Right sided tears are significantly less likely than left sided tears because of the protective effect of the liver [2, 16, 27]. This could also be explained by better visualisation of the left diaphragm, on diagnostic laparoscopy, but restricted visualisation of the right diaphragm [28]. The systematic review of literature

has confirmed 27 cases of left sided rupture [4, 8, 11, 13, 16–19, 21, 22, 24, 26, 29, 30] and 13 cases of right sided selleck products rupture were reported [2–4, 7, 15, 24, 31–33]. The rarely reported sites include 1 check details central diaphragmatic hernia [20], 2 bilateral [12, 24] and 1 trans-diaphragmatic intercostal hernia [34] The systematic review of literature also confirmed intra abdominal and retroperitoneal contents in the hernial sac, which are summarised in the table below (Table 1) [35–37]. Table 1 Type of visceral herniation Sac Contents YH25448 mw No of cases References Strangulated Transverse Colon 1 [13] Perforated Transverse Colon 3 [16, 19, 21] Splenic flexure 2 [12, 18] Splenic flexure cancer 1 [4] Intrathoracic Splenosis 2 [8, 35] Spleen 2 [12, 22] Right hepatic lobe 6 [2, 7, 15, 31–33]

Small Bowel 1 [31] Stomach/Perforated gastric ulcer 6 [8, 12, 17, 26, 29, 30] Intra-thoracic gastric volvulus 2 [36, 37] Kidney, Ureter and Renal Vein 1 [7] Part of Ascending and Transverse Colon 1 [7] Gall Bladder

1 [7] Omentum/Mesentery 2 [20, 34] Investigations The studies published before 1996 have quoted that 12–69% of diaphragmatic ruptures are missed at the pre operative phase [38–40]. CT scan was not widely used investigation when Non-specific serine/threonine protein kinase these papers were published. However, with the introduction of reformatting of images the sensitivity of the CT scan in picking up the diaphragmatic rupture has significantly increased[41]. While audible bowel sounds on the chest auscultation suggests displaced bowel loops, a chest x ray is the first line of investigation, repeated imaging increases sensitivity[8]. Insertion of a naso-gastric tube can decompress the intra-thoracic stomach to delineate a chest x ray interpretation [8, 29] and increase the diagnostic sensitivity to approximately 75%[8]. The sensitivity of chest radiographs is 46% for left sided ruptures and 17% for right sided ruptures [42]. Helical CT with axial, sagittal and coronal reconstruction increases the sensitivity to 73% and the specificity to 90%[12]. A diagnostic laparoscopy and/or diagnostic thoracoscopy could be performed as a semi-elective procedure, the timing planned in accordance with the heamodynamic and respiratory status of the patient [27, 28]. Meticulous inspection and palpation of the diaphragm should be performed during laparotomy in patients with trauma [12].