Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Background:  
Traumatic diaphragmatic injuries can be 
difficult to diagnose, even with advanced imaging. If 
a hollow viscus herniates through a defect in the 
diaphragm, diagnosis can easily be made with a plain 
chest x-ray. But if the injury consists of only a 
laceration in the diaphragm, it must be diagnosed by 
direct visualization. In this chapter we discuss 
decision making in patients at risk for diaphragmatic 
injury and surgical planning for patients with acute 
or chronic presentation of diaphragmatic hernia.  
Blunt diaphragmatic injury is caused by a 
sudden increase in intra-abdominal pressure, which 
leads to rupture of the diaphragm. This occurs on the 
left side ⅔ of the time, where the diaphragm is not 
“protected” from pressure by the liver. Blunt 
diaphragmatic injuries are usually large. When 
bowel is herniated through the defect, the diagnosis 
can be made by seeing viscera above the left 
hemidiaphragm on imaging.  
Penetrating diaphragmatic injury is caused by 
a stab or gunshot wound in the “Junctional Region,” 
anywhere between the nipples and the costal margin 
anteriorly, or the tips of the scapula and the costal 
margins posteriorly. Stab or gunshot wounds in this 
region can also injure the heart, great vessels, 
esophagus, lungs, or chest wall vessels. The 
diaphragm defect is smaller than in blunt injury, 
usually the size of the penetrating object. Because of 
this fact, herniation of viscera is often not present on 
presentation, making these injuries difficult to 
diagnose. Keep in mind that a missile entering the 
body outside the Junctional Region can still cross the 
diaphragm if its path is tangential enough.  
 
 
Penetrating injuries inside the “Junctional Region” (Red box) 
can potentially injure the diaphragm.  
 
Anatomy:  
 
The diaphragm is composed of a central 
tendinous portion and a lateral muscular portion. 
Depending on the respiratory cycle, its apex can be 
located as high as the T4 dermatome, which 
corresponds with the nipples anteriorly and the tip of 
the scapulae posteriorly. Innervation is by the right 
and left phrenic nerves, which begin at the C3, 4, and 
5 nerve roots, run anterior to the scalene muscles in 
the neck and on the lateral surface of the pericardium 
in the chest, and insert into the central portion of the 
diaphragm. Anterior and posterior branches of the 
phrenic nerve then spread through the diaphragm, 
running parallel to the ribs about 5cm from them. The 
edge of the diaphragm is innervated by branches of 
the intercostal nerves. 
Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
 
The diaphragm, seen here from inside the abdominal cavity, 
consists of a central, tendinous portion and a lateral muscular 
portion.  
 
Principles:  
 
Diaphragmatic 
injury 
occurs 
 
in 
approximately 1% of all blunt abdominal trauma. It 
should be suspected in any patient presenting acutely 
after trauma with an indistinct or abnormally shaped 
diaphragm on chest x-ray. In some cases, the 
diagnosis will be quite obvious on x-ray, but in others 
it will be difficult to distinguish from hemothorax 
and/or pulmonary contusion. A CT scan of the chest 
and abdomen will almost always make the diagnosis 
if there is bowel herniated through the defect. If CT 
is not available to you, you must decide based on the 
x-ray, as explained further below. If the acute patient 
has a completely normal diaphragm shadow on x-ray 
after blunt abdominal trauma, diaphragmatic injury 
is very unlikely. This is definitely not the case in 
penetrating injury, as explained further below.  
 
This patient presenting acutely after blunt abdominal trauma 
very clearly has a defect in the left hemidiaphragm with 
herniated stomach and transverse colon in the chest. No further 
investigations are needed, they should be taken directly for 
laparotomy.  
 
 
Patients presenting more than 6 weeks after 
blunt abdominal trauma often have intra-thoracic 
adhesions or compression of the lung that make 
repair through an abdominal incision impossible. 
The surgeon must ask thoroughly for a history of 
trauma, which may have been many years 
previously. It might be difficult to distinguish 
between a congenital diaphragmatic hernia. We have 
even 
been 
fooled 
by 
a 
congenital 
cystic 
malformation of the lung on one occasion.  
 
Another 
possible 
late 
presentation 
of 
diaphragmatic 
hernia 
is 
strangulation 
and 
intrathoracic rupture. These patients are often quite 
sick and sometimes need intervention in both the 
chest and the abdomen.  
In the patient with penetrating trauma, the 
likelihood of diaphragmatic injury depends on the 
location of the missile entry. These patients often 
have an associated injury, such as  hemothorax, 
splenic laceration, or hollow viscus injury. In 
patients who need laparotomy after penetrating 
trauma, be sure to examine the diaphragm 
thoroughly while considering the trajectory of the 
missile. As always, before surgery you must perform 
a thorough examination of the completely disrobed 
patient, no matter how unstable they are. If possible,  
x-rays with markers at all entry or exit points also 
help you sort out where to look for damage. Decision 
Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
making in such patients is explained further in 
“Approach to Penetrating Abdominal Trauma.”  
The difficulty arises when the patient has a 
stab wound in the lower chest or upper abdomen, but 
is otherwise able to undergo non-operative 
management. Even a well performed CT scan with 
IV 
contrast 
is 
unreliable 
for 
detecting 
a 
diaphragmatic defect in such cases, as it may be only 
a few cm long. In such cases we prefer diagnostic 
laparoscopy. Especially with the patient’s upper 
body tilted upwards, it is possible to examine all of 
the left and right diaphragm, inspect for other 
injuries, and even to repair a small laceration.  
 
Decision Making: 
 
In all instances, the diaphragm is repaired 
using interrupted slowly absorbable or non-
absorbable 
sutures 
in 
horizontal 
mattress 
configuration. Avoid taking large bites, as these may 
put tension on the diaphragm or possibly encircle a 
branch of the phrenic nerve.  
 
Properly placed diaphragm sutures, seen through a left 
posterolateral thoracotomy. One trick for suturing in a tight 
space is to not cut the previously placed suture and use it for 
traction while placing the next one.  
 
Blunt Trauma, Acute Presentation 
 
If the diagnosis is clear, proceed to 
laparotomy. Make the incision long enough to 
inspect all of the abdomen, as always in abdominal 
trauma. Adequate retraction and an incision that goes 
to one side of the xiphoid are very helpful for 
operations on the upper abdominal cavity (See 
“Midline Abdominal Incision.”) A self-retaining 
retractor makes this operation much easier, if the 
defect is large. Irrigate the hemithorax through the 
diaphragm defect before you close, and leave a small 
chest tube in the affected hemithorax to evacuate any 
air and blood.  
 
If the diagnosis is unclear, and you do not 
have a CT scan, pass a NG tube. If the tip is above 
the diaphragm, the diagnosis is made. If you are still 
unclear on what is happening in the chest, place a 
chest tube, to rule out a hemothorax. If the diaphragm 
is still not distinct, the most likely diagnosis is acute 
diaphragmatic hernia and you should operate. Make 
the incision big enough to inspect all of the intestines. 
If you can do laparoscopy, and the patient’s abdomen 
is completely nontender, this may save them an 
unnecessary laparotomy. But if you do not, the 
morbidity of missing this injury is great enough that 
you should not hesitate to do a laparotomy if you 
suspect it.  
 
Blunt Trauma, Late Presentation 
 
There is some controversy as to the best 
approach here. Many textbooks favor approaching 
all such diaphragmatic hernias through the chest. 
This is reasonable if facilities and expertise are 
available.  We offer the following principles:  
● Most late-presenting hernias, especially those 
containing bowel that fills the entire 
hemithorax, should be approached through 
the chest by a posterolateral thoracotomy 
(See “Posterolateral Thoracotomy.”) This 
allows the surgeon to perform decortication 
or otherwise free an entrapped lung, if 
necessary.
 
X-ray of a delayed presentation of left-sided diaphragmatic 
rupture with small intestine clearly visible in all of the left chest. 
This injury is best treated by a thoracic approach. Case 
courtesy of Dr Lemuel Marquez Narcise, From the case 
https://radiopaedia.org/cases/46844?lang=us  
 
Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Stomach and small intestine in the left hemithorax with 
compression of the lung (Red arrow) in this delayed 
presentation of traumatic diaphragmatic hernia.  
 
 
Herniated small and large bowel filling the left chest seen 
through a posterolateral thoracotomy. 
 
 
After return of the viscera through the defect, it can easily be 
closed through the thoracic incision.  
 
● Small hernias containing only part of the 
stomach or colon can be approached through 
the abdomen. Most often, even a late-
presenting hernia can be completely reduced 
by this approach.  
● If you attempt to reduce a late-presenting 
hernia through an abdominal approach and 
are unable, it is acceptable to convert to a 
thoracoabdominal incision. 
 
 
Laparotomy converted to a thoracoabdominal incision after the 
surgeon is unable to fully reduce the bowel from the chest 
during abdominal approach for chronic hernia.  
 
● Diaphragmatic hernia with strangulation and 
intrathoracic perforation of the viscera is a 
difficult situation. These patients need an 
intra-abdominal 
approach 
for 
bowel 
resection 
and 
anastomosis 
or 
ostomy 
creation, but they may also need a thoracic 
approach for adhesions or lung decortication. 
Place the patient in 30 degrees lateral 
decubitus and prepare and drape the chest so 
you can enter it if necessary. After reducing 
the bowel, irrigate the chest cavity well 
through the diaphragm laceration and leave a 
chest tube. If you are unable to reduce the 
bowel because of adhesions, or if the lung 
fails to expand, make a thoracoabdominal 
incision as shown in the figure above.  
 
Penetrating Trauma In The Junctional Region 
 
Patients should be managed according to the 
principles in “Approach to Penetrating Abdomial 
Trauma.” 
Briefly, 
patients 
with 
peritonitis, 
evisceration, or hemodynamic instability should be 
operated without delay. Be sure to carefully inspect 
the diaphragm on both the left and right sides. Those 
Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
who do not need urgent surgery may be managed 
non-operatively by one of the techniques described 
in the chapter. But there is a potential for missed 
diaphragm injury if the stab wound is between the 
costal margin and the nipples anteriorly, or between 
the costal margin and the tips of the scapulae 
posteriorly.  
 
In such patients, we favor diagnostic 
laparoscopy when this is available. You may place 
the patient in lithotomy position (see “Lithotomy 
Position”) and stand between the patient’s legs for 
the best access to the diaphragm area. Perform a 
thorough inspection of the stomach, small bowel and 
colon adjacent to the stab wound. If there is any 
injury to these structures, convert to an open 
operation unless you are an expert laparoscopist. If 
there is an injury to the liver or spleen and it is not 
bleeding, you may safely leave it alone. If it is 
bleeding, convert to open to deal with it (see the 
Chapters on Liver and Spleen injury.) If there is a 
small diaphragmatic defect and no other injury, this 
is a relatively simple operation so try to advance your 
laparoscopic skills a bit: place some non-absorbable 
or slowly absorbable sutures in an interrupted 
horizontal mattress configuration. Place a small chest 
tube which you can remove in a day or two.  
In the more likely case where you do not have 
laparoscopy available, you face a difficult situation. 
A hole in the diaphragm may not have abdominal 
contents herniated through it at the time, but it almost 
certainly will if you do not repair it. As always, you 
must rely on your own clinical reasoning to detect 
such an injury.  
Elements of the history that you should 
emphasize include pulmonary symptoms, including 
any dyspnea or cough. The patient’s recollection of 
the event may provide important clues: how long was 
the knife? Were they stabbed in an upward or 
downward motion?   
Physical examination on its own is unlikely 
to detect a diaphragm injury without visceral 
herniation. However, adjunct investigations can be 
quite helpful. In a patient with an isolated abdominal 
stab wound, there should be absolutely no fluid in the 
chest. If any is seen at chest ultrasound or chest x-
ray, diaphragm injury is very likely- a laparotomy 
and careful inspection of the diaphragm is justified.   
As we discuss in the chapter on penetrating 
abdominal injuries, our goal is to perform 
laparotomy on patients who need it, and to avoid it 
on those who do not. In a patient with penetrating 
trauma who does not otherwise need laparotomy, a 
clinical scenario which puts them at risk for 
diaphragm injury is usually enough reason to explore 
the abdomen.  
 
Avoiding Missed Injuries 
 
Blunt diaphragm injury is one reason why all 
blunt trauma patients should undergo a chest x-ray. 
At times it can be difficult to distinguish between 
hemo-pneumothorax and herniated viscera above the 
diaphragm. If you see an air collection that is circular 
or spherical, especially on the left side, consider 
diaphragm injury. As described above, a nasogastric 
tube whose tip is above the diaphragm makes the 
diagnosis (though absence of this sign does not rule 
it out.) 
One final point is worth mentioning: you 
should get in the habit of exploring the diaphragm 
very thoroughly in every laparotomy you perform. 
On the right side, look carefully next to the liver and 
especially posterolaterally, an area that can be 
difficult to see. On the left side, make sure you see 
posteriorly all the way to the retroperitoneum and 
Gerota’s fascia, the fatty covering of the left kidney. 
To inspect this area properly, you must have good 
lighting, good exposure with a strong assistant, and 
an incision that extends up to one side of the xiphoid. 
If there are adhesions in this area, you must take them 
down until you have seen all the diaphragm’s 
surface.  
 
Conclusion: 
 
Diaphragm injuries are much more easily 
treated in the acute phase rather than late. Patients 
whose diaphragm ruptures because of blunt trauma 
will usually have bowel contents in the chest; this is 
easily diagnosed by plain chest x-ray. Conversely, 
patients with penetrating trauma may have injuries to 
the diaphragm without herniation, though viscera 
will almost certainly herniate through the defect in 
the future. The clinician must recognize patients 
whose injury pattern places them at risk for this 
complication and take measures to make the 
Approach to Diaphragmatic Injuries 
Richard Davis, Mehret Dessalegn, Abebe Bekele 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
diagnosis. At times, the only way to make the 
diagnosis will be surgical exploration.  
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
Mehret Enaro Dessalegn MBBS 
AIC Kijabe Hospital 
Kenya 
 
Abebe Bekele MBBS FCS(ECSA) 
University of Global Health Equity, Rwanda 
Addis Ababa University, Ethiopia 
 
