Missed diaphragmatic perforation caused by penetrating trauma can lead to subsequent strangulation of a hollow viscus, which has prompted the use of invasive diagnostic procedures to exclude occult diaphragmatic injuries
in asymptomatic, high-risk patients. The objective of this study was to determine the incidence of occult diaphragmatic injuries
caused by stab wounds
of the lower chest and upper abdomen, and to examine the natural history and consequences of missed diaphragmatic injuries
On the basis of patient data from two previous randomized studies from our institution, a retrospective analysis was performed on 97 patients treated for anterior stab wounds
located between the nipple line, the umbilical level, and the posterior axillary lines not having indications for immediate surgical exploration. The patients were divided into two groups on the basis of their initial randomized management (open or laparoscopic exploration vs. expectant observation).
In the exploration group (n = 47), four diaphragmatic injuries
(9%) were detected (three left-sided and one right-sided). Excluding patients with associated injuries requiring surgical repair, the incidence of occult diaphragmatic injuries
was 3 of 43 (7%). In the observation group (n = 50), there were two patients (4%) with delayed presentation of missed left-sided diaphragmatic injury 2 and 23 months later, respectively. Both injuries resulted from stab wounds
of the left flank and presented with herniation of the stomach or small bowel and colon. The overall incidence of occult diaphragmatic injuries
in left-sided thoracoabdominal stab wounds
was 4 of 24 (17%), and was much lower after stab wounds
of left epigastrium (0%), right lower chest (0%), and right epigastrium (4%).
In asymptomatic patients with anterior or flank stab wounds
of the lower chest or upper abdominal area, the risk of an occult diaphragmatic injury is approximately 7% which, if undetected, is associated with a high risk of subsequent hollow viscus herniation. Exclusion of an occult diaphragmatic injury with invasive diagnostic methods, such as laparoscopy
, should be considered at least in left-sided stab wounds
of the lower chest.