[Considerations on 45 cases of injuries of the diaphragm].

The authors make an analysis of 45 cases of diaphragmatic trauma, of which 27 were wounds and 18 were ruptures. The wounds of the diaphragm, in most cases determined by bullets, were of small dimensions, but were accompanied by serious lesions of the organs in the vicinity, while ruptures of the diaphragm, determined by closed traumas, were extensive, but with less important lesions of the viscera. Rapid transportation, and efficient intensive care have permitted the performance of emergency interventions in all the patients with wounds, except 3 who died in the emergency room. In 37% of the cases there was involvement of the liver, while the spleen was involved in 33% of the patients. Wounds following gunshot with explosion of the liver and involvement of the supra-hepatic veins could not be recovered. The continuity solution of the diaphragm determined penetration of the abdominal organs and of their contents into the thorax, and this was followed by respiratory and circulatory failure. The diagnosis of diaphragmatic rupture was established in some cases at some distance from the traumatic point. In all the patients with wounds it was necessary to perform emergency surgery. The approach was selected in relation to the localization of the entrance and of the emergence points of the wound. In cases with thoraco-abdominal wounds on the left side the abdominal approach was the most frequent choice, while in patients with wounds on the right side the preferred approach was thoracic in the high-placed wounds, and abdominal, or thoraco-abdominal in the low-placed ones. In the case of ruptures the approach was determined by the localization of the impact zone, and by the viscera supposedly involved. In most of the patients the clinical picture was dominated by the associated lesions, especially by the cranio-cerebral ones. For this reason some of these patients were operated in a later stage, with diaphragmatic hernia. The overall mortality rate in the operated patients was 15.8%.