Case Report: Diagnostic pitfalls and laparoscopic repair of a delayed large right-sided traumatic diaphragmatic hernia

Abstract

Background Delayed right-sided traumatic diaphragmatic hernia (TDH) may be overlooked during polytrauma assessment because concomitant injuries dominate attention and the liver can obscure diaphragmatic discontinuity. Subsequent respiratory and gastrointestinal symptoms may remain nonspecific until obstruction or visceral compromise develops. Case description A 50-year-old man presented with more than 20 h of nausea and vomiting 19 months after severe blunt trauma. Since the injury, he had experienced intermittent dyspnea, chest tightness, postprandial fullness, abdominal distension, and abdominal pain. His admission oxygen saturation was 94%, with no supplemental oxygen recorded. Examination revealed diminished right-sided breath sounds and bowel sounds in the lower right hemithorax. Computed tomography demonstrated discontinuity of the right hemidiaphragm and herniation of the stomach, liver, gallbladder, and hepatic flexure. Transabdominal laparoscopy confirmed an approximately 8.0 cm×15.0 cm posterolateral defect. After adhesiolysis, all herniated organs were reduced and remained viable. The defect was closed primarily without mesh because the mobilized edges were robust and could be approximated without a residual gap, visible tearing, or excessive tension. Respiratory and gastrointestinal symptoms resolved, and early postoperative imaging confirmed restoration of the abdominal viscera below the diaphragm. Conclusion After high-energy trauma, discordant respiratory and meal-related symptoms plus intrathoracic bowel sounds should prompt targeted multiplanar CT review. In selected stable patients, transabdominal laparoscopy can combine reduction, assessment of visceral viability, and repair. The approach and need for reinforcement should be individualized according to adhesions, tissue quality, and achievable edge approximation.