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Semmelweis University Budapest, Hungary
Correspondence to: Lajos Kotsis, PhD, Thoracic Surgical Clinic, Semmelweis University, H-1529 Budapest, Pihenö u. 1, Budapest, Hungary
To the Editor:
The article published in CHEST by Seelig and associates (January 1999)1 on a very rare complication of occult diaphragmatic hernia has an important theoretical and practical value.
Like the authors, we found that the diagnosis of blunt traumatic rupture of the diaphragm may represent a challenge. In the majority of 13 patients managed at our clinic between 1989 and 2000, the fact of blunt thoracic trauma and/or abdominal trauma had been forgotten and the injury to the diaphragm was not suspected before admission to the clinic. In three other cases, rupture of the left diaphragm was missed during the prior laparotomy, a recurrent left-sided diaphragmatic hernia was interpreted as a posttraumatic phrenic nerve palsy (at another institution), and an erroneous diagnosis of a massive hiatal hernia was made.
However, in all our patients the correct diagnosis was established preoperatively. In all instances, visceral herniation (ie, stomach, intestine, spleen, liver, and omentum) into the chest cavity was present, most commonly through the pericardiac area in the left and central tendon on the right side. A left posterolateral thoracotomy was the preferred approach, except in two cases in which a left thoracolaparotomy was required or on one occasion when a right thoracotomy was required for hernia repair with an interrupted suture buttressed with vicryl mesh.
The delay of the diagnosis in latent blunt diaphragmatic ruptures may be attributed to several factors,2 3 4 but a careful history of abnormalities, plain chest roentgenograms, CT scans, and barium studies of the alimentary tract are the most useful diagnostic tools. Extensive adhesions between the herniated viscera and the lung or pericardium are difficult to remove through laparotomy, so a transthoracic approach and suture-repair of the diaphragm is the best choice of procedure.
References
General Hospital Ludwigshafen Ludwigshafen, Germany
Correspondence to: Matthias Seelig, MD, Department of Surgery, General Hospital Ludwigshafen, Bremserstrasse 79, Ludwigshafen 67063, Germany 
To the Editor:
I appreciate Dr. Kotsis’ comment on our study (January 1999)1 concerning the fact that a diaphragmatic rupture following blunt abdominal trauma remains a surgical challenge and should always be kept in mind as a potential complication in this setting. It is also worthwhile to note that this diagnosis may be missed during an exploratory laparotomy, although a meticulous search for this kind of injury should be part of any abdominal exploration following blunt abdominal trauma.
In contrast, the etiology for the late presentation in the case reported was an old stab wound to the chest, which had occurred 2 years earlier and had been treated by placement of a chest tube. It was the focus of our case report that a synchronous diaphragmatic injury following a stab wound to the chest may easily be missed when no intra-abdominal organ has been injured.
I cannot agree with Dr. Kotsis’ conclusion that the transthoracic approach should be preferred in any case of visceral herniation to the chest. As long as no further resection for perforation or ischemia due to strangulation is required, the hernia may be repaired via a thoracotomy. In our case, however, a perforation of the left hemicolon was demonstrated preoperatively, and it required a left hemicolectomy.1 Even for a well-trained thoracic surgeon, it may be impossible to perform this operation transthoracically. It was also obvious from the review of the literature that, in the case of intrathoracic colonic perforation, a laparotomy was the preferred approach in almost 70% of cases and a combined procedure was preferable in the remaining cases.2 As long as no perforation of intra-abdominal organs into the chest is suspected, a transthoracic approach should be preferred since it allows a better exploration of the thoracic cavity. In the presence of a complicated herniation (ie, strangulation or perforation), a laparotomy will be required, which may be combined with a thoracotomy.
References
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