Traumatic Diaphragm Repair
[Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
Same
Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy / thoracoabdominal incision], primary closure [/ mesh reinforcement]
[***, MD/DO]
[Resident name]
General endotracheal. [Double-lumen ETT for thoracic approach.]
Patient presents with [acute blunt / penetrating] trauma to the [left / right] thoracoabdominal region with [diaphragmatic laceration on CT / bowel herniation into chest on CXR / incidental finding at laparotomy for other injuries]. [Gastric / small bowel / omentum] herniated into thorax. [Acute presentation: [X] hours post-injury / Delayed presentation: [X] weeks after index trauma, previously missed.] Risks including pulmonary complications, hernia recurrence, and organ ischemia (if herniated) discussed. Consent [obtained / waived].
[Left / right] diaphragm laceration [X] cm: [radial / transverse / complex tear / blowout]. [Stomach / small bowel / spleen / omentum] herniated through defect. Herniated contents [viable / [strangulated; required resection]]. Defect [primarily repairable / large; required mesh].
[LAPAROTOMY (acute):] The patient was positioned supine. Midline laparotomy performed. The [left / right] diaphragm was inspected. [Herniated contents identified and reduced by gentle traction; [viable].] The diaphragm laceration was identified and measured: [X] cm.
[THORACOTOMY (delayed/chronic):] Positioned [right lateral / left lateral]. [Left / right] thoracotomy performed through the [7th / 8th] intercostal space. Adhesions between herniated contents and thoracic organs divided. Contents reduced into the abdomen.
PRIMARY CLOSURE: The diaphragm was repaired with [interrupted / figure-of-eight] [0-Prolene / 0-Ethibond] sutures, closing the defect completely. Tension on repair assessed: [minimal tension / moderate tension; mesh reinforced].
[MESH REINFORCEMENT:] A [biosynthetic / polypropylene] mesh was used to reinforce the repair. Secured with [interrupted 0-Prolene]. Overlap of [2 cm] on all sides.
[A chest tube was placed through a separate stab incision.] Fascia closed. Skin closed. Patient tolerated the procedure well.
None
[Resected bowel if strangulated / None]
[X] mL
[Chest tube / None]
Patient to trauma ICU / floor in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Acute / delayed] traumatic diaphragmatic injury, [left / right], with [gastric / bowel / omental herniation]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Repair of traumatic diaphragm laceration, [left / right], via [laparotomy / thoracotomy / thoracoabdominal incision / laparoscopy / VATS], [primary closure / mesh reinforcement]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal [/ double-lumen ETT]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with [acute / delayed] [left / right] traumatic diaphragm laceration and [stomach / bowel / omentum] herniation. [Acute: *** hours / Delayed: *** weeks post-injury.] Risks including organ ischemia, recurrence, and pulmonary complications discussed. Consent [obtained / waived].
FINDINGS: [Left / right] diaphragm laceration *** cm: [radial / transverse / blowout]. [Stomach / bowel / omentum] herniated; [viable]. Defect [repairable primarily / large; mesh required].
DESCRIPTION OF PROCEDURE:
[LAPAROTOMY: Midline laparotomy; herniated contents reduced; defect identified *** cm.] [THORACOTOMY: Left lateral position; thoracotomy [7th / 8th] ICS; adhesions divided; contents reduced.] Primary closure with interrupted/figure-of-eight 0-Prolene sutures. [Mesh reinforcement with biosynthetic mesh, 2 cm overlap, 0-Prolene sutures.] [Chest tube placed.] Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Chest tube / None]
DISPOSITION: Patient to [ICU / floor] in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Right-sided diaphragm injury
Right diaphragm injuries are less common (liver buffers approximately 75-80% of diaphragm injuries are left-sided) and are often missed on initial imaging. Thoracotomy is commonly preferred for right-sided repair to allow liver retraction. Document right triangular ligament division and degree of liver mobilization required for exposure. State whether concomitant liver injury was present.
Delayed/chronic diaphragm hernia
Thoracotomy is classically preferred due to intrathoracic adhesions between herniated contents and pleura; laparoscopic repair is feasible in selected cases with limited adhesions. Document timeline from index injury to diagnosis (Grimes classification: acute, latent, or obstructive phase). Stomach, colon, and spleen are the most common herniated contents. Higher complication rate than acute repair, including re-herniation and pulmonary morbidity.
Charting Tips
- Document laceration size, location (radial/transverse/blowout), and mechanism (blunt vs. penetrating). AAST Diaphragm Injury Scale:
- Grade I = contusion
- II = <2 cm laceration
- III = 2-10 cm
- IV = >10 cm with tissue loss <25 cm²
- V = >25 cm² tissue loss
State AAST grade for trauma registry.
- State herniated organ(s), viability after reduction, and whether resection was required for strangulated or necrotic contents.
- Note repair technique (primary vs. mesh-reinforced), suture type and pattern (interrupted vs. figure-of-eight), and whether tension-free closure was achieved.
- Document chest tube placement, side, and initial output.
Documentation & Reimbursement Considerations
- Primary service: Report Traumatic Diaphragm Repair as the primary service when it is the definitive operation performed.
- These are mutually exclusive primary codes — bill one or the other based on clinical presentation.
- Approach (laparotomy vs. thoracotomy vs. thoracoabdominal vs. laparoscopic/VATS) does not change the reporting options. Document the approach used. EAST 2018 guidelines conditionally recommend laparoscopic repair for acute penetrating diaphragm injury without other intra-abdominal concerns.
- Document each procedure explicitly. Distinct-service reporting or separate-structure reporting may be required by some payers when multiple unrelated trauma procedures are billed.
- Mesh reinforcement is NOT separately billable for diaphragmatic hernia repair — it is considered inherent to the primary and related services.
- 90-day global: pulmonary complications, pleural effusion management, and wound care are bundled. Return to OR for recurrence within 90 days uses related unplanned return-to-the-operating-room reporting. Note: reporting 2027 will introduce approach-specific codes for diaphragm repair (laparotomy vs. thoracotomy vs. laparoscopy); track this for future updates.