Cholecystitis Calculosa in Posttraumatic Diaphragmatic Hernia
Cholecystitis Calculosa in Posttraumatic Diaphragmatic Hernia
Rupture of the diaphragm is a serious complication of blunt trauma. Diaphragmatic hernia is often initially overlooked in the acute setting and is only correctly diagnosed in 30 to 40 percent of cases. In our case, diaphragmatic injury was diagnosed seven years after the injury.
A rupture of the right side of the diaphragm is uncommon. Approximately 69 percent of hernias are left-sided, 24 percent are right-sided, and 15 percent are bilateral. Although autopsy studies have revealed equal incidence of right- and left-sided diaphragmatic ruptures, antemortem study reports suggest 88 to 95 percent of them occur to the left side. Right-sided tears are significantly less likely than left-sided tears because of the protective effect of the liver. They are associated with high mortality and morbidity.
Prolapse of the gallbladder is rare. There are just a few articles that report the presence of the gallbladder in posttraumatic diaphragmatic hernia. In our case, an impeded presentation of the ruptured diaphragm and the presence of the gallbladder can be explained by the hypothesis of delayed detection. The 'delayed detection' hypothesis assumes that a diaphragmatic defect created at the time of the injury becomes clinically evident only when herniation occurs or when problems arise from the hernia contents. In our case, the symptoms appeared with the presence of stones in the gallbladder.
The operative treatment for diaphragmatic rupture consists of hernia reduction, pleural drainage and repair of the defect. The surgical approach could be either transabdominal or transthoracic, or both. However, laparoscopic surgery, thoracoscopy, or artificial patches have become very popular in recent years. Our patient underwent a transabdominal approach and a mesh repair of his diaphragmatic hernia. A transabdominal approach is recommended for a cholecystectomy, even if the gallbladder is in the thoracic cavity. On the other hand, the mesh decreased the risk of a recurrence of the hernias. This was caused by the shearing of a stretched membrane and avulsion of the diaphragm from its points of attachments due to a sudden increase in intra-abdominal pressure, transmitted through the viscera.
Discussion
Rupture of the diaphragm is a serious complication of blunt trauma. Diaphragmatic hernia is often initially overlooked in the acute setting and is only correctly diagnosed in 30 to 40 percent of cases. In our case, diaphragmatic injury was diagnosed seven years after the injury.
A rupture of the right side of the diaphragm is uncommon. Approximately 69 percent of hernias are left-sided, 24 percent are right-sided, and 15 percent are bilateral. Although autopsy studies have revealed equal incidence of right- and left-sided diaphragmatic ruptures, antemortem study reports suggest 88 to 95 percent of them occur to the left side. Right-sided tears are significantly less likely than left-sided tears because of the protective effect of the liver. They are associated with high mortality and morbidity.
Prolapse of the gallbladder is rare. There are just a few articles that report the presence of the gallbladder in posttraumatic diaphragmatic hernia. In our case, an impeded presentation of the ruptured diaphragm and the presence of the gallbladder can be explained by the hypothesis of delayed detection. The 'delayed detection' hypothesis assumes that a diaphragmatic defect created at the time of the injury becomes clinically evident only when herniation occurs or when problems arise from the hernia contents. In our case, the symptoms appeared with the presence of stones in the gallbladder.
The operative treatment for diaphragmatic rupture consists of hernia reduction, pleural drainage and repair of the defect. The surgical approach could be either transabdominal or transthoracic, or both. However, laparoscopic surgery, thoracoscopy, or artificial patches have become very popular in recent years. Our patient underwent a transabdominal approach and a mesh repair of his diaphragmatic hernia. A transabdominal approach is recommended for a cholecystectomy, even if the gallbladder is in the thoracic cavity. On the other hand, the mesh decreased the risk of a recurrence of the hernias. This was caused by the shearing of a stretched membrane and avulsion of the diaphragm from its points of attachments due to a sudden increase in intra-abdominal pressure, transmitted through the viscera.
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