Does a Negative Emergency Celiotomy Exclude the Possibility of Significant Diaphragmatic Injury? A Case Report and Review of the Literature.

INTRODUCTION: Diaphragmatic rupture (DR) is an uncommon, potentially serious complication following blunt or penetrating abdominal trauma. Even with a high index of suspicion, the diagnosis of DR can easily be missed for a long period post injury. Delayed or missed diagnosis [delayed diagnosis of diaphragmatic rupture (DDDR)] and delayed diaphragmatic rupture (DDR) are possible explanations in cases where the initial operative exploration fails to show the diaphragmatic damage.

CASE PRESENTATION: Here we present a patient with suspected DR that was not seen on initial open abdominal exploration, but was suggested by subsequent serial imaging. This injury was ultimately identified on laparoscopic exploration. The procedure was converted to open (celiotomy) due to poor tolerance of the pneumoperitoneum required for laparoscopy, and the laceration was primarily repaired. We propose that DDR and DDDR be considered as a differential diagnosis in patients with a previous thoraco-abdominal trauma when presenting with radiologic/clinical signs suspicious for DR, even when the immediate post traumatic exploration failed to demonstrate a DR.

CONCLUSIONS: A high index of suspicion is essential for early detection of DDR and DDDR. Patients with high impact injuries or surrounding organ damage should be followed with serial clinical examinations, follow-up radiologic assessments, and even re-exploration in situations highly suspicious for diaphragmatic injuries.