Diaphragm Repair (Trauma)
What the Examiner Expects
Primary repair of traumatic diaphragmatic rupture, which occurs from blunt or penetrating thoracoabdominal trauma. The examiner expects you to know that left-sided injuries are 3x more common (the liver buttresses the right hemidiaphragm), blunt mechanism causes large radial tears (usually in the posterolateral diaphragm), and penetrating trauma causes small defects that may be missed initially but enlarge over time as abdominal contents herniate into the chest. Acute repair is performed with non-absorbable interrupted sutures (1-0 or 0 Prolene or Ethibond) in a horizontal mattress pattern. Chronic hernias with adhesions may require mesh reinforcement.
Key Examiner Focus Points
- Left-sided diaphragm injuries are 3x more common (right side protected by liver)
- Blunt mechanism causes large radial tears; penetrating causes small holes
- Acute repair: primary closure with non-absorbable interrupted sutures (figure-of-eight or horizontal mattress)
- Missed injury leads to chronic diaphragmatic hernia — may present years later with obstruction/strangulation
- Laparoscopy during penetrating left thoracoabdominal trauma has high sensitivity for diagnosing occult injuries
Common Curveballs
Chest X-ray after a left thoracoabdominal stab wound shows an elevated left hemidiaphragm — patient is stable and otherwise asymptomatic
A normal chest X-ray does not rule out a penetrating diaphragm injury — small lacerations may not be visible initially. Diagnostic laparoscopy is recommended for left thoracoabdominal penetrating trauma between the nipple and costal margin to evaluate for occult diaphragm injury. If found, repair primarily.
Two years after a motor vehicle crash, a patient presents with bowel obstruction and a left hemithorax full of bowel on chest X-ray
Chronic traumatic diaphragmatic hernia. This requires operative repair — thoracic or abdominal approach. The bowel must be reduced (carefully, as it may be incarcerated), adhesions lysed, non-viable bowel resected, and the diaphragm repaired with mesh reinforcement if the defect cannot be closed primarily.
Practice this topic with an AI-powered mock oral exam.
Browse Practice Cases