PMC4717597_01
Chest x-ray showing a raised left hemidiaphragm with the presence of stomach shadow in the lower half of the left hemithorax
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Fig1
The initial chest radiograph demonstrated an elevated left hemidiaphragm with the presence of a stomach gas shadow in the lower half of the hemithorax (Fig. 1).
a Preoperative computed tomographic scan showing herniation of the patient's stomach into the left thorax and of the small bowels into an abdominal wall defect. b Computed tomographic scan of the patient's abdomen obtained at 2 weeks after the accident showing fat stranding and presence of air locules suggestive of infection of abdominal wall collection (arrow)
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Fig2
Computed tomography (CT) of the patient's abdomen showed a large posterolateral left diaphragmatic defect with herniation of the stomach into the left thorax, together with herniation of the small bowel through the left eighth intercostal space and an adjacent rent through the left transversus abdominis muscle (Fig. 2a). Nevertheless, there was extensive fat stranding in the previous abdominal wall fluid collections, along with presence of some air locules, suggestive of superimposed infection (Fig. 2b).
Schematic illustration with intraoperative view of traumatic diaphragmatic rupture and traumatic abdominal wall hernia. TRA transversus abdominis muscle
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Fig3
Perioperatively, we found a 10-cm-long radial tear in the posterolateral aspect of the diaphragm, which extended to the left anterior abdominal wall with complete disruption of all muscular layers (Fig. 3). There was an associated left ninth rib fracture with torn intercostal muscles between the eighth and ninth ribs (Fig. 3).
Axial (a) and sagittal (b) computed tomographic images showing continuity of the left hemidiaphragm (highlighted within the circle) reinforced with mesh (thick arrows) and ProTack (narrow arrows)
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Fig4
In addition, CT showed continuity of the left hemidiaphragm reinforced with mesh and ProTack (Fig. 4).