title: A rare case of chronic traumatic diaphragmatic hernia requiring complex abdominal wall reconstruction.
abstract: BACKGROUND
  Traumatic diaphragmatic hernia is a rare and often under recognized complication of penetrating and blunt trauma. These injuries are often missed or there is a delay in diagnosis which can lead to enlargement of the defect and the development of abdominal or respiratory symptoms.
  
  
  METHODS
  We report a case of an otherwise healthy 37 year old male who was involved in a motor vehicle accident at age twelve. He presented 25 years later with vague lower abdominal symptoms and was found to have a large chronic left sided diaphragmatic hernia involving the majority of his intra-abdominal contents. Repair of the defect with a biologic mesh was undertaken and the patient also required complex abdominal wall reconstruction due to loss of intra-abdominal domain from the chronicity of the hernia. A staged closure of the abdomen was performed first with placement of a Wittmann patch. Medical management of intra-abdominal hypertension was successful and the midline fascia was sequentially approximated at the bedside for three days. The final closure was performed with a component separation and implantation of a fenestrated biologic fetal bovine mesh to reinforce the closure. In addition, a lightweight Ultrapro mesh was placed for additional lateral reinforcement. The patient recovered well and was discharged home.
  
  
  CONCLUSIONS
  These injuries are rare and diagnosis is challenging. Mechanism and CT scan characteristics can aid clinicians.
  
  
  CONCLUSIONS
  Blunt diaphragmatic injury is rare and remains a diagnostic challenge. Depending on the chronicity of the injury, repair may require complex surgical decision making.
authors.affiliation: Trauma Surgery, Critical Care, Acute Care General Surgery, Kern Medical Center, 1700 Mt. Vernon Ave. Bakersfield, CA 93306, USA. Electronic address: APakula333@aol.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Pakula
authors.affiliation: Trauma Surgery, Critical Care, Acute Care General Surgery, Kern Medical Center, 1700 Mt. Vernon Ave. Bakersfield, CA 93306, USA.
authors.forename: Amber
authors.initials: A
authors.lastname: Jones
authors.affiliation: Radiology, Kern Medical Center, 1700 Mt. Vernon Ave. Bakersfield, CA 93306, USA.
authors.forename: Javed
authors.initials: J
authors.lastname: Syed
authors.affiliation: Trauma Surgery, Critical Care, Acute Care General Surgery, Kern Medical Center, 1700 Mt. Vernon Ave. Bakersfield, CA 93306, USA.
authors.forename: Ruby
authors.initials: R
authors.lastname: Skinner
keywords: Diaphragm hernia; Hernia repair; Mesh; Traumatic hernia