Clinical-morphological and treatment aspects in traumatic diaphragmatic hernia in children

Abstract

Background. Traumatic diaphragmatic hernia in children is rarely reported, with an incidence ranging from 0.08% to 8%, and the death rate ranges from 16.6% to 33.3%. Diagnostic difficulties are found in 50-70% of cases. Late manifestation of traumatic lesions of the diaphragm is well studied in adults, as opposed to children. In this context we present the following clinical case. Case report. Patient S., 4 years old, was transferred to our institution from a district hospital with suspicion to a paraesophageal hiatal hernia, but a destructive pulmonary process with pulmonary abscess formation was not excluded. The anamnesis allowed to specify that two weeks before hospitalization the child fell, hitting the chair, the accident was overlooked by the mother. The clinical examination revealed the serious general condition, conditioned by the presence of signs of exicosis, stable hemodynamics. Palpator - painful abdomen all over the surface, predominantly in the epigastric region and in the left hypochondriac region. Laboratory examination revealed anemia and neutrophil leukocytosis. The thoracic and abdominal radiography, performed by emergency in the clinic, showed the transdiaphragmatic positioning of the intestinal handles in the left hemithorax, the diaphragmatic hernia having comparatively larger dimensions. The diagnostic of certainty was established with the help of thoracic CT with dynamic contrast in angiographic regime. Surgery was performed, intraoperatively, a defect of the left hemidiaphragm was detected at the level of fusion of the anterior part of the tendon with the muscular part, through which the intrathoracic hernia omentum, the colon and the small intestine handles. After the organs were repositioned, the integrity of the diaphragm was restored with non-absorbable interrupted sutures and consolidation with a biodegradable acellular biological graft fragment by equine pericardium (Bioteck Heart). Conclusions. The results of the histological examination indicate that the mechanism of development of the diaphragmatic defect in children may occur as a result of a contusional tissue injury and the subsequent disjunction of the resident hemidiaphragmatic tissue. Therefore, preoperative diagnosis of HDT in young children is quite difficult, with chest angiographic CT with dynamic contrast being an effective method in establishing the diagnosis with certainty. The primary repair, with the application of non-absorbable sutures and the concomitant use of the acellular pericardial graft for consolidation, represents an effective option in the surgical reconstruction of traumatic diaphragmatic defects.