The diaphragm is a muscle layer and a tendon that separates the chest and abdominal cavity and is essential in respiratory function. Ruptures can be asymptomatic or cause complications such as respiratory distress, perforation, and strangulation, leading to sepsis and multi-organ failure (6).
Although it is a rare condition, traumatic diaphragmatic injuries are classified into blunt or penetrating diaphragmatic injuries based on the mechanism of injury. Blunt trauma was common in industrialized countries, whereas penetrating stab wounds and physical assault were the most common injury mechanisms in underdeveloped nations, as reported in most of the series from African countries (7).
The prevalence of TDI was 7.2%, with penetrating injuries accounting for two-thirds of the patients, whereas blunt trauma for the remaining one-third. Among all patients undergoing emergency laparotomy for trauma-related scenarios, around 5% have a diaphragmatic injury, which nearly correspondences to our reported rate (8,9). Lower incidence rates of 1.3% and 4.2% of TDI in patients who sustained thoracoabdominal trauma were reported by Okonta KE et al. and Tokgöz et al., respectively, which is in contrast to our study findings (6,10). Traoré A et al. from Mali reported a similar incidence to our study, who reported an increasing frequency in TDIs patients from 1999–2015 from a range of 3.7–5.5% (11).
Our study's mean patient age was 36 ± 8.5 years, with ruptures primarily affecting the left diaphragm. The most common and frequently related cause was penetrating trauma, especially a gunshot. More than eighty percent of the cases were male, and over two-thirds had gunshot injuries. The probable reason is that males participate in wars and are more vulnerable to explosion injuries. Several studies have documented a greater incidence of TDR in men in the fourth decade of life. Serhat et al. reported a mean age of 37.6 years, and 75% of the patients were males (12).
As observed in our study, a similar predominance of left diaphragmatic injuries was reported in the previous studies in the literature (13,14). Our study noticed a higher rate of right-site involvement of TDI of about 32.5% compared to the rates reported in the literature due to gunshot and explosive injuries. Right hemidiaphragm trauma is rarer than left, mainly after severe blunt or penetrating traumas (right to a left ratio of 1:3), and is diagnosed later (15). The liver reduces herniation because of occupying the right side. Half of the cases have been detected lately, which may lead to progressive herniation of intraabdominal contents into the thorax (16). A traumatic diaphragmatic hernia occurs 75% on the left and 25% on the right. Due to enhanced imaging techniques, the right-sided incidence has grown, but it is underreported (17).
Because TDI is so uncommon, no specific symptoms may be used to diagnose it before surgery, especially in unstable patients (18). Hemopneumothorax and anatomical diaphragmatic boundary disruption can lead to a suspicion of the diagnosis before surgery (19). Over 90% of patients were not diagnosed pre-operatively and detected during explorative laparotomy.
DTI diagnostic methods include chest x-ray, fast ultrasound, CT-scan, MRI, and video-assisted thoracoscopy; these modalities depend on the patient's stability and availability. No standardized test exists for identifying diaphragmatic injuries (20). Simple chest X-rays are the most commonly used differential diagnostic method. However, they have low sensitivity and specificity (21). On the contrary, high-resolution, multi-slice CT of the chest and the abdomen has recently demonstrated increased accuracy in diagnosing TDI, with sensitivity ranging from 33–83% and specificity ranging from 76–100%. (22). Approximately 7–66% are not recognized during admission (2). Of 17.5% of the patients in our study had a delayed presentation with herniation.
There are different surgical modalities for the management of TDIs. Laparotomy, thoracoabdominal approach, minimally invasive laparoscopy, and thoracoscopy are various approaches, depending on the nature and location of the injury, the patient's stability, and the surgeon's experience (23). Because of the high frequency of concomitant abdominal injuries and the ability to fully explore the abdominal cavity, laparotomy is the primary emergency method. Thoracotomy is indicated in individuals with concomitant thoracoabdominal injuries and right diaphragmatic damage (24). The minimally invasive approach is intended for hemodynamically stable individuals with isolated diaphragmatic damage (25). According to the management approach in our study, 75% of the patients were managed through laparotomy due to instability and hypovolemic shock caused by visceral perforation, 17.5% through the thoracoabdominal approach, and 7.5% were managed by thoracotomy.
Multiple factors contribute to increased mortality in patients with TDI. Solid organ and multi-traumatic injuries remain the primary cause of death in these patients (26). Solid organ injury, hemorrhagic shock, young age, blood transfusion, and physical trauma increase morbidity and mortality (27). The mortality rate in our study was high at about 22.5%, and all aforementioned factors were present as most of these cases were due to gunshots and explosion injuries. Several studies reported a 3–36% mortality rate associated with TDIs (24,28). A lower mortality rate of 16% was reported by Abdelshafy M and colleagues in 50 TDI patients (29).
The limitations of our study include that it used a retrospective design that missed some variables influencing the prognosis, including transportation time and blood transfusion status. Second, the study was single-center-based. This is the first and only study from Somalia investigating traumatic diaphragmatic injuries.