A complete blood count check revealed a decrease in hemoglobin (7 mg/dl), and therefore it was decided to perform surgery in midline laparotomy [6, 7]. After laparotomy, a significant amount of blood was evacuated to identify the site of bleeding. Liver inspection showed an 8 cm long, 1 cm deep laceration with active bleeding in segments Cell Cycle inhibitor IV-V (Grade II lesion classification AAST). A careful inspection of the abdominal cavity also showed a 12 cm length right diaphragmatic lesion with signs of active bleeding that accounted for the presence of free air seen in the CT images.

No other intestinal lesions were found. Temporary packing was used to treat the liver bleeding. After evacuating the right hemothorax, we proceeded with repair of the diaphragmatic lesion with non-absorbable sutures,

and by placing a thoracic Bouleau drainage. The suture was completed applying a medicated sponge containing thrombin and human find more fibrinogen in order to control learn more hemostasis and facilitate the building of the tissues and healing process [8]. After stopping the bleeding from the liver and bile leakage it was decided to adopt a conservative approach applying hemostatic matrix on liver injury (Figure 2). Surgery was concluded with the placement of abdominal drains, in the right subphrenic space. One transfusion was carried out during surgery. In post-operative time, blood pressure was 120/80 mmHg, hemoglobin 9 mg/dl. Chest tube was removed 4 days post surgery, after an x-ray which confirmed resolution of hemopneumothorax. Figure 1 Computed tomography results of the patient. a) presence of a right hemothorax without pulmonary lesions; b) discrete hemoperitoneum by an active bleeding parenchymal liver laceration and “free air” in the abdomen. Figure 2 Characteristics

of the stab wound and intra-operative findings. a) bleeding stab wound in the right upper quadrant; N-acetylglucosamine-1-phosphate transferase b) liver laceration and right diaphragmatic injury; c) application of hemostatic matrix (Floseal®) on liver lesion; d) repair of diaphragmatic lesion with non-absorbables sutures and positioning of medicated sponge containing thrombin and human fibrinogen (Tachosil®). Discussion The diaphragm is the principle muscle of respiration. With the contraction of striated muscle fibers it carries more than 70% of the work creating a negative intrathoracic pressure which is necessary for the proper performance of respiratory mechanics, as well as encouraging proper venous return to the heart. The integrity of the diaphragm separates the chest cavity from abdominal positive pressure, which ensures proper maintenance of the different pressure regimes of the two chambers, and prevents the migration of the abdominal organs into the chest.