Laparoscopic management of blunt diaphragmatic injury

Diaphragmatic injury is difficult to diagnose using current radiological modalities, and missed diagnosis has been associated with a mortality of 20-36%. Laparotomy is the most sensitive of the standard diagnostic tools, but its unnecessary use can be up to 25% and carries a morbidity of 20%.

The use of the laparoscope in three cases of blunt diaphragmatic injury is reported here. Two cases were non-acute. The diagnosis of diaphragmatic injury could not be confirmed pre-operatively in any of the cases.

One, a left-sided injury, was easily diagnosed and repaired laparoscopically. The second, right-sided, was confirmed laparoscopically but had to be repaired by open due to difficulty with liver retraction. The third case, an acute injury, was not diagnosed at laparoscopy. Findings of free blood and distended small bowel warranted laparotomy and prevented the establishment of a safe, satisfactory pneumoperitoneum. Repair was performed open. None of the cases was complicated by pneumothorax.

Laparoscopy is a useful tool for diagnosis of non-acute blunt diaphragmatic injury but has limitations in the acute setting. Left-sided injuries can be repaired laparoscopically but right-sided injuries proved difficult and may be better dealt with thoracoscopically.