Nocturnal Dyspnea in a Young Adult Male Patient: A Typical Case of an Unrecognized Traumatic Rupture of the Diaphragm

摘要

A 36-year-old man was admitted to our emergency department complaining of worsening nocturnal and ex-ertional dyspnea that had appeared a few months previously, and that occasionally was associated with pain in the right dorsal region. Hypoventilation and hypophonesis at the right base of the thorax were found, and a history of blunt thoraco-abdominal trauma 7 years previously, with multiple right rib fractures, was reported. The suspicion of a diaphragmatic lesion on the chest radiography was borne out by a magnetic resonance imaging scan (Fig. 1), which confirmed the presence of a voluminous diaphragmatic hernia including the transverse colon and the liver. Viscera reached the thoracic apex with each respiration and caused a contralateral deviation of the mediastinum. Considering the symptoms and the diagnostic findings, we preferred an abdominal access (right-sided subcostal laparot-omy), which deprived us of a direct visual image but guaranteed better vascular and biliary control of the liver. Laparoscopy was avoided because of concern for a worsening of respiratory function. An ample laceration of the diaphragm (approximately 17 cm) was found, and the defect was repaired with a 20 X 15-cm expanded polytetrafluoroethylene prosthesis (Gore-Tex) secured with interrupted nonabsorb-able sutures to the intact edges of the diaphragm. A chest drain was inserted. The postoperative period was uneventful and the patient was discharged on the seventh day.