c l i n i c a l f o l i o s : d i s c u s s i o n

Occult Diaphragmatic Injury



Related narrative: Incidental Diaphragmatic Hernia

Occult diaphragm injuries carry significant sequelae, as the reported mortality rate from delayed presentation is an impressive 36% (1). Since isolated diaphragm injuries are frequently asymptomatic in and of themselves, their detection in the acute setting requires a high index of suspicion. Laparoscopy has been shown to be highly sensitive and specific, but carries the disadvantage of invasiveness (2). Thoracoscopy also allows for visualization of the diaphragm surface, with the added advantage of allowing for evacuation of any retained hemothorax (3). It, too, is highly invasive however, and if positive does not allow for inspection of the peritoneal cavity for any associated injuries. Finally, diagnostic peritoneal lavage is an alternative diagnostic modality, but no consensus exists for what the optimal threshold is for operative exploration or management (4-6). Once detected, the injury should be repaired with a nonabsorbable suture.


1. Madden MR, Paull DE, Finkelstein JL, et al. Occult diaphragmatic injury from stab wounds to the lower chest and abdomen. J Trauma. 1989;29:292-8.

2. Friese RS, Coln E, Gentilello LM. Laparoscopy is sufficient to exclude occult diaphragm injury after penetrating abdominal trauma. J Trauma. 2005;58:789-92.

3. Ochsner MG, Rozycki GS, Lucente F, et al. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma. 1993;34:704-9.

4. Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma? J Trauma. 2007;62:853-7.

5. Gallbraith TA, Oreskovich MR, Heimbach DM, et al. The role of peritoneal lavage in the management of stab wounds to the abdomen. Am J Surg. 1980;140:60-4.

6. Gonzalez RP, Turk B, Falimirski ME, et al. Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge. J Trauma. 2001;51:939-43.

This page was last modified on 5-Jun-2007.