no longer an uncommon occurrence , its incidence has steadily increased with the rising number of blunt traumas secondary to road - traffic accidents . , we report a case of traumatic diaphragmatic rupture causing small bowel obstruction 20 years after initial injury . the patient , a middle - aged woman , underwent successful laparoscopic assisted diaphragmatic repair with small bowel resection . this case illustrates the importance of vigilance when confronted with abdominal pain and a past history of significant blunt abdominal trauma . finally , the case demonstrates the ability to manage these cases laparoscopically , which has not previously been reported . she reported 2 days of absolute constipation and mild abdominal distension . the night prior to admission she had been awoken from sleep with severe pleuritic pain and dyspnoea . her medical history was unremarkable except for a road - traffic accident ( rta ) 20 years previously . auscultation of the chest revealed crepitation 's at the right base and marked epigastric tenderness on examination of the abdomen . an electrocardiogram revealed a sinus tachycardia and a cxr revealed right - sided basal shadowing . relevant blood tests were as follows : hb 15 g / dl , wcc 14.9  10/l , crp 63 mg / l , amylase 40 u / l . arterial blood gases on 28% oxygen ph 7.39 , po2 16.9 kpa , pco2 4.5 kpa , hco 21.5 mmol / l , lactate 2.6 mmol / l , be 3.7 mmol / l . in the light of her pleuritic pain a d - dimer was performed which was raised at 564 ng / ml . in light of her clinical presentation a ctpa was performed which revealed a large defect in the right hemi diaphragm and small bowel in the thorax with evidence of small bowel obstruction ( see fig .  1 ) . figure  1:(a ) and ( b ) large right - sided diaphragmatic hernia with obstructed bowel ( white arrows ) evident on ctpa . ( a ) and ( b ) large right - sided diaphragmatic hernia with obstructed bowel ( white arrows ) evident on ctpa . she had hit the steering wheel hard and her foot had become stuck in the foot well . when examined in hospital she had suffered a broken wrist , four broken ribs on the left and a laceration to the liver which was managed conservatively . after an initial resuscitation she underwent laparoscopic repair of a diaphragmatic hernia and resection of strangulated jejunum . at laparoscopy , there was a large 5  5 cm defect noted posterolaterally on the right hemidiaphragm . to reduce the herniated small bowel , the defect first had to be enlarged with diathermy . careful bowel handling was necessary to avoid bowel perforation and prevent pleural and peritoneal contamination . the defect was then primarily closed with 0 pds continuous suture , the small bowel resection was then performed through a protected mini - laparotomy ( see fig .  2 ) . images demonstrate ( a ) right hemidiaphragmatic defect containing a loop of small bowel the distal end of which is ischaemic , ( b ) extraction of the bowel loop from the diaphragmatic defect and ( c ) laparoscopic repair of the defect with 0 pds . images demonstrate ( a ) right hemidiaphragmatic defect containing a loop of small bowel the distal end of which is ischaemic , ( b ) extraction of the bowel loop from the diaphragmatic defect and ( c ) laparoscopic repair of the defect with 0 pds . however , the incidence is low , occurring in only 0.81.6% of blunt injury trauma . this incidence may be higher as the diagnosis is often missed . left - sided rupture is more common than right , but there is an increasing frequency of right - sided ruptures . this may reflect an increased survival of patients with severe trauma in who right - sided tdr is more common . a high frequency of associated injuries ( 95100% of cases ) often distracts from the diaphragmatic injury . if not recognized during the acute phase the patient may remain asymptomatic , suffer from chronic abdominal pain or breathing difficulties or present in crisis with signs of obstruction and strangulation . chest radiography is the primary imaging modality with a sensitivity of 2756% for left sided , but only 17% for right - sided injuries . the most specific radiographic sign is an air containing viscus in the thorax , with focal constriction of the viscus at the site of herniation (  collar sign ) . findings suggestive of rupture include elevation of a hemidiaphragm , compression atelectasis of the lower lobe , and irregularity of the diaphragmatic outline . helical ct scanning is a more valuable tool with a sensitivity of 70% for left - sided , 50% for right - sided injuries and a specificity of 100% . while not appropriate in the acute setting , mri allows for optimum visualization of the hemidiaphragm . the parietoperitoneal pressure gradient results in a tendency for enlargement of the defect and herniation of abdominal viscera . early surgical repair is therefore appropriate with the surgical approach often dictated by associated injuries . in the delayed presentation , surgical intervention is complicated by adhesions between abdominal viscera and thoracic organs , with authors therefore recommending a thoracotomy . authors have also reported difficulties in attempting a laparoscopic approach including difficulty retracting the liver and establishing a pneumoperitoneum . tdr is increasing in incidence and although usually associated with major blunt trauma can occur after much smaller injuries . the diagnosis of a ruptured diaphragm is frequently missed during the acute phase with a high mortality during delayed presentations . a high index of suspicion is required and the diagnosis should always be considered in those with a history of blunt abdominal or chest trauma who develop gastrointestinal symptoms . chest radiography is a useful tool with ct gaining increasing recognition as the primary diagnostic investigation . early surgical intervention is recommended which as this case has demonstrated can be performed via a laparoscopic approach thereby aiding post - operative recovery .
traumatic rupture of the diaphragm ( tdr ) presents diagnostic difficulty , with basic radiological investigations discovering less than half of all cases . as a consequence , 
 complications of diaphragmatic rupture may present long after the initial injury has occurred  the time delay obscuring diagnosis . 
 once discovered repair is necessary with previous reports advocating open repair . here 
 , we report a case of traumatic diaphragmatic rupture causing small bowel obstruction 20 years after initial injury . 
 the patient , a young woman , underwent successful laparoscopic assisted diaphragmatic repair with small bowel resection . 
 tdr is an unusual but important differential diagnosis of an acute abdomen . a high index of suspicion is required to avoid delayed diagnosis and increased mortality .