title: Diaphragmatic hernia repair more than four years after severe trauma: Four case reports.
abstract: BACKGROUND
  Diaphragmatic rupture is an infrequent complication of trauma, occurring in about 5% of those who suffer a severe closed thoracoabdominal injury and about half of the cases are diagnosed early. High morbidity and mortality from bowel strangulation and other sequelae make prompt surgical intervention mandatory.
  
  
  METHODS
  Four Brazilian men with a delayed diagnosis of a rare occurrence of traumatic diaphragmatic hernia. Patient one had diaphragmatic rupture on the right side of thorax and the others three patients on the left thoracic side, all they had to approach by a laparotomy and some approach in the chest, either thoracotomy or VATS. This injuries required surgical repositioning of extensively herniated abdominal viscera and intensive postoperative medical management with a careful control of intra-abdominal pressure.
  
  
  CONCLUSIONS
  The negative pressure of the thoracic cavity causes a gradually migration of abdominal contents into the chest; this sequestration reduces the abdomen's ability to maintain the viscera in their normal anatomical position. When the hernia is diagnosed early, the repair is less complicated and requires less invasive surgery. Years after the initial trauma, the diaphragmatic rupture produces dense adhesions between the chest and the abdominal contents.
  
  
  CONCLUSIONS
  All cases demonstrated that surgical difficulty increases when diaphragmatic rupture is not diagnosed early. It should be noted that when trauma to the thoraco-abdominal transition area is blunt or penetrating, a thorough evaluation is required to rule out diaphragmatic rupture and a regular follow-up to monitor late development of this comorbidity.
authors.affiliation: Americo Brasiliense State Hospital, Alameda Aldo Lupo, 1260, 14820-000 Américo Brasiliense/SP, Brazil; Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, Avenida Bandeirantes, 3900, 14048-900 Ribeirão Preto/SP, Brazil. Electronic address: talesusp@yahoo.com.br.
authors.forename: Tales Rubens
authors.initials: TR
authors.lastname: de Nadai
authors.affiliation: Americo Brasiliense State Hospital, Alameda Aldo Lupo, 1260, 14820-000 Américo Brasiliense/SP, Brazil. Electronic address: jcpaivalopes@terra.com.br.
authors.forename: José Carlos Paiva
authors.initials: JC
authors.lastname: Lopes
authors.affiliation: Americo Brasiliense State Hospital, Alameda Aldo Lupo, 1260, 14820-000 Américo Brasiliense/SP, Brazil. Electronic address: caiocirino@yahoo.com.br.
authors.forename: Caio César
authors.initials: CC
authors.lastname: Inaco Cirino
authors.affiliation: Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, Avenida Bandeirantes, 3900, 14048-900 Ribeirão Preto/SP, Brazil. Electronic address: godinho.mauricio@gmail.com.
authors.forename: Maurício
authors.initials: M
authors.lastname: Godinho
authors.affiliation: Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, Avenida Bandeirantes, 3900, 14048-900 Ribeirão Preto/SP, Brazil. Electronic address: alfredo@fmrp.usp.br.
authors.forename: Alfredo José
authors.initials: AJ
authors.lastname: Rodrigues
authors.affiliation: Department of Surgery and Anatomy, Ribeirão Preto School of Medicine, University of São Paulo, Avenida Bandeirantes, 3900, 14048-900 Ribeirão Preto/SP, Brazil. Electronic address: sandro@fmrp.usp.br.
authors.forename: Sandro
authors.initials: S
authors.lastname: Scarpelini
keywords: Diaphragmatic hernia; Intra-abdominal pressure; Trauma; Videothoracoscopy