SAŽETAK

Traumatska ruptura dijafragme je retka povreda koja u ukupnom traumatskom morbiditetu učestvuje u manje od 2% slučajeva. Međutim, ova povreda je od izuzetnog hirurškog značaja zbog mogućih, po život opasnih, posledica ukoliko se na vreme ne prepozna i ne leči. U periodu od 1990. do 2005. hirurški smo zbrinuli 38 traumatskih rascepa dijafragme. Lečeno je 28 osoba muškog i 10 osoba ženskog pola, prosečne starosti 43,7 godina. Najčešći uzrok rupture dijafragme bila je tupa torakoabdominalna trauma u sklopu saobraćajnog traumatizma, padova sa visine na čvrstu podlogu i kompresije grudnog koša. U oko 25% slučajeva rascepi su uzrokovani penetrantnom traumom toraksa i/ili epigastrijuma. Serijske frakture donjih rebara, povrede slezine, kontuzije i laceracije pluća, povrede jetre i želuca bile su najčešće udružene povrede. Dijagnoza je preoperativno postavljena kod 85%, a intraoperativno, akcidentalno kod 15% hirurški lečenih. Dijagnozu smo postavljali na osnovu kliničkih znakova rupture dijafragme, radiološkim metodama - konvencionalnim i profilnim radiogramom grudnog koša, kontrastnom radiografijom gastrointestinalnog trakta, radiološkom procenom položaja nazogastrične sonde ultrasonografijom, CT-om toraksa i abdomena. Kod 40% pacijenata, kao uvod u torakotomiju, koristili smo videoasistiranu torakoskopiju (VATS), što se pokazalo izuzetno korisno. U 10% slučajeva hirurški pristup bila je laparatomija, 80% povređenih zbrinuto je kroz torakotomiju, a 10% traumatskih rascepa dijafragme hirurški je rešeno videoasistiranim torakoskopskim pristupom. Direktna sutura rascepljene dijafragme pojedinačnim, povratnim, neresorptivnim šavovima bila je metoda izbora u hirurškom lečenju 90% povređenih. U 10% slučajeva definitivno hirurško zbrinjavanje ledirane hemidijafragme postignuto je rekonstrukcijom uz upotrebu sintetičkih materijala.

Ključne reči: torakoabdominalna trauma, ruptura dijafragme

SUMMARY

A traumatic rupture of the diaphragm is a rare injury making less than 2% of the total traumatic morbidity. However, it is of the top surgical importance, as if not timely recognized and properly treated, the rupture may have serious, life-threatening complications. Over the period from 1990 to 2005, there were 38 surgically treated ruptures of the diaphragm, 28 in male and10 in female patients at the mean 43.7 years of age. The diaphragm rupture was most frequently due to a dull thoracoabdominal trauma within traffic traumas, falls from heights onto the firm surface and chest compression. In about 25% of the cases, the diaphragm rupture was induced by a penetrative trauma of the thorax and/or epigastrium. Serial fractures of the lower ribs, spleen injuries, contusion and laceration of the lungs, liver and gastric injuries often accompanied the diaphragm rupture. The diagnosis was preoperatively established in 85% and intraoperatively by accident in 15% of the operated patients. The diagnosis was established due to the clinical signs, radiologically by standard and profile chest X-ray, contrast radiography of the gastrointestinal tract, radiological assessment of the nasogastric sonde position by ultrasound and CT screening of the chest and abdomen. In 40% of the patients, video-assisted thoracoscopy (VATS) was applied to introduce thoracotomy, proven as exceptionally useful. Laparotomy, thoracotomy or video-assisted thoracoscopy were the applied surgical approaches in10%, 80% and 10% of diaphragm ruptures respectively. Direct suturing of the ruptured diaphragm by interrupted, nonabsorbable sutures was the suturing method of choice in 90% of the operated cases, while in 10% the definitive surgical restoration of the hemidiaphragm was achieved by synthetic materials.

Key words: thoracoabdominal trauma, diaphragm rupture