66.5 Rupture of the diaphragm

A patient’s diaphragm more commonly ruptures on the left, so that his viscera herniate into his left chest. This is fortunate, because injuries on the left are more easily repaired. Sometimes his injury is so severe that he can hardly breathe, or it can be so mild that it may not be discovered for several weeks. Exclude rupture of the diaphragm by taking a routine chest X–ray. There are sure to be other injuries also.

RUPTURE OF THE DIAPHRAGM

This is not an easy operation, refer the patient if you can.

If the patient is severely dyspnoeic, try emptying his stomach with a nasogastric tube.

ANAESTHESIA Insert an intercostal drain and anchor it securely to the patient’s chest. Give him a general anaesthetic, intubate him, and if possible give him a long–acting relaxant. Avoid distending his stomach.

LAPAROTOMY Divide the left triangular ligament of the patient’s liver and draw its left lobe downwards and to the right. Pull his abdominal viscera out of his chest.

Retract the torn margins of his diaphragm downwards, and repair it with heavy interrupted non–absorbable sutures. Use the long ends of each stitch for gentle traction, until you insert the next one. The tear usually extends to his oesophageal hiatus. Repair this with special care.

Connect his chest drain to an underwater seal bottle (65.2), and remove it at 48 hours.

Figure 66.10: ANATOMY FOR SPLENECTOMY. When you operate you will find a large friable, bloody mass—it will not look quite like this! A, shows the left recess of the patient’s lesser sac extending to his spleen. B, shows the vessels that you will have to tie his splenic artery and his short gastric arteries. When you tie his splenic artery, don’t put your ligature round the tail of his pancreas. After Maingot and Gray, with kind permission.