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“Background Diaphragmatic injuries are a diagnostic and therapeutic challenge GSK2126458 for the surgeon. They are often un recognized, and diagnostic delay causes high mortality from these injuries [1]. In countries with a low incidence of inter-personal violence, it is quite a rare trauma, with only 4-5% of patients undergoing laparotomy for trauma presenting a diaphragmatic injury [2]. These are mainly caused by blunt trauma of the chest and abdomen (75%) and, more rarely, by penetrating ones (25%) [3]. Clinical presentation

varies from a state of hemodynamic instability secondary to bleeding of the diaphragm and organs involved in the trauma [4] to a condition of intestinal obstruction and respiratory failure that can occur months, or even years, after the trauma, due to diaphragmatic hernia [5]. Diagnosis is made difficult both by the frequent presence of concomitant multi-organ injuries that deviate the surgeon’s attention from the diaphragm, and by the lack of adequate diagnostic imaging studies regarding the diaphragmatic muscle. In hemodynamically stable patients with penetrating wound of the abdomen, in which there

is a strong suspicion of diaphragmatic injury, with a given negative diagnostic imaging, INK 128 cell line laparoscopy is considered a valuable diagnostic and therapeutic tool in the presence of experienced surgeons. In hemodynamically unstable patients a midline laparotomy is the recommended approach as it allows exploration of the entire abdominal cavity [6]. Methods We report the clinical case of a 45 year-old man who came to our observation with a stab wound in the right upper abdomen, without cyanosis or dyspnea. Blood pressure was 130/80 mmHg and hemoglobin 12.5 mg/dl. On clinical examination, the patient had

a lacerated, bleeding stab wound in the right upper quadrant through which part of the omentum, without other macroscopically visible injuries, could be seen. The type or length of the knife used as it was extracted from from the victim after the fight. A focused assessment with sonography for trauma (FAST) test was carried out which showed subdiaphragmatic and perihepatic blood. Due to abundant tympanites and lack of cooperation on the part of the patient, nothing more could be seen. It was decided to have to patient undergo a CT scan of the abdomen to determine if there were any lesions to the abdominal organs. From the scan, the presence of a right hemothorax without pulmonary lesions was seen, with moderate hemoperitoneum from an active bleeding parenchymal liver laceration and subdiaphragmatic air in the abdomen as a bowel perforation (Figure 1). Initially, the suspect of a bowel perforation suggested a laparoscopic approach, but the patient’s hemodynamic condition rapidly changed.