Traumatic diaphragmatic injury: a narrative review

Background and Objective: Traumatic diaphragmatic injuries (TDIs) are uncommon injuries in the trauma patient, though they carry significant rates of associated mortality. Significant knowledge gaps related to diagnosis and management considerations exist. The objective of this review is to provide an up-to-date review regarding the associated anatomy, physiology, presentation, diagnosis, management, and complications of these injuries. Methods: A PubMed search of English-language articles was performed, utilizing search terms of diaphragm injury, traumatic diaphragm hernia, diaphragm rupture, or diaphragm repair. Studies from the last 25 years were emphasized. Only studies in adults were reviewed. Key Content and Findings: Injuries to the diaphragm generally do not spontaneously heal due to the continuous movement of the muscle and constant pressure differential, thus making any missed diagnosis a long-term issue. Presentation of TDI varies widely, from patients who are asymptomatic to those with life-threatening incarceration of herniated organs. These injuries are hard to diagnose despite improvements in imaging technology, and thus, stable patients often require invasive diagnostic techniques such as diagnostic laparoscopy (DL). Detailed algorithms addressing diagnosis and management of acute TDI are provided. Techniques of repair range widely, including laparotomy, thoracotomy, laparoscopy, robotic-assisted laparoscopy, and thoracoscopy. Non-absorbable sutures are frequently recommended for all but the smallest of injuries; the use of mesh is more controversial and can be considered for extensive defects that are not amenable to primary closure. Complications of surgical repair include surgical site infections, nosocomial pneumonia, and atelectasis. Conclusions: The diagnosis of TDI continues to require a high index of suspicion given the wide range of presenting symptoms. These injuries do not heal spontaneously and may require invasive modalities to assure diagnosis. Most often, the acute management occurs via an abdominal approach, whether laparotomy or laparoscopy. Management of chronic TDI remains patient-specific given its rarer incidence.