Section 5 Chest

Diaphragm
Chapter

19 Lydia Lam and Caroline Park

Surgical Anatomy
• The diaphragm consists of a peripheral muscular segment
and central aponeurotic segment. It is attached to the lower
sternum, the lower six ribs, and the lumbar spine. During
expiration it reaches the level of the nipples. The central
tendon of the diaphragm is fused to the base of the
pericardium.
• It has three major openings, which include the aortic
foramen – which allows passage of the aorta, the azygos vein,
and the thoracic duct – the esophageal foramen for the
esophagus, and the vagus nerves, and finally the vena cava
foramen, which contains the inferior vena cava (Figure 19.1).
Inferior
Vena Cava
Aorta Esophagus
Figure 19.1 Anatomy of the diaphragm and its major foramens.
• The arterial supply stems from the phrenic arteries that
are direct branches off of the aorta as it exits the hiatus,
while the venous drainage is directly into the inferior
vena cava.
• The diaphragm is innervated by the phrenic nerve,
which originates from the C3–C5 nerve roots, courses
over the anterior scalene muscle, continues into the
mediastinum along the pericardium, and terminates in the
diaphragm.
General Principles
• The diagnosis of isolated, uncomplicated diaphragmatic
injuries can be challenging because they are often
asymptomatic and the radiological findings may be subtle
or absent.
• Untreated diaphragmatic injuries may result in a
diaphragmatic hernia, which can manifest long after the
injury (Figure 19.2a and 19.2b).
• Traumatic diaphragmatic hernias occur almost always in
the left diaphragm, although in rare cases they may occur
in right-sided large diaphragmatic tears due to blunt
trauma or small anterior stab wounds.
• The most common herniating viscera include the
omentum, stomach, and colon. Less often, the spleen and
the small bowel may herniate through an unrepaired
diaphragmatic injury.
• A diaphragmatic hernia may cause bowel obstruction or
result in ischemic necrosis of the herniating viscus. These
conditions are associated with significant morbidity and
mortality.
• In penetrating injuries, the diaphragmatic tear is about
3–4 cm. In blunt trauma it is significantly larger, at about
7–8 cm (Figures 19.3a and 19.3b).

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 Chapter 19: Diaphragm

(a) (b)

Figure 19.2 (a, b) Left diaphragmatic hernia with stomach and colon in the left chest, following a stab wound to the left thoracoabdominal area many years
previously.

(a) (b)

Figure 19.3 (a) Penetrating injury to the left diaphragm (circle). The laceration in penetrating trauma is fairly small, usually about 3–4 cm long. (b) Rupture of the left
diaphragm due to blunt trauma (arrows). The laceration in blunt trauma is large, usually about 7–8 cm long. Deceleration injuries may cause avulsion of the
diaphragm from its attachments.

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 Section 5: Chest
Nipple
Sternum
Stab wound
Le Costal Margin
Figure 19.4 All asymptomatic penetrating injuries to the left
thoracoabdominal area, between the nipple superiorly and the costal margin
inferiorly, should be evaluated laparoscopically to rule out diaphragmatic injury.
• Any asymptomatic penetrating injury to the left
thoracoabdominal area, between the nipple superiorly and
the costal margin inferiorly, should be evaluated
laparoscopically to rule out diaphragmatic injury
(Figure 19.4). A normal chest X ray or CT scan do not
reliably exclude diaphragmatic injury.
• Patients with hemodynamic instability or signs of
peritonitis should undergo an emergency exploratory
laparotomy.
• Laparoscopic evaluation and possible repair of
diaphragmatic injuries should be considered in
asymptomatic patients with left thoracoabdominal
penetrating injuries, irrespective of radiological findings.
The procedure should be performed at least 6–8 hours after
admission, in order to allow any associated hollow viscus
injuries to manifest clinically or with leukocytosis.
Special Instruments
• Standard laparoscopic equipment for diagnostic/
therapeutic laparoscopy. It should include a 30-degree
10 mm or 5 mm laparoscope, 10 mm or 5 mm trocar for
the umbilical port, one 5 mm port for retraction and
mobilization, and one 10 mm working port (Figure 19.5).
• Equipment for the open operation would include a major
laparotomy tray. A Bookwalter retractor improves the
exposure of posterior diaphragmatic injuries.
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Laparoscopic Repair
Positioning
• Patient should be placed in the supine and reverse
Trendelenburg position with the left side up. The stomach
should be decompressed with an orogastric tube.
Trocar Placement
• Trocar placement should adhere to general laparoscopy
principals of triangulation to allow access to likely areas of
injury on the diaphragm. To begin, a standard
periumbilical trocar can be used to insert a camera for
diagnostic confirmation of the injury. Once the injury is
localized, additional ports can be inserted to maximize
access to the injury.
• During insufflation of the abdomen, monitor closely
for signs of tension pneumothorax (tachycardia,
hypotension, increased peak inspiratory pressures,
hypoxia). If there is a suspicion of tension pneumothorax,
the abdomen should be deflated immediately and a chest
drain should be placed.
• In some cases, it is not possible to maintain the abdominal
insufflation pressures because of gas loss through the
diaphragmatic defect and into the chest drain. Grasping the
edge of the wound with a forceps or clamp and partially
twisting it occludes the defect and allows abdominal
insufflation.
Xiphoid
Le costal
margin
10 mm trocar
Figure 19.5 Hasson 10 mm trocar is placed just above the umbilicus and is
used for the insertion of the scope. Two additional 5 mm ports are placed in the
epigastrium and left abdomen. If a diaphragmatic injury is diagnosed and
warrants repair, one of the 5 mm ports may be upsized to a 10 mm to allow for
passage of a needle.
 Chapter 19: Diaphragm

Repair (a)
• After laparoscopic evaluation of the abdomen for any other
associated injuries, any herniating viscus through the
diaphragmatic defect is reduced with gentle traction and
the extent of the injury is assessed. One of the 5 mm ports
is upsized to a 10 mm to allow for passage of a needle with
suture (Figures 19.6a and 19.6b).
• Diaphragmatic defects are repaired with interrupted figure-
of-eight nonabsorbable sutures, using standard
laparoscopic techniques. Alternatively, laparoscopic hernia
staples may be used (Figures 19.7a and 19.7b).

(a)

(b)

Omentum

(b)

Figure 19.7 (a and b) Laparoscopic repair of left diaphragmatic defect with

figure-of-eight sutures.

Open Repair
Positioning
• Patient should be placed in the supine position with both
arms abducted.
Figure 19.6 (a) Laparoscopic appearance of a left diaphragmatic injury (circle)
• A standard trauma preparation from the chin to the knees
with omentum herniating through the defect (arrow). (b) Diaphragmatic defect is used as access to the chest for a thoracostomy tube
after reduction of the herniating omentum. insertion may be necessary.

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 Section 5: Chest

Incision • If there is a diaphragmatic hernia, reduce the contents with

gentle traction. If necessary, enlarge the diaphragmatic
• A standard upper midline laparotomy incision starting at
defect to reduce incarcerated contents. Inspect contents for
the xiphoid and long enough to allow a complete
any ischemic necrosis.
exploration of the abdomen.
• A thoracotomy should never be used for acute repair of a
diaphragmatic injury because it does not allow exploration Repair
for associated intra-abdominal injuries or resection of • Before diaphragmatic repair, a suction catheter is inserted
ischemic viscera in cases with an incarcerated hernia and through the defect into the thoracic cavity and any
gangrenous stomach or intestine. associated hemothorax is suctioned out. If there is an
• For chronic diaphragmatic hernias, a thoracic approach associated hollow viscus injury with contamination,
may be considered. The choice of thoracotomy versus copious irrigation and suctioning of the pleural cavity
laparotomy is a matter of personal preference. should be performed.
• The diaphragmatic injury is pulled with an Allis or Kocher
Exposure clamp into the surgical field, as described above.
• The diaphragmatic defect is repaired with interrupted
• The patient is placed in the reversed Trendelenburg
figure-of-eight sutures, using number 0 or 1 monofilament,
position and the operating table is turned slightly to the
nonabsorbable sutures (Figure 19.9).
patient’s right side to improve exposure of the left
diaphragm. • High-energy deceleration injuries can result in avulsion of
the diaphragm from its chest wall attachments. In these
• Superior caudal retraction of the costal margins is key to
instances, the diaphragm will need to be secured to the
adequate exposure of the diaphragm. The use of a fixed
chest wall. It may be necessary to perform a thoracotomy
retractor, such as the Bookwalter retractor, is strongly
to allow horizontal mattress sutures to be placed around
recommended.
the ribs to secure the diaphragm in its normal position. The
• For posterior diaphragm injuries, the exposure can be
use of synthetic meshes is rarely necessary in the acute
improved by medial rotation of the spleen.
setting as tissue loss and domain loss have not had time
• The diaphragmatic wound edges are grasped with Allis to occur.
clamps and pulled anteriorly and downwards, to improve
• A tube thoracostomy should always be placed after the
exposure and repair. Clamps can be placed at the apices to
diaphragm repair.
line up the edges of the laceration and facilitate suturing.
This is particularly important for posterior injuries, which
are difficult to access (Figure 19.8).

Allis clamp

Figure 19.8 An Allis or Kocher forceps is placed to the diaphragmatic defect

and traction is applied to deliver the diaphragmatic injury into the surgical field
and make the repair easy. Figure 19.9 Repair of a large left diaphragmatic injury following blunt trauma.

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 Chapter 19: Diaphragm

Tips and Pitfalls exposure by placing the patient in the reverse

Trendelenburg position, and rotate the spleen medially.
• In the presence of a diaphragmatic defect, there is a risk of
Grasp the edges of the wound with Allis or Kocher
tension pneumothorax during abdominal insufflation for
forceps and pull the diaphragm towards the laparotomy
laparoscopy. Monitor closely the hemodynamic and
incision.
oxygenation status and peak inspiratory pressures. If any
• In the presence of peritoneal intestinal content
sign of tension pneumothorax develops, release the
contamination, there is an increased risk of empyema.
abdominal insufflation and make sure that a chest drain is
Wash out the pleural cavity through the diaphragmatic
in place or inserted.
defect and remove any gross contamination.
• In some cases, laparoscopic repair may be difficult because
• Although rare, during repair of the diaphragm below the
of the loss of the insufflation pressure through the
pericardium, place the sutures under direct visualization to
diaphragmatic defect and into the chest drain. Grasping the
avoid inadvertent injury to the myocardium.
edge of the wound with forceps or clamp and partially
twisting it can occlude the defect and allow repair. • After diaphragmatic repair, always place a thoracostomy
tube for postoperative drainage.
• Repair of posterior diaphragmatic wounds during
laparotomy is difficult due to poor exposure. Improve

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