Direct and Indirect Diaphragmatic Bullet-Induced Lacerations with a Very Minor Injury to the Lung

Purpose: Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. We reported a bullet that resulted in two separate diaphragmatic lacerations and hernias: One by the penetrating bullet and the second by the associating blunt trauma. Observations: A 23 years old young man who sustained a bullet injury resulting in isolated diaphragmatic lacerations with minor lung impact. The diaphragmatic injuries resulted in omental herniations. Symptoms of diaphragmatic injuries were masked by associated injuries and missed in the Primary Care Unit. After referring the patient to our Unit in Abo-khalifa Hospital for Emergency and Fine Surgeries because of upper abdominal discomfort, computerized tomography showed two diaphragmatic tears and the herniated omentum. A lateral small tear in line with the inlet and exit of the bullet and adjacent to the minor lung lesion can be explained by direct bullet injury. The second larger medial radial diaphragmatic tear can be due to indirect trauma caused by markedly increased intrathoracic pressure with closed epiglottis; this pressure was immediately created on penetration of skin. This increasing pressure is going to be relieved by either bronchial or diaphragmatic rupture. Thoracoscopy confirmed the diagnosis and assisted complete management. Smooth reduction of the hernias, closure of the diaphragmatic defects and application of one clip onto the lung lesion. Conclusions: High suspicion of diaphragmatic injuries helps early diagnosis of these rare traumatic lesions. Computerized tomography of the chest with barium meal has a high sensitivity and specificity for diagnosis of traumatic diaphragmatic hernias. Uniporter thoracoscopy is a good safe diagnostic and therapeutic tool for traumatic diaphragmatic lacerations with hernias.