Current status of minimally invasive surgery for traumatic diaphragmatic injury: a narrative review

Traumatic diaphragmatic injury (TDI) is a rare but life-threatening condition. Herniation of the abdominal organs through a traumatic diaphragmatic defect may progress to ischemia, perforation, and obstruction. The mortality rate associated with emergency surgery for TDI is 10% to 45%. In most cases, prompt repair is required once TDI has been confirmed. Computed tomography (CT) is the gold standard for diagnosing TDI. However, in situations with high clinical suspicion, the possibility of TDI cannot be definitively ruled out even if the CT scan is negative. Diagnostic laparoscopy and thoracoscopy are particularly useful when CT findings are equivocal and a diaphragmatic injury is suspected. The traditional emergency surgical approach to TDI is open surgery. Although minimally invasive approaches offer improved outcomes, traditional open approaches are still predominantly used. This is because the choice of minimally invasive surgery can be influenced by selection bias, varying trauma severity and complexity, and various practical obstacles. The four approaches (laparotomy, thoracotomy, laparoscopy, and thoracoscopy) have their own advantages and disadvantages. Therefore, it is important to select the approach that is best suited to the condition of each patient with TDI. Robotic surgery has been reported in four TDI cases, regardless of the literature search period. Notably, in one reported case, robotic surgery was performed as early as 2 days after the initial injury. In robotic emergency surgery for TDI, further studies are required to obtain significant clinical evidence.