الفهرس 
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Abstract
The diaphragm is a domed fibromuscular sheet that separates the abdominal and thoracic cavities. The major role of the diaphragm is inspiratory, but it is used also in abdominal straining. During inspiration contraction of the diaphragm pulls the lower surface of the lungs downward then during expiration the diaphragm simply relaxes and the elastic recoil of the lungs, chest wall and abdominal structures compresses the lungs.
There is higher incidence of left-sided diaphragmatic injury ascribed to the force-buffering effect of the liver on the hemi diaphragm on the right side and the relative congenital weakness of the hemidiaphragm on the left side.
The preoperative diagnosis of traumatic DR is difficult. Patients with undiagnosed rupture of the diaphragm can develop symptoms after a delay of weeks, months, or even years. The diagnosis of the diaphragmatic hernia may be possible in only 25% to 50% of the cases after the trauma.
Symptoms and signs of diaphragmatic rupture without herniation of abdominal viscera into the chest are present in the minority of patients initially seen after the blunt injury. Most symptoms present are related to other organ system injuries or to the prescence of hypovolemic shock.
Gibson, 1929, stressed the importance of clinical signs in the diagnosis of diaphragmatic hernia. He cited the following diagnostic signs: (1) diminished expansion of the chest; (2) impairment of resonance; (3) adventitious sound; (4) cardiac displacement; (5) circulatory collapse; (6)cyanosis and dyspnea; and (7) asymmetry of hypochondria.
Modalities for the diagnosis of traumatic diaphragmatic rupture include the following: Chest radiograph; Standard, nasogastric tube in situ, or after oral administration of contrast media; Computed tomography, Ultra songraphy; Peritoneal lavage; Peritoneography (dye contrast , radio isotopic scinitigraphy); Liver spleen radioisotopic scintigraphy; magnetic resonance imaging and Thoracoscopy. Uncommon other diagnostic maneuvers have been described to diagnose diaphragmatic injuries, like angiography, instillation of contrast martial into the chest or abdomen and fluoroscopy.
Since 1993, when video assisted thoracoscopic surgery (VATS) was first used to diagnose blunt diaphragmatic rupture, it has been proposed as a safe, expeditious, and accurate method of evaluating the diaphragm in trauma patients.
Laparotomy seems to be more appropriate in unstable patients when associated intra-abdominal injuries are expected. Thoracotomy is suitable for stable patients without intra-abdominal injuries or contra lateral DR, associated intrathoracic injuries, and late presentation (more than 7 days).
As with any trauma, the patient’s condition must be stabilized, and must be resuscitated as much as possible before the operation. People with traumatic hernias frequently have concomitant injuries and require emergency exploration. When diagnosed, surgery must be performed as soon as possible, as any delay might cause a herniation of any abdominal organ. The choice of surgical approach can be thoracotomy, laparotomy or both if necessary.
The use of minimally invasive surgery for repair of DH is controversial. Thoracoscopic and laparoscopic approaches have been described. In some cases laparoscopy following VATS can help to assess the intra-abdominal viscera and inspect the contra lateral hemidiaphragm.
The mortality for diaphragmatic repairs is generally indictated by the number and severity of concomitant injuries. There is a wide variation in mortality results for diaphragmatic herniation secondary to both blunt trauma (15%–40%) and penetrating trauma (10%–30%).