of T. Ya. Aryev and O. A. Mikhailova (1953) and E. F. Zobnin (1962), considering the features of closed damage to the diaphragm.

Astrup and Ziesler (1951), analyzing 10 observations of phrenopericardial hernia (9 collected in the literature and 1 their own), only in 2 patients were able to associate its development with the trauma suffered. Frenopericardial hernia after subcutaneous rupture of the diaphragm is also described by Stein, Colmore, Green (1953) and others. The observation of Rehn (1963) is of interest.

A 60-year-old man has been repeatedly subjected to x-ray examinations over the past 20 years due to chronic gastritis, during which no signs of a diaphragmatic hernia were found in the patient. In February 1961, he was seriously injured with a broken pelvis and a ruptured bladder. The bladder wound was urgently sutured. No intraoperative revision of the diaphragm was performed. After 11 days, a traumatic diaphragmatic hernia was detected by X-ray. It was decided to postpone the operation, and 49 days after the injury the patient was discharged for outpatient treatment. After 8 1/2 months he was taken to the clinic with symptoms of acute intestinal obstruction. A strangulated diaphragmatic hernia was diagnosed and emergency surgery from a left-sided thoracotomy incision. The strangulated transverse colon, which remained viable, was reduced, the hole in the dome of the diaphragm was sutured. After repositioning the colon, there was a sharp increase in the size of the heart sac and heart pulsation was no longer detectable. When opening the pericardium, it was discovered that the reduced intestine fell into its cavity through a hole measuring 5X8 cm. The defect, which had scarred edges, was sutured. The patient recovered.

We also discovered a phrenopericardial hernia, which arose after a closed injury, during an operation (1958) in patient Ya., 15 years old. The rupture of the dome of the diaphragm passed to the pericardium, into the cavity of which the greater omentum penetrated through a hole measuring 5 cm.

The possibility of developing a traumatic phrenopericardial hernia, in our opinion, should be taken into account by surgeons performing “abdominalization” of the heart according to G. A. Reinberg for coronary insufficiency.

Intercostal traumatic diaphragmatic

the hernia, described, according to Zenker (1957), in 1828 by Cruhveilhier, develops after injury in the area of ​​the prephrenic space or costopleural sinus. It is characterized by prolapse of the abdominal organ (usually the greater omentum) successively through a defect in the diaphragm, and then the intercostal space (or damaged rib) under the skin. We do not consider acute prolapse of the greater omentum during an open thoracoabdominal wound to be a case of “acute hernia.” As for chronic intercostal hernias, we have never observed them. The first description of an intercostal diaphragmatic hernia in Russia belongs to D.I. Tatarinov (1906).

A 47-year-old patient in April 1905 received a through-and-through bullet wound to the right half of the chest. In the places of the inlet (6 cm below the right nipple) and outlet (along the right posterior axillary line at the level of the IX rib) persistent fistulas formed, between which, corresponding to the destroyed IX rib, a swelling of 7 X 12 cm in size arose, covered with unchanged skin, dense, painful when palpated. During the operation performed on 17/VIII 1905, prof. G.I. Dyakanov, an intercostal diaphragmatic hernia was discovered.

As a rule, this hernia occurs after an open wound, but occasionally it develops after a closed injury to the diaphragm by a broken rib. A. A. Oshman and G. L. Sartsevich (1909) described a patient with a left-sided intercostal hernia that appeared after a closed injury (kick by a horse’s hoof).

CLINICAL AND DIAGNOSTICS OF TRAUMATIC

DIAPHRAGMAL HERNIA

CLINICAL MANIFESTATIONS

Clinical manifestations of traumatic diaphragmatic hernias can occur soon after the injury or after various, sometimes very long, periods after it. This depends both on the time of prolapse of the abdominal organs through a defect in the diaphragm, and on the characteristics of the hernial orifice and the nature of the prolapsed organs, which we have already discussed in the section on the general semiotics of diaphragmatic hernias.

IN clinical course V.I. Petrov (1949) distinguishes 4 periods of traumatic diaphragmatic hernias: 1) acute, corresponding to the picture of a thoracoabdominal injury; 2) period of asymptomatic course; 3) the period of formed diaphragmatic hernia and 4) the period of acute strangulation.

However, this division is very arbitrary, since all the above periods are not always expressed in the clinic of diaphragmatic hernias. Thus, an asymptomatic period may be absent, and immediately after the acute period, pronounced clinical symptoms of a diaphragmatic hernia may appear or in acute period infringement may occur.

Therefore, it is clinically more advisable to distinguish between: 1) acute, 2) chronic and 3) traumatic diaphragmatic hernia, since each of them has characteristic symptoms and requires very specific medical tactics.

However, such a division does not exclude the possibility of asymptomatic or latent period both for acute and chronic diaphragmatic hernias (Carter, Giuseffi, Felson, 1951; Wichowski, Holmes, 1960; Blades, 1963).

Due to the peculiarities of the clinic, diagnosis and surgical treatment

Injured diaphragmatic hernias, which can be not only traumatic; we discuss this form of diaphragmatic hernia in a special chapter.

The clinical picture of acute traumatic diaphragmatic hernia, which we observed in 23 cases immediately or shortly after thoracoabdominal injury, has already been mainly described in the chapter on injuries to the diaphragm.

Let us only recall that in these cases, with large defects and a significant volume of prolapsed organs, cardiorespiratory disorders prevail, and when the gas-containing organs of the abdominal cavity are compressed in a narrow hernial orifice, gastrointestinal symptoms predominate.

When studying the anamnesis of 20 patients with chronic traumatic diaphragmatic hernias we observed, it was revealed that clinically the occurrence of an acute diaphragmatic hernia could be thought of in 7 of them, since immediately after the injury they developed characteristic symptoms.

Patient K. fell with a burning plane in 1943 and received a head injury,

chest and left fracture humerus. Immediately after his condition improved, when he began to walk, he noted the appearance of gurgling and rumbling in the left side of the chest, but no other health problems were noted. An X-ray examination revealed a diagnosis of diaphragmatic hernia due to a rupture of the left dome of the diaphragm.

After several years, shortness of breath and palpitations gradually began to appear during physical activity and especially after eating, but the general condition remained satisfactory. Only in 1957, 14 years after the injury, pain began to occur in the left half of the abdomen and chest. The frequency, duration and intensity of painful attacks gradually increased, and with moderate intake of food the pain was insignificant, but with the consumption of large quantities or flour products, sharp spasmodic pain occurred in the left half of the chest.

Despite the fact that this patient's hernia occurred immediately after the injury, the first signs of health problems (shortness of breath, palpitations, pain) appeared several years later, and a gradual increase in symptoms was noted.

On the contrary, patient P., immediately after a blunt abdominal injury received in 1943, developed shortness of breath and pain in the left hypochondrium, which gradually intensified and by 1957 reached significant intensity.

A long (4 to 10 years after injury) asymptomatic period was observed in 4 of our patients.

Patient K. in 1943 received multiple shrapnel wounds to the left half of the chest. Until 1958, he did not make any complaints and only 15 years after the injury began to notice shortness of breath that occurred when walking and in horizontal position.

Thus, symptoms of a diaphragmatic hernia may appear immediately or shortly after the injury, or after a more or less long period of asymptomatic (latent) course.

Symptoms of diaphragmatic hernia in some cases gradually increase and a progressive deterioration of the patient’s condition occurs, while in others the disease is intermittent, when a period of increased symptoms is replaced by a more or less long period of improvement, and sometimes complete temporary disappearance of clinical manifestations.

However, in these cases there is usually a tendency towards a gradual increase in frequency and intensification of attacks. I. D. Korabelnikov’s (1951) indication of the possibility of symptom stability is obviously due to the insufficient period of observation (about 3 years) in the case he cited to illustrate this point.

A careful study of the medical history allows not only to establish in some cases a causal relationship between injury and the development of a diaphragmatic hernia, but also to clarify the dynamics of the development of clinical symptoms in this disease.

The clinical symptoms of traumatic diaphragmatic hernias are very diverse, but in general they fit into two main types of disorders: gastrointestinal and cardiorespiratory, to which we should also add general symptoms. The frequency of various subjective symptoms in non-strangulated traumatic diaphragmatic hernias is well illustrated by a table compiled by I. D. Korabelnikov based on 100 observations taken from domestic literature, which provide a detailed description of the clinical picture. We only slightly modified this table, regrouping the symptoms and excluding several insufficiently characteristic signs (Table 2).

Table 2

Frequency of symptoms in chronic traumatic diaphragmatic hernia

All of the above symptoms in various combinations were expressed to one degree or another in our patients. We consider the most characteristic symptoms to be increased pain in the epigastric region, the corresponding half of the chest or hypochondrium, shortness of breath and palpitations immediately after eating or shortly after it, as well as a feeling of heaviness after eating and the ability to eat only in small portions. This makes patients, who often feel practically healthy on an empty stomach, afraid to eat and limit the amount of food they eat. Very typical signs include vomiting (often multiple times) after eating and especially a feeling of relief and disappearance of symptoms that follows gastric emptying. There is also often an improvement in the condition and a decrease in symptoms after bowel movement.

The above signs, indicating a direct relationship between the degree of filling of the gastrointestinal tract and the severity of symptoms, have a very important diagnostic value. The connection between symptoms and the movement of internal organs into the chest may also be indicated by increased shortness of breath in a horizontal position of the patient, in the absence of heart disease, which we observed in 2 patients.

A sign that indicates the movement of gas-containing abdominal organs into the chest is a feeling of gurgling and rumbling in the corresponding half, noted by 4 of our patients and then confirmed during physical examination.

PHYSICAL INVESTIGATION

Examination of patients with a diaphragmatic hernia that has developed as a result of open injuries, first of all, allows us to detect the presence of a scar. In the case of a through-and-through wound, the location of the scars at the entrance and exit holes and taking into account the projection of the wound canal in some cases irrefutably indicates a previous thoracoabdominal injury and the associated possibility of developing a diaphragmatic hernia.

The location of the scars of the entrance and exit holes in 2 patients we observed even made it possible to judge the localization of the hernial orifice, which was confirmed during the operation.

In case of blind wounds, clarification of the mechanism of injury, the position of the victim at the time of injury and the possible direction of the wounding projectile also makes it possible to suspect damage to the diaphragm, especially with injuries to the lower chest and upper abdomen. However, a more distant location of the scars does not exclude this possibility, and often an X-ray examination of a blind wound with an unremoved wounding projectile makes it possible to diagnose a previous thoracoabdominal wound.

Deformation of the chest or pelvis is often observed after blunt trauma, which can also direct the doctor’s thoughts in the right direction and help establish a diagnosis. In some cases, protrusion of the chest on the affected side is noted. In one patient, 5 years old, with an extensive left-sided traumatic diaphragmatic hernia, we observed protrusion of the sternum and adjacent parts of the III–VI costal cartilages. Often the chest on the affected side lags behind the healthy half when breathing. When a significant part of the abdominal organs moves into the chest, a retraction of the abdomen often occurs, described by N.I. Pirogov, which increases with inhalation and decreases with exhalation, and after eating is often replaced by bloating.

Children with a traumatic diaphragmatic hernia usually experience a delay in physical development, which is also noted in those of our adult patients whose hernia occurred in childhood.

However, the most characteristic data to suspect the presence of a diaphragmatic hernia can be obtained by percussion and auscultation.

These include dullness, usually with a tympanic tint, or tympanitis above the chest on the side of the hernia, which in one of our patients reached the level of the clavicle in front and the upper edge of the scapula in the back. The area of ​​dullness and tympanitis changes depending on the degree of filling of the stomach and intestines, as well as when the patient’s body position changes. When moving a non-gas-containing organ (liver or spleen) that has prolapsed through a defect in the diaphragm, a distinct dullness of the percussion sound is observed in the area of ​​the usual pulmonary one. An equally common sign is a displacement of the heart to the healthy side, which is more pronounced the higher the zone of dullness and tympanitis is located.

During auscultation in the area corresponding to dullness and tympanitis, a significant weakening and sometimes complete absence of respiratory sounds is noted, instead of which rumbling and often splashing sounds are detected. Heart sounds are usually muffled, and the points at which they are best heard are moved to the healthy side. As with percussion, auscultation data is characterized by variability during repeated examinations, and sometimes during one examination.

According to I.D. Korabelnikov, per 100 patients with traumatic diaphragmatic hernia, the following frequency of the above symptoms was noted:

Dullness to percussion

Sound........................................................ .. 31

Tympanitis above the chest....... 21

Weakening or absence of breathing

unwanted noises......................................... 29

Rumbling in the chest................................... 10

The sound of splashing in the chest................................... 7

Displacement of cardiac dullness......... 25

However, these symptoms, especially dullness with a tympanic tinge over the half of the chest where there is a hernia, are actually even more common, and in one or another combination they occurred in all the patients we observed.

The combination of dullness and tympanitis, weakening or complete absence of respiratory sounds, rumbling and splashing noise, varying depending on the degree of filling of the gastrointestinal tract, over the corresponding half of the chest with a displacement of the heart to the opposite side allows one to suspect a diaphragmatic hernia. In this case, an indication of a closed chest injury suffered in the past,

abdomen or pelvis, as well as the presence of scars that suggest a previous thoracoabdominal injury, makes the diagnosis of a traumatic diaphragmatic hernia quite reasonable. In a number of patients this diagnosis was made by us during an outpatient visit. However, a reliable diagnosis of traumatic diaphragmatic hernia can only be established by X-ray examination.

X-RAY DIAGNOGICS TPABMATIC

DIAPHRAGMAL HERNIA

The X-ray picture of a traumatic hernia of the diaphragm, as well as of its other types, depends on the nature and volume of the displaced abdominal organs.

With isolated gastric prolapse above the diaphragm, one large gas bubble with a horizontal fluid level is usually detected. Insertion of a probe into the stomach or a contrast study makes it possible to clarify the nature of the gas bubble with a horizontal level, establish prolapse of the stomach into the chest cavity and exclude other diseases (pleurisy, hydropneumothorax), in which a similar picture may be observed. It is also characteristic that the horizontal level rises after eating or drinking and decreases on an empty stomach, as well as after inserting a probe and pumping out the contents.

In some cases, when the entire stomach falls into the pleural cavity and volvulus occurs, not one, but two horizontal levels are often visible.

If the diaphragm is not clearly contoured, the level of its location can be judged by the compression and deformation of the stomach at the level of the hernial orifice, which is more clearly visible with a contrast study.

However, with large defects, for example, with a complete rupture of the dome, as we observed in one patient, there was no formed hernial orifice and compression of the stomach did not occur. In these cases, the entire stomach, with the exception of the cardiac section, moves into the chest cavity, turning with the greater curvature upward, and the latter is often mistaken for the diaphragm and in the case of a hernia, a diagnosis of relaxation is made. We discuss the differential radiological diagnosis of these two diseases in detail in the chapter on diaphragm relaxation.

With large defects, when along with the stomach, intestinal loops also prolapse into the pleural cavity, in addition to the large gas bubble of the stomach lying medially, against the background of diffuse darkening of the pulmonary field, individual areas of clearing, often round or irregular in shape, are determined. The pulmonary field has a coarse and fine-mesh structure, and often with prolapse of the large intestine, clearing with typical haustration is detected (Fig. 12, 13).

If colon filled with feces, then against the background of the lung tissue a more intense darkening is often detected, which is also observed with concomitant prolapse of parenchymal organs or omentum.

Finally, with isolated prolapse of one of the intestinal loops (most often the splenic angle), a round or irregularly shaped shadow with clearing and often with haustration may be observed above the diaphragm. Colonic prolapse can best be confirmed by administering a contrast agent in an enema.

According to the level of passage of the intestinal loops through the defect of the diaphragm, depression is also noted on them.

Multiaxial contrast-enhanced examination of the gastrointestinal tract, thanks to the flow symptom, usually makes it possible to fairly accurately determine the location and size of the hernial orifice, as well as the nature of the prolapsed organs, which is of particular importance for the choice of access and surgical plan.

Characteristic for traumatic, as for other diaphragmatic hernias, is the variability of the x-ray picture depending on the degree of filling of the gastrointestinal tract, and changes are often noted during one study.

The most difficult to diagnose are those rare cases when only parenchymal organs (liver, spleen, kidney) or omentum are displaced and fluoroscopy shows only a more or less defined darkening of the lower parts of the corresponding pulmonary field. When a section of the liver is detached or the spleen prolapses due to the presence of a outlined shadow above the diaphragm, the assumption most often arises of a tumor or lung cyst or the liver, and with central localization - the mediastinum. To establish an accurate diagnosis in these cases, it is necessary to resort to diagnostic pneumoperitoneum, in which the passage of gas into the pleural cavity is often observed, or to pneumothorax, when gas penetrates below the diaphragm, which makes it possible to establish the presence of a defect in it.

For adhesions in the area of ​​the hernial orifice, when communication between the abdominal and pleural cavities cannot be established, splenoportography can be used, and if one is thinking about kidney displacement, pyelography can be used. On diagnostic value We have already discussed these methods in the chapter on research methods and the section on x-ray diagnostics of tumors and cysts of the diaphragm.

A feature of the X-ray picture of traumatic diaphragmatic hernias is the possibility of an “atypical” location of the defect in any part of the diaphragm, as well as the presence of adhesions and other signs indicating an injury.

TREATMENT OF TRAUMATIC DIAPHRAGMAL HERNIA

It is now generally accepted that both all diagnosed wounds of the diaphragm and all established traumatic diaphragmatic hernias are subject to surgical treatment. The indication for surgery is the risk of strangulation, which is especially great in case of traumatic hernias. Thus, in one of the 17 patients we operated on, the indication for intervention was acute strangulation of a left-sided hernia, and the other two had previously been operated on for strangulation. Only with very compelling reasons general contraindications radical intervention, you can refuse a planned operation, warning the patient about the need for emergency hospitalization if signs of infringement appear. Of the 20 patients, one was not operated on by us due to severe coronary artery sclerosis and bundle branch block. In addition, two patients refused surgical intervention.

If the operation is not performed for one reason or another, then the patient must be advised to adhere to the appropriate regimen. All factors that contribute to increased intra-abdominal pressure should be excluded. Patients should not lift heavy objects, perform work that involves straining the abdominal muscles, or wear a tight belt. You need to eat in small portions often, avoiding, if possible, foods that contribute to flatulence. It is not advisable to drink beer and fizzy drinks. Constipation, which often occurs with traumatic diaphragmatic hernia, must be combated.

Surgery for diaphragmatic hernias, as already noted, began to develop relatively late, and initially the operation was performed involuntarily for strangulation. V.I. Petrov (1949) during the first decade of the current century found in the domestic literature a description of 6 operations for traumatic diaphragmatic hernia. In the second decade, the number of operations also turned out to be 6. Then these operations began to be performed somewhat more often, and by 1950 their total reached 170 (I. D. Korabelnikov, 1951).

If in the past many surgeons preferred transperitoneal approaches, now for chronic non-strangulated traumatic diaphragmatic hernia they almost always use the transpleural approach, which is the method of choice.

The use of intratracheal anesthesia eliminated the need for preliminary application of pneumothorax, which until relatively recently was widely used by some surgeons (V.I. Petrov, 1940; Yu.Yu. Dzhanelizde, 1950, etc.).

In all 17 patients we operated on for chronic traumatic diaphragmatic hernia, transpleural access was used (one 5-year-old patient died from acute heart failure, which developed on the second day after surgery). We most often make the incision along the seventh intercostal space, crossing the costal arch. In the presence of a separation of the diaphragm and when the hernial orifice is located in its posterior-6th sections, it is more convenient to use an incision in the eighth intercostal space.

Very often, the pleural cavity is closed and only above the diaphragm a free section is found, filled with abdominal organs that have prolapsed through the hernial orifice. As already indicated, most often we encounter a loop of the colon, stomach, and omentum. Before widening the thoracotomy wound, it is necessary to separate the adhesions of the lung with the underlying portion of the chest wall and the diaphragm.

After gaining ample access, the prolapsed trouser organs are mobilized. We only encountered great difficulties once during this stage of the operation. Isolation is carried out by acute and blunt methods. The adhesions are crossed under their tension created by careful removal of the attached organ. Infiltration of adhesions with a solution of novocaine (hydraulic preparation) can also provide some assistance. A complex, at first glance, situation with methodical and sequential separation of adhesions is quickly simplified, and the operation becomes easily feasible.

The strongest adhesions are in the area of ​​the diaphragm defect, where the surgeon’s work is greatly hampered by the need to also mobilize part of the lower surface of the thoraco-abdominal obstruction. At the same time, one should not limit the indications for dissection of narrow hernial orifices. The latter also greatly facilitates the repositioning of prolapsed organs. The contents of the stomach must be removed with a probe before mobilization.

If deserosis of certain areas of prolapsed organs sometimes occurs, the damaged areas should be sutured. In the above-mentioned patient G., whose hernia arose after pleuropulmonectomy during separation from the adhesions of the stomach, soldered by the greater curvature to the subclavian vessels, there was even a through wound of 3 cm, which was sutured with a three-row suture.

Reduction of prolapsed organs under modern intubation anesthesia with the use of muscle relaxants is usually easy, and therefore there is no need to resort to artificial paralysis of the diaphragm, which in the past many surgeons caused by transecting or crushing the phrenic nerve.

In the vast majority of cases with a traumatic diaphragmatic hernia, suturing the diaphragm defect is easy. In this case, only some flattening of the dome occurs. If the flaps of the torn diaphragm have fused with the chest wall, then suturing the defect becomes possible only after their complete mobilization.

When pronounced cicatricial changes in the edges of the hernial orifice are observed occasionally, some authors excise the scar to healthy tissue, which, in our opinion, should not usually be resorted to, since this reduces the strength of the edges of the diaphragm. In cases where the edges of the hernial orifice are partially dissected during mobilization and reduction of organs, the bleeding vessels of the diaphragm should be lined with catgut.

We close the hole with separate silk sutures at a distance of 0.8 - 1.0 cm from each other, trying to create a duplication whenever possible by placing one edge of the diaphragm on the other. We used, like Sauerbruch, Yu. Yu. Dzhanelidze and other surgeons, U-shaped sutures passing at the base of the lower flap and at some distance from the edge of the opposite side of the hole.

After tying these seams, the remaining free section of the diaphragm is laid in the form of a coat hem and, with slight tension, is hemmed to the diaphragm (Fig. 14).

Harrington additionally applies a continuous suture with a strip of fascia lata to prevent cutting through the sutures and strengthen the duplication.

In case of diaphragm tears, the technique of applying transcostal or removable sutures according to V.F. Voino-Yasenetsky can be successfully applied. Although some modern authors (Bernatz, Burnside, Clagett, 1958, etc.) sometimes use thoracoplasty to facilitate suturing of the diaphragm defect, we are not supporters of this traumatic operation, which leads to irreversible deformation of the chest.

In one patient we operated on back in the days when surgeons did not have alloplastic prostheses at their disposal, we closed a large defect in the left dome of the diaphragm by suturing the left lobe of the liver to its edges. When examining the patient after 4 1/2 years, no relapse was found.

In cases where a more or less pronounced border of the diaphragm tissue remains at the chest wall, sutures are placed on it, also capturing the intercostal muscles. We used this suturing technique in one patient. It is also possible to slightly increase the size of this border by mobilizing the extrapleural part of the diaphragm in the area of ​​the prediaphragmatic space, for which it is necessary to dissect the parietal pleura along the bottom of the costophrenic sinus. The same technique can be used to reduce the tension of the diaphragm and when suturing more centrally located defects.

If the defect is sutured without tension and the diaphragm tissue is not significantly changed, then there is no need for additional alloplastic strengthening of the suture line. If tension occurs, the suture line can be covered from above with a prosthesis, fixing it along the periphery with separate sutures to the healthy tissues of the diaphragm with slight tension. This, in addition to creating an additional artificial layer of the diaphragm, reduces the load on the main sutures, which contributes to faster fusion of the edges of the healed defect. The use of a reinforcing prosthesis is also desirable in cases of extended scar degeneration and thinning of tissue in the area of ​​the hernial orifice.

During surgery (N. O. Nikolaev) in a patient after mobilization of adherent

To the chest wall of the diaphragm flaps, significant thinning of their edges was found. Part of the defect was sutured without tension, but subsequent sutures began to erupt. Therefore, further suturing was carried out while simultaneously strengthening the thinned area with two layers of nylon fabric. First, a pair of sutures were placed on both edges of the prosthesis and the diaphragm within the unchanged tissue. The resulting tension in the diaphragm brought the edges of the defect closer together. The third suture was used to stitch the edges of the defect and the middle of the prosthesis. tying a seam over the last one (Fig. 15).

In this case, the finger inserted into the defect protected the abdominal organs from damage by the needle. The subsequent application of such sutures made it possible to easily and reliably close the diaphragm defect. Taking into account the incompleteness of the tissues of the lateral part of the diaphragm, the outer edge of the prosthesis was fixed together with the diaphragm to the chest wall with several transcostal sutures.

The placement of middle row sutures through the edges of the diaphragm defect and the prosthesis, in addition to preventing their eruption, also ensured a tighter fit of the caspron tissue to the diaphragm, preventing the accumulation of reactive effusion between them.

Since the presence of alloplastic material in the pleural cavity usually leads to the development of reactive serous pleurisy, in one case, with good results, we used the strengthening of the suture line by suturing a 5X.5 cm polyvinyl alcohol plate to the lower (abdominal) surface of the diaphragm. After expanding the hole in the diaphragm in the lateral direction to the abdominal surface of the anterior flap of the diaphragm in the area of ​​the hernial orifice, but significantly extending beyond the area that had scar changes, the edge of a polyvinyl alcohol sponge was sutured with knotted sutures.

Then the posterior flap was bent and the second edge of the prosthesis was sutured to it, also within healthy tissue. At the same time, continuous traction of the thread holder applied to the anterior flap was carried out.

Following this, the hernial orifice was sutured edge to edge over a polyvinyl alcohol plate. The cut area of ​​the unchanged part of the diaphragm is sutured (Fig. 1b).

In some patients, placing an alloplastic prosthesis between both sheets of duplication from the thinned edges of the hernial orifice can also be used.

In two patients, the tissue of the diaphragm was not enough to close the entire wide defect, which, apparently, should be explained by the occurrence of a traumatic hernia in early childhood, i.e., a period rapid growth body. In one of these patients (S., 5 years old), a prosthesis made of polyvinyl alcohol sponge was used to close a through residual triangular defect of 7 X 5 cm remaining after suturing the main part of the hernial orifice.

In the second case (patient Sh., 18 years old), a plate of polyvinyl alcohol sponge and a nylon mesh were sewn into the defect (Fig. 17). Other methods of closing large diaphragm defects are reported in Chap. III.

Surgical elimination of the relatively rare intercostal diaphragmatic hernia has some peculiarities. In this regard, the operation performed in 1905 by P. I. Dyakonov, a professor at the hospital surgical clinic of Moscow University, is quite typical.

Let us recall that the patient, in addition to a hernia, also had chronic fistulas in the area of ​​the entrance and exit holes of the through bullet wound.

Under anesthesia, the incision was made along the hernial protrusion between the openings of both fistulas. The omentum and small intestine were exposed, extending into the subcutaneous tissue through a chest wall defect measuring 8 X 12 cm, located between the VIII and X ribs. After widening the wound, it was established that the indicated abdominal organs pass through a hole in the thoraco-abdominal barrier measuring 3 X 6 cm. The intestine and omentum are easily inserted into the abdominal cavity. The hernial orifice in the diaphragm is sutured with silk sutures. To eliminate the chest wall defect, periosteal flaps with bases facing each other were prepared from the above and below the ribs. By stitching both flaps together, the gap through which the hernia protruded was closed. The patient recovered.

The decisive moment of the operation for intercostal diaphragmatic hernia is the closure of the defect in the thoraco-abdominal barrier.

Our experience in studying traumatic diaphragmatic hernias shows that diaphragmatic defects in these cases can be located in any part of the diaphragm, and their sizes are very diverse. The clinical manifestations of this often difficult to diagnose disease can also be different and depend mainly on the size of the defect in the thoraco-abdominal barrier and on the number of organs moved into the chest cavity through this defect. Prolapsed abdominal organs often merge with the mediastinal and costal pleura and lungs and cause displacement of the latter and the heart with symptoms of dysfunction, sometimes reminiscent of the clinical picture of other lesions of these organs. All this obliges, when diagnosing diseases of the organs of the thoracic and abdominal cavities, to be attentive to the examination of the detected signs, to clarify the anamnesis in detail, especially when there are scars or other traces of damage to the skin in these areas, and more often to resort to auxiliary research methods.

When diagnosing traumatic diaphragmatic hernias, it is necessary to conduct an X-ray examination and carefully determine the causes of unusual inclusions detected during the study (unclear darkening, clearing, etc.). You should also resort to contrast examination of the gastrointestinal tract and the imposition of diagnostic pneumoperitoneum or pneumothorax. Radiography in at least two projections makes it possible to determine the location and size of the defect and select surgical access.

As we have already indicated, generally accepted indications for surgical treatment are diagnosed wounds and established traumatic hernias of the diaphragm. Any defect in the diaphragm, even a very small one, can, under certain conditions, cause strangulation of the organ. The danger of this infringement is especially great in case of traumatic hernias, and may require emergency surgical intervention in worse conditions than could have been the case when the operation was carried out as planned. We repeat that only with very strong general contraindications to radical intervention can one refuse a planned operation, be sure to warn the patient about compliance with the appropriate regimen and the need for emergency hospitalization in case of signs of infringement.

The success of surgical treatment of traumatic diaphragmatic hernia depends primarily on the right choice method of closing the defect at the time of the operation itself. Therefore, the surgeon must be well acquainted with everyone using existing methods plasty of the abdominal barrier. In most cases, traumatic defects of the diaphragm can be eliminated using its own tissues, without resorting to complex autoplastic methods or alloplasty. In this case, it is necessary to remember that the edges of a ruptured diaphragm usually curl up in the form of a tourniquet, or grow together with its surface, forming a kind of duplication. Meanwhile, the separation of these adhesions usually allows one to free up quite significant areas of the diaphragm, which are often sufficient to close the defect using one’s own tissues. The suturing of the defect can also be facilitated by dissection of the pleura along the bottom of the costophrenic sinus, which will allow mobilizing this part (prediaphragmatic space) of the diaphragm.

In cases where reliable suturing of the defect with one’s own tissues is not possible, in order to replace this defect, one should use dense prostheses made of Teflon, Terylene or a two-layer prosthesis, for example, a combination of nylon mesh with a polyvinyl alcohol sponge. The latter can also be successfully used to strengthen the diaphragm seam. In this case, it is better to sutured it to the lower surface of the diaphragm in order to isolate the alloplastic material from the free pleural cavity. Often you also have to resort to various improvisations, using combinations of a wide variety of techniques. All this makes it possible to achieve good results in the treatment of patients with traumatic diaphragmatic hernias. When studying long-term results and periods up to 18 years, there were no recurrences of hernias in the patients we operated on.

Mortality depending on surgical approach (Hedblom)

The degree of radicality of the operation depending on the access (Hedblom)

Outcomes of surgical treatment depending on access, according to Russian literature.

Closed diaphragm injury symptoms or contusion can occur as a result of a sudden increase in pressure in the abdominal area or pleural cavity, which causes excessive stretching or even rupture. In most cases, the rupture line runs along the border between the tendons and muscle tissue of the diaphragm. In some cases, a severe impact causes the diaphragm to tear off at the lower chest outlet.

When a diaphragm injury occurs, the consequences can be very serious, since the injury can be accompanied by fractures of the ribs, pelvic bones and spine. As a result, the organs in the abdominal cavity are displaced into the pleural region or mediastinum.

Diagnosis of diaphragm injury

When conducting diagnostics, doctors tap the chest and listen to the intestines, and also prescribe an X-ray examination of the chest and abdominal cavities. From an x-ray, a qualified specialist can tell a lot about the damage that the victim received due to injury.

When performing diagnostics, doctors take into account the presence of injuries and assess the mobility of the chest and the condition of the intercostal space. Sometimes it is necessary to fill the peritoneum with gas so that tumors can be seen on an x-ray.

In addition to X-ray examination, specialists in some cases prescribe esophagoscopy. The procedure involves examining the insides of the esophagus using a special apparatus.

Symptoms of diaphragm damage

Symptoms of bruised diaphragm can vary, but among the main and most common are respiratory failure. When a blow to the chest area leads to tissue rupture, it can usually be recognized only during surgery, so doctors often prescribe a laparotomy to check the domes of the muscular septum.

A complete rupture of the muscular septum can be diagnosed by two sets of symptoms:

Displacement of internal organs in the abdominal cavity into the pleural cavity;
. signs of cardiopulmonary failure.

In rare cases, the victim develops pleuropulmonary shock. When diagnosing the consequences of a diaphragm injury, doctors are guided by the following signs and symptoms:

Reduced respiratory activity of the chest due to injury;
. symptoms of compression of the lung on the side of the bruise;
. displacement of the boundaries of the mediastinum and cardiac muscle;
. distinct peristalsis;
. the absence of a clear line of the septal dome on an x-ray or the presence of a shadow of the stomach or intestines in the pleural cavity.

Additional symptoms include hemopneumothorax and signs of intestinal obstruction due to entrapment of organs trapped in the pleural area.

Treatment of bruised diaphragm

Treatment after a diaphragm injury with rupture or damage requires urgent surgical intervention, during which surgeons suture the muscular septum.

In cases where the degree of damage is serious, specialists can install a nylon, nylon or lavsan prosthesis. The displaced organ, when a hernia is strangulated due to a bruise, is relegated to the abdominal cavity, and if this is not possible, it is ectomized and the defect is sutured.

After surgery, the patient should sleep with his head elevated and control his bowel movements. He should not take positions that promote reflux. Recommended frequent meals in small portions, and should not be eaten before bedtime.

Among victims with closed chest and abdominal trauma, patients with diaphragm injuries occupy a special place. These injuries occur in 0.5-5% of all cases of combined injury. About 70% of such victims die from shock, blood loss and respiratory failure, and ruptures of the diaphragm are detected only at autopsy. The left half of the diaphragm is most often ruptured, since the liver absorbs most of the impact energy and thus protects the right half of the diaphragm. Rarely, rupture of the diaphragm on both sides is observed (no more than 10% of cases). Even less common are multiple injuries to the diaphragm.

The rupture most often occurs at the border between the muscle and tendon parts. The shape and size of the diaphragm rupture varies widely (Fig. 53-35).

Rice. 53-35. Diaphragm rupture (intraoperative photograph).

In most victims, ruptures of the diaphragm occur during severe combined trauma with damage to three to five anatomical areas. Ruptures of the diaphragm can cause movement of abdominal organs into the pleural cavity. With left-sided ruptures, the stomach, large, small intestine and spleen are more often displaced into the pleural cavity; for right-sided - liver, gallbladder. Such a movement is dangerous due to possible infringement of organs with the development of necrosis.

Diagnostics

Most often, patients complain of difficulty breathing, shortness of breath, a feeling of lack of air, chest pain when breathing, and abdominal pain. The patient's position is often forced, and his behavior is restless. Skin often pale, there is a lag of the chest when breathing on the side of the injury. Dullness of percussion sound in the lower parts of the chest on the right is detected due to movement of the liver into the pleural cavity, tympanic sound due to movement of the stomach or intestines into the pleural cavity when the diaphragm ruptures on the left. Breathing sounds on the injured side are usually sharply weakened or not heard at all. When intestinal loops move into the pleural cavity, bowel sounds may be heard, but this symptom is not always detected. The pulse is increased, and there is a tendency toward arterial hypotension. The abdomen may be asymmetrical. When a rupture of the diaphragm is combined with damage to parenchymal organs and intra-abdominal bleeding, dullness of percussion sound in sloping areas of the abdomen is determined. Palpation of the abdomen is slightly painful. If hollow organs are damaged, symptoms of peritoneal irritation are determined.

Various laboratory tests (blood tests, urine tests, biochemical blood tests, etc.) are only auxiliary diagnostic methods that do not provide any characteristic information. The leading role in the diagnosis of diaphragm ruptures still belongs to the X-ray method, but recently it is increasingly combined with ultrasound, X-ray computed tomography, and thoracoscopy. X-ray diagnosis of a rupture of the diaphragm, especially its left half, is possible only when the abdominal organs (usually the stomach or the splenic flexure of the colon) are moved into the chest cavity. In the absence of such movement on the left and in the case of a rupture of the right half of the diaphragm, X-ray diagnosis of its damage presents certain difficulties.

If a rupture of the left half of the diaphragm is suspected, it is necessary to contrast the stomach with a barium suspension or a water-soluble contrast agent. If the patient is in a coma, contrast is administered through a nasogastric tube. When the diaphragm ruptures, the stomach is located in the pleural cavity, and a displacement of the esophagus to the right of the spine is noted (Fig. 53-36).

Rice. 53-36. X-ray of a rupture of the left dome of the diaphragm, leading to strangulation of the stomach.

A victim with suspected movement of the colon into the pleural cavity undergoes irrigography (Fig. 53-37).

Rice. 53-37. X-ray (irrigogram) of a rupture of the left dome of the diaphragm and strangulation of the colon.

A possible rupture of the diaphragm should be differentiated from the relaxation of its corresponding half. A differential diagnostic feature that allows one to distinguish between rupture of the diaphragm and its relaxation can be the thickness of the line bordering the air cavity (gastric vault): during relaxation, this line represents the total shadow of the stomach wall and the diaphragm itself and can reach 15 mm. The rate of correct diagnosis of left diaphragmatic rupture is 85%. For ruptures of the diaphragm on the right, the x-ray method is ineffective. It should be noted that in some cases there are no signs of damage to the diaphragm during artificial ventilation. However, after the patient is transferred to spontaneous breathing, the abdominal organs move into the pleural cavity, which requires surgical intervention.

Ultrasound with the patient lying on his back, on his side, sitting, from subcostal, intercostal and epigastric access is of great importance for diagnosing diaphragmatic ruptures. Direct signs of diaphragm rupture include visualization of its defect and detection of movement of abdominal organs into the pleural cavity. Indirect signs rupture - high standing of the diaphragm, the presence of free fluid in the pleural and abdominal cavities, displacement of the mediastinum. With ruptures of the left half of the diaphragm, separation of the pleura with the presence of contents of a heterogeneous structure was noted. Most often, these data are interpreted as a coagulated hemothorax. With ruptures of the right half of the diaphragm, the liver, as a rule, is located very high (at the level of the second intercostal space); the contours of the diaphragm cannot always be traced.

In difficult cases, when a rupture of the diaphragm on the right is suspected, as well as when carrying out differential diagnosis with relaxation of the diaphragm, video thoracoscopy is the most informative. It should be carried out carefully, using upper approaches, due to the risk of damage to the abdominal organs displaced into the pleural cavity.

Treatment

Diaphragm ruptures are sutured with separate Dacron sutures or double-row continuous synthetic seam(Fig. 53-38).

Rice. 53-38. Stitched diaphragmatic rupture (intraoperative photograph).

The edges of the diaphragm should be excised before suturing only if they are crushed. Diaphragm suture failure is rare.

The postoperative period is difficult for most patients. Postoperative and overall mortality for diaphragmatic ruptures remains high - 35% and 60%, respectively. In most cases, this is due to the severity of combined organ damage.