Evaluation of Thoracoscopy with Single-Lumen Endotracheal Tube Intubation and Laparoscopy in the Diagnosis of Occult Diaphragmatic Injuries in Penetrating Thoracoabdominal Trauma

Abstract

Background:

The diagnosis of traumatic diaphragmatic injuries (TDIs) after penetrating thoracoabdominal trauma is challenging and conventional imaging is unreliable. Laparoscopy and thoracoscopy are minimally invasive modalities of choice in the diagnosis and management of TDI. A little is known on the value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) in the diagnosis of occult diaphragmatic injuries, and how it compares with laparoscopy.

Methods:

A prospective study evaluated thoracoscopy with SLETI as a diagnostic tool for occult TDI. Thoracoscopy was followed by diagnostic laparoscopy to confirm the findings and manage diaphragmatic and intra-abdominal injuries.

Results:

Thirty-one patients underwent thoracoscopy followed by laparoscopy. Majority were men (n = 27, 87%). The median age was 30 years. Twenty-six patients had stab wounds (83.8%), and 5 had gunshot wounds (16.1%). The incidence of diaphragmatic injury was 42% (n = 13). Thoracoscopy with SLETI correctly identified 12 (92%) patients with diaphragmatic injury, but 1 patient had dense pleural adhesions. Diagnostic laparoscopy identified all injuries.

Conclusion:

Thoracoscopy with SLETI and laparoscopy are feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.

Introduction

The overall incidence of traumatic diaphragmatic injury (TDI) is reported between 0.46% and 8%, with a penetrating versus blunt trauma ratio of 2:1.^1,2 Of all penetrating wounds, the incidence of TDI is 10%–15%.² Diaphragm injury is found in 32%–38% of stable patients with penetrating injury in the thoracoabdominal area but without any other indication for surgical exploration.^3–5

A plain chest radiograph is diagnostic or strongly suggestive of a large diaphragmatic defect in 66.6% in the first 12 hours.⁶ However, a plain chest radiograph will be unremarkable in cases of small diaphragmatic defect. Nonspecific signs of the diaphragmatic injury on the computed tomography (CT) scan are difficult to recognize, and may lead to misdiagnosis.⁷ Detecting occult TDI poses a significant diagnostic challenge and missed diaphragmatic injury inevitably will result in chronic diaphragmatic hernia due to pressure differences across the diaphragm.

Among minimally invasive techniques, thoracoscopy is proven to be an accurate diagnostic modality. However, double-lumen endotracheal intubation, inability to access intra-abdominal injuries, and contralateral diaphragm remain the main limitations of the technique.³ More recently, diagnostic laparoscopy had become frequently used modality to evaluate the diaphragm in asymptomatic patients with penetrating thoracoabdominal trauma.^4,8

The diagnostic accuracy of laparoscopy in detecting TDI has not been compared with thoracoscopy. Moreover, the diagnostic value of thoracoscopy with single-lumen endotracheal tube intubation (SLETI) has not been studied.

The purpose of this study was to prospectively assess the feasibility and value of thoracoscopy with SLETI in detecting occult TDI in stable asymptomatic patients with penetrating thoracoabdominal trauma and compare it with laparoscopy.

Methods

This was a prospective interventional study evaluating the value of thoracoscopy with SLETI in diagnosing TDI after penetrating thoracoabdominal trauma for a period from September 2015 till September 2016 at a single center (Dr. George Mukhari Academic Hospital).

All patients >18 years of age who sustained penetrating thoracoabdominal injuries, who were hemodynamically stable, and did not have signs of peritonitis were included in the study. Exclusion criteria: unstable patients, patients with signs of peritonitis, and patients <18 years of age.

The thoracoabdominal area was defined as the area above the lower costal and below the nipple line (anteriorly the fourth intercostal space) circumferentially on each side of the midline. The thoracoabdominal area was subdivided by the anterior and posterior axillary lines into anterior, lateral, and posterior areas.

Each patient underwent two procedures: first, thoracoscopy with SLETI on the side of suspected injury for evaluation of the diaphragm, and second, diagnostic laparoscopy.

Patients were operated on in supine position under general anesthesia with SLETI. The rank of anesthetist performing the procedure was not documented; however, the majority would have been performed by trainees based on institutional practice.

Data were prospectively collected on pro forma forms and included the patient demographics, the body mass index (BMI), mechanism of injury, and site of injury. Procedural information included telescope port position, time to evaluate diaphragm, associated injuries, and the presence of diaphragmatic injury on thoracoscopy and laparoscopy. Demographic and clinical details were summarized descriptively. Continuous data were summarized by mean, standard deviation, median, interquartile range, minimum, and maximum values. Categorical data were summarized by frequency counts and a percentage calculation. Paired samples t-test and chi-square tests were performed to test the difference between laparoscopy and thoracoscopy. A significance level P < .05 was used.

All statistical procedures were performed on IBM SPSS statistics 23 running under Microsoft Windows on a personal computer. Ethical approval was obtained from the Sefako Makgatho Health Sciences University Research Ethics Committee (SMUREC).

Results

Thirty-one patients met the inclusion criteria. There were 27 men (87%) and 4 women (13%). The age range was from 19 to 56 years, and the mean age was 30 years. The mean BMI was 23 (18–35), 7 patients were overweight with BMI >26, and 1 patient had BMI <18.

Twenty-six (84%) sustained stab wounds, and 5 patients (16%) sustained gunshot wounds. Eighteen patients (58%) had left-sided injury, and 13 patients had right-sided injury (42%). The diaphragmatic injury was present in 13 (42%) patients. The most common location of injury (51%) was the posterior thoracoabdominal area (Table 1). The sixth intercostal space was the most commonly injured area (32%).

Table 1.

Characteristics of Patients with Thoracoabdominal Injuries

	Diaphragmatic injury
Characteristics	Present	Absent	Total	P
Patients	13 (42%)	18 (58%)	31
Men	11 (85%)	16 (89%)	27 (87%)	.56
Women	2 (15%)	2 (11%)	4 (13%)	.56
Age (mean/median, range)	29/29 (20–36)	31/30 (19–56)	30/29 (19–56)	.52
BMI	23/22 (18–30)	24/24 (19–35)	23/23 (18–35)	.29
Mechanism
GSW	4 (31%)	1 (6%)	5 (16%)	.08
Stab	9 (69%)	17 (94%)	26 (84%)	.08
Location
Right	9 (69%)	4 (78%)	13 (42%)	.01
Left	4 (31%)	14 (22%)	18 (58%)	.01
Anterior	3 (23%)	4 (22%)	7 (23%)	.93
Lateral	4 (31%)	3 (17%)	7 (23%)	.93
Posterior	6 (46%)	10 (56%)	16 (51%)	.93
Anterior and posterior	0	1 (6%)	1 (3%)	.93

BMI, body mass index; GSW, gunshot wound.

All procedures were performed under general anesthesia with SLETI. Patients were in supine position with the operating table tilted to the right. Each patient first underwent thoracoscopy followed by diagnostic laparoscopy and repair of the diaphragm if necessary.

The decision to use the intercostal drain (ICD) site or the site of penetrating trauma for the telescope port was left for the operating surgeon. In 26 cases (84%) the ICD site was used, and in 4 patients (13%) the injury site was used. Two to three ports were used for thoracoscopy.

Carbon dioxide (CO₂) was insufflated into the chest to create working space in the absence of single-lung ventilation. The pressure of 9–15 mmHg was used. All patients maintained hemodynamic stability and adequate oxygen saturation throughout the procedure regardless of intrathoracic CO₂ pressure.

The diaphragm was adequately visualized in 30 cases. Only in one case the adequate inspection of the diaphragm was not possible due to dense adhesions after previous pulmonary tuberculosis (TB). The time to visualize the diaphragm ranged from 1 to 45 minutes (Table 2). The longer time was related to adhesions and clotted hemothorax.

Table 2.

Thoracoscopy and Laparoscopy Findings

	Diaphragmatic injury
Characteristics	Present	Absent	Total	P
Total	13 (42%)	18 (58%)	31
Thoracoscopy	12 (92%)	18	30	.42
Laparoscopy	13 (100%)	18	31	.42
Time to visualize the diaphragm at thoracoscopy	20/15 (1–40)	23/20 (10–45)	22/20 (1–45)	.33

Thoracoscopy identified injuries in 12 (92%) cases and excluded an injury in 18 (100%) cases. In one case thoracoscopy was not possible due to adhesions from previous TB. Diagnostic laparoscopy findings correlated with thoracoscopic findings identifying 12 injuries and excluding 19 (including the case in which thoracoscopy was not possible). Seventeen patients had clotted hemothorax; however, the amount of blood was not specified.

Three (23%) patients had associated intra-abdominal injuries (liver laceration, splenic laceration, and gastric injury) diagnosed during laparoscopy. The gastric injury was repaired, whereas the liver and splenic injury did not require any therapeutic procedures.

Discussion

Diaphragmatic injuries are present in 40% of penetrating thoracoabdominal injuries.⁹ Entirely asymptomatic patients may harbor TDI in up to 38%.⁵ These patients may present later on with obstructive symptoms due to incarcerated organs in the diaphragmatic defect or eventual strangulation, and the clinical presentation may be delayed from 1 day to 50 years after trauma.¹⁰

Traumatic diaphragmatic hernias are easily missed on CT scan due to nonspecific signs suggesting the injury resembling normal variations. Radiological signs implying TDI on CT are as follows: 1.

direct monitoring of the diaphragmatic defect (36%–82.7% sensitive and 88.1%–95% specific),

intrathoracic herniation of organs (Although the specificity is as high as 94.1%–100%, the sensitivity varies widely from 8% to 81%),

collar sign (sensitivity range of 24%–85%, a specificity rate of 80.7%–100%),

dependent viscera sign (specificity of 71%–96.5% and low sensitivity of 46.6%–52%),

diaphragm thickening,

contrast extravasation around the diaphragm,

band sign and hump sign, and

trace of penetrating injury.

The sensitivity of CT may increase with the presence of more than one sign in the same patient.⁷

The diagnostic peritoneal lavage is found to be not reliable in asymptomatic patients with TDI.¹¹

Thoracoscopy has become a very reliable and accurate minimally invasive technique in stable patients to detect diaphragmatic injury.³ Utilizing either the injury or ICD site as a port site minimizes surgical trauma to a patient. The visualization of the diaphragm by thoracoscopy is reported to be better than laparoscopy.¹¹ We confirm that the inspection of the diaphragm during thoracoscopy is faster and easier. However, in one case it was not possible to visualize the diaphragm because of the obliterated pleural cavity due to previous TB. In that case, the injury to the diaphragm was visualized and repaired during laparoscopy.

Another limitation of thoracoscopy is an inability to rule out intra-abdominal injuries. In this study, 3 (23%) patients had associated intra-abdominal injuries, and one case of gastric injury was repaired.

Ivatury et al. found laparoscopy has an excellent diagnostic accuracy for TDI.¹² The diaphragm repair is reported to be the most common laparoscopic therapeutic intervention.^13–15 The mobilization of the liver, spleen, and splenic flexion of the colon may be required to expose the entire diaphragm. Advancing the 30° telescope through the diaphragmatic defect may allow limited inspection of the pleural cavity.

Insufflation of CO₂ into the pleural cavity through either laparoscopy or thoracoscopy is required to create a working space, and may potentially cause gas embolism or hemodynamic deterioration. However, in this study, we did not observe any complications during the low-pressure CO₂ pneumothorax in patients with SLETI. Koto et al. suggest, after having controlled bleeding, to start abdominal exploration with the diaphragm inspection to avoid respiratory deterioration of a patient.¹⁶ Guth and Pachter used a low-pressure pneumoperitoneum of 8–10 mmHg to visualize the diaphragms and increased to 15 mmHg if the diaphragms were intact.⁹

In this study, SLETI was sufficient enough to perform thoracoscopy and to visualize the entire hemidiaphragm. These findings are in agreement with other studies reporting safety and feasibility of thoracoscopic surgery with SLETI and CO₂ insufflation in nontrauma patients.^17,18

After mobilizing all adhesions and attachments to the diaphragm and meticulous inspection of its entire surface, the missed diaphragmatic injury seems to be unlikely. Visualization of the diaphragm with the telescopes is better when compared with laparotomy. No missed diaphragmatic injuries were reported during laparoscopy or thoracoscopy.^9,19,20 Visualization of the diaphragm at laparotomy appears to be more difficult and missed injury was reported.²¹

Using laparoscopy as a primary technique to evaluate the patient with the penetrating thoracoabdominal injuries may result in missing significant intrathoracic injuries. Guth and Pachter reported 2 of 10 (20%) patients after negative laparoscopy required urgent surgery for ongoing intrathoracic bleeding.⁹ In our study, clotted hemothorax was the most common findings during thoracoscopy.

We would suggest that thoracoscopy with SLETI in supine position may be used in patients with penetrating thoracoabdominal wound with pneumo-/hemothorax and asymptomatic or minimally symptomatic abdomen. If diaphragmatic injury is ruled out, the laparoscopy is not performed. If diaphragmatic injury is identified, the laparoscopy is performed to rule out associated intra-abdominal injuries. The diaphragmatic repair may be performed from either cavity.

In the presence of extensive adhesions, thoracoscopy may be aborted, and laparoscopy should be performed to inspect the diaphragm. Laparoscopy may be the primary procedure in cases of bilateral thoracoabdominal injuries.

In patients with symptomatic abdomen, laparoscopy may be a primary approach with limited inspection of the pleural cavity through the diaphragmatic defect, and if inspection is not satisfactory or further therapeutic procedures required in the pleural cavity, the thoracoscopy is performed.

Some limitations of this study are worth to mention. It was a single-center study with small numbers. Further studies with the larger numbers are required to adequately provide information regarding the proposed approach. The results may be reproducible only in institutions with comparable expertise in laparoscopic surgery.

Conclusion

Thoracoscopy with SLETI and laparoscopy are two feasible, safe, and accurate approaches in detecting TDI in stable patients with penetrating thoracoabdominal injuries. However, dense pleural adhesions may prevent inspection of the diaphragm at thoracoscopy. Laparoscopy allows inspection of both hemidiaphragms and diagnoses associated intra-abdominal injuries. The choice of primary technique will depend on the individual clinical scenario.

Authors' Contributions

M.K. participated in study conception and design (M.K., O.M., L.N.), literature search (O.M.), data collection (L.T.), analysis and interpretation of data (M.K., O.M.), preparation and revision of the article (O.M.), and critical review (M.K., O.M., L.N.).

Footnotes

Disclosure Statement

No competing financial interests exist.

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