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hernia Diafragmatica Traumatica

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hernia Diafragmatica Traumatica

  1. 1. HERNIA DIAFRAGMÁTICA TRAUMÁTICA Unidad de Cirugía de Urgencias Laura Sánchez Moreno Isaías Alarcón del Agua 11/4/07
  2. 2. RESEÑA HISTÓRICA <ul><li>Sennertus 1541, primer caso de hernia traumática del diafragma </li></ul><ul><li>Ambrosio Paré 1579 primer caso de hernia traumática del diafragma diagnosticado en autopsia </li></ul><ul><li>Riolfi 1886 primera reparación diafragmática con éxito </li></ul>Schneider CF. Traumatic diaphragmatic hernia. Am J Surg 1956;91:290-4. Hanby WB. The case reports and autopsy records of Ambroise Par& Springfield, IL: Thomas, 1968:50-1.
  3. 3. INCIDENCIA accidentes de tráfico Traumatismo cerrado 1% al 7% Traumatismo penetrante 10% al 15% de las heridas penetrantes torácicas y/o abdominales Reber PU, Schmied B, Seiler CA, Baer HU, Patel AG, Buchler MW. Missed diaphragmatic injuries and their long-term sequelae. J Trauma 1998;44(1):183–8
  4. 4. ANATOMÍA DEL DIAFRAGMA
  5. 5. ANATOMÍA DEL DIAFRAGMA
  6. 6. ETIOPATOGENIA CAUSA DEL TRAUMATISMO TRAUMA CERRADO - Accidentes de tráfico (+frec) - Otras causas: atropellamiento, caídas de altura y las agresiones <ul><li>TRAUMA PENETRANTE </li></ul><ul><li>Heridas por arma de fuego </li></ul><ul><li>Heridas por arma blanca </li></ul>
  7. 7. ETIOPATOGENIA LOCALIZACIÓN DE LA LESIÓN Sitio de lesión en el trauma cerrado AUTORES N° SERIES N° PACIENTES IZQUIERDA DERECHA BILATERAL Lenriot 3 (1994) 14 508 76% 21% 2,4% Mansour 4 (1997) 1 908 68% 24% 1,5% Asensio 2 (2000) 32 1598 75% 23% 2,0% MANSOUR KA. Trauma to the diaphragm. Chest Surg Clin N Am 1997; 7: 373-383
  8. 8. ETIOPATOGENIA <ul><li>Papel protector del hígado </li></ul><ul><li>Puntos débiles en el diafragma izquierdo, correspondientes a los sitios de fusión de los esbozos embriológicos </li></ul><ul><li>Mayor resistencia a la tensión del hemidiafragma derecho </li></ul>FACTORES <ul><li>Subdiagnóstico de las lesiones derechas, mayor mortalidad por el tipo de lesión asociada (fundamentalmente lesiones graves hepáticas y del complejo cava-suprahepática ) </li></ul>
  9. 9. ETIOPATOGENIA LOCALIZACIÓN DE LA LESIÓN <ul><li>Predominio de las </li></ul><ul><li>lesiones del hemidiafragma izquierdo (agresor diestro) </li></ul><ul><li>Puerta de entrada es </li></ul><ul><li>habitualmente anterior </li></ul><ul><li>Ambos hemidiafragmas con igual frecuencia </li></ul><ul><li>Trayecto adoptado por la bala es aleatorio, y pueden </li></ul><ul><li>existir lesiones diafragmáticas con orificios de entrada en la pelvis o en sectores altos del </li></ul><ul><li>tórax. </li></ul>HERIDA POR ARMA BLANCA HERIDA POR ARMA DE FUEGO
  10. 10. Clasificación Morfológica de la Asociación Americana de Cirujanos de Trauma (AAST) MOORE EE, MALANGONI MA, COGBILL TH, SHACKFORD SR, CHAMPION HR, JURKOVICH GJ, et al. Organ injury scaling IV: Thoracic vascular, lung, cardiac, and diaphragm. J Trauma 1994; 36: 299-300 Laceración con pérdida tisular > 25 cm 2 V Laceración >10 cm con pérdida tisular <=25 cm 2 IV Laceración 2-10 cm III Laceración <= 2 cm II Contusión I TIPO DE LESIÓN GRADO
  11. 11. FISIOPATOLOGÍA -P +P CARTER JW. Diaphragmatic trauma in southern Saskatchewan. An 11- year review. J Trauma 1987; 27: 987-993
  12. 12. CONTENIDO HERNIARIO MULTIVISCERALES UNIVISCERALES
  13. 13. LESIONES ASOCIADAS Traumatic rupture of the diaphragm: experience with 65 patients P. Mihos et al. / Injury, Int. J. Care Injured 34 (2003) 169–172 4 9 3 16 1 15 20 3 26 24 14 3 7 2 1 Traumatismo craneal Laceración pulmonar Neumotorax Hemotorax Laceración pericardica Fractura costal Fractura extremidad Laceración vena cava inf Laceracion esplenica Laceración hepática Laceración intestinal Ruptura renal Ruptura gastrica Ruptura vesical Avulsión ovárica
  14. 14. LESIONES ASOCIADAS Boulanger BR, Milzman DP. A comparison of right and left blunt traumatic diaphragmatic injuries .J Trauma l993;35:255-60. LESIONES ASOCIADAS INTRABADOMINALES Ruptura hemidiafragma DERECHO Ruptura hemidiafragma IZQUIERDO 100% 76%
  15. 15. CLINICA HENRY I. BOWDITCH ON DIAPHRAGMATIC HERNIA (1853).Am J Cardiol. 1963 Aug;12:244-8 <ul><li>CRITERIOS ESTABLECIDOS POR BOWDITCH, EN 1853 </li></ul><ul><li>Prominencia con inmovilidad del hemitórax izquierdo. </li></ul><ul><li>Desplazamiento del área cardíaca a derecha. </li></ul><ul><li>Ausencia de murmullo alveolovesicular en el hemitórax izquierdo. </li></ul><ul><li>Presencia de ruidos hidroaereos en hemitórax izquierdo. </li></ul><ul><li>Timpanismo a la percusión de hemitórax izquierdo. </li></ul>
  16. 16. CLINICA <ul><li>INCIDENCIA DE SHOCK E INSUFICIENCIA RESPIRATORIA AGUDA </li></ul><ul><li>AUTORES SHOCK % IRA % </li></ul><ul><li>Rodriguez-Morales (1986) 66 52 </li></ul><ul><li>Carter (1987) 36 </li></ul><ul><li>Beal (1988) 54 81 </li></ul><ul><li>Van Vugt (1989) 60 53 </li></ul><ul><li>Lenriot (1994) 47 29 </li></ul>
  17. 17. CLINICA HENRY I. BOWDITCH ON DIAPHRAGMATIC HERNIA (1853).Am J Cardiol. 1963 Aug;12:244-8 <ul><li>CRITERIOS ESTABLECIDOS POR BOWDITCH, EN 1853 </li></ul><ul><li>Prominencia con inmovilidad del hemitórax izquierdo. </li></ul><ul><li>Desplazamiento del área cardíaca a derecha. </li></ul><ul><li>Ausencia de murmullo alveolovesicular en el hemitórax izquierdo. </li></ul><ul><li>Presencia de ruidos hidroaereos en hemitórax izquierdo. </li></ul><ul><li>Timpanismo a la percusión de hemitórax izquierdo. </li></ul>
  18. 18. CLÍNICA <ul><li>SÍNTOMAS (n=38) Nº % </li></ul><ul><li>Menores </li></ul><ul><li>(dolor, disnea, tos ...) 24 63,15 </li></ul><ul><li>Mayores </li></ul><ul><li>Shock TA < 80 ingreso 21 55,26 </li></ul><ul><li>Abdomen agudo 4 10,52 </li></ul><ul><li>Anemia grave, Hto < 35 Hb <10 11 28,94 </li></ul><ul><li>Hipoxia PO2 < 60 5 13,15 </li></ul>Traumatismos diafragmáticos. J.M. Couselo, M.M. Moreda, emergencias 2003;15:207-210
  19. 19. DIAGNOSTICO The diagnosis of ruptured diaphragm is frequently missed in the acute phase because of the presence of shock, respiratory insufficiency, visceral injuries, and coma. McCune RP, Roda CP, Eckert C. Rupture of the diaphragm caused by blunt trauma. J Trauma 1976;16:531-7.
  20. 20. DIAGNOSTICO <ul><li>ESTUDIOS NO-INVASIVOS </li></ul><ul><li>- Radiografía de tórax </li></ul><ul><li>- Estudios contrastados - Ecografía. </li></ul><ul><li>- Tomografía. </li></ul><ul><li>- Resonancia magnética. </li></ul><ul><li>ESTUDIOS INVASIVOS </li></ul><ul><li>- Inducción de neumoperitoneo. </li></ul><ul><li>- Lavado peritoneal diagnóstico. </li></ul><ul><li>- Inyección intraperitoneal de radioisótopos. </li></ul><ul><li>- Estudios minimamente invasivos (Laparoscopía y toracoscopía) </li></ul>
  21. 21. DIAGNOSTICO <ul><li>Morgan 42% 53% 5% </li></ul><ul><li>Ilgenfritz 50% 50% .,. </li></ul><ul><li>Beaucharnp 62.5% 20.8% 16.6% </li></ul><ul><li>Smithers 62.3% 29.4% 8% </li></ul><ul><li>Troop 35.7% 57% 7.1% </li></ul><ul><li>De la Rocha 41.6% 16.6% 33.3% </li></ul><ul><li>Van Vugt 50% 39.2% 10.7% </li></ul><ul><li>Ward 25% 68.7% 6.2% </li></ul><ul><li>Christophi 61.9% 28.5% 9.5% </li></ul><ul><li>Rodriguez 40% 56.6% 3.3% </li></ul>PREOPERATORIO INTRAOPERATORIO RETADADO
  22. 22. DIAGNOSTICO <ul><li>RX TORAX </li></ul><ul><li>PATOGNOMONICOS </li></ul><ul><li>SNG en torax </li></ul><ul><li>Estudio con gastrografin positivo </li></ul><ul><li>SUGESTIVOS </li></ul><ul><li>Visualización de burbujas gaseosas con nivel en un hemitórax, </li></ul><ul><li>Borramiento del contorno del diafragma. </li></ul><ul><li>Elevación de un hemidiafragma. </li></ul><ul><li>Irregularidad en el contorno del diafragma. </li></ul><ul><li>Desplazamiento del mediastino hacia el lado contralateral. </li></ul>Van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to blunt trauma: a retrospective analysis. J Trauma 1989;29: 683- 6 50% normal
  23. 23. DIAGNOSTICO <ul><li>RX TORAX </li></ul>ESTOMAGO COLON
  24. 24. DIAGNOSTICO <ul><li>RX TORAX </li></ul>Shanmuganathan K, Mirvis SE. Imaging diagnosis of nonaortic thoracic injury. Radiol Clin NorthAm 1999; 37:533–551 . SNG <ul><li>Diagnostica en el 27-60% </li></ul><ul><li>de la rupturas izquierdas </li></ul><ul><li>Sólo en el 17% de las derechas </li></ul>
  25. 25. DIAGNOSTICO <ul><li>TAC </li></ul><ul><li>baja sensibilidad 11% a 40%, en el diagnóstico de heridas traumáticas de diafragma </li></ul><ul><li>Fundamentalmente cuando son lesiones pequeñas y sin hernia. </li></ul><ul><li>Hemotórax dificulta su diagnostico. </li></ul>ASENCIO JA, DEMETRIADES D, RODRIGUEZ A. Injury to the diaphragm, en MOORE EE, MATTOX KL, FELICIANO DV (eds): Trauma, ed 4. McGraw-Hill, New York 2000, pp 603-632
  26. 26. DIAGNOSTICO <ul><li>TAC </li></ul>
  27. 27. DIAGNOSTICO <ul><li>TAC </li></ul>
  28. 28. DIAGNOSTICO <ul><li>RMN </li></ul><ul><li>Boulanger reporta 5 casos, pero este estudio al igual que la Tomografía, tiene </li></ul><ul><li>escasa sensibilidad cuando se trata de lesiones sin hernia, o son hernias pequeñas. </li></ul><ul><li>Uso limitado cuando el TAC es incierto, o cuando se presentan signos tardios de alteraciones diafragmaticas. </li></ul>BOULANGER BR, MIRVIS SE, RODRIGUEZ A. Magnetic resonance imaging in traumatic diaphragmatic rupture: case report. J Trauma 1992; 32: 89-93
  29. 29. CONTRASTE ORAL COMO CONFIRMACION <ul><li>Iochum S, Ludig T, Walter F, Sebbag H, Grosdidier G, Blum AG. Imaging of diaphragmatic injury: a diagnostic Challenge? Radiographics. 2002;22:S103-18. </li></ul><ul><li>No suele usarse de urgencias </li></ul><ul><li>Uso mas extendidos en formas cronificadas y tardias </li></ul>
  30. 30. RESUMEN DIAGNOSTICO Alta sospecha clinica Rx Torax con SNG TAC CIRUGIA
  31. 31. MORTALIDAD

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