Intrapericardial diaphragmatic hernia into the pericardium after esophagectomy: a case report

Abstract

BackgroundIntrapericardial diaphragmatic hernia (IPDH), defined as prolapse of the abdominal viscera into the pericardium, is a rare clinical condition. This case illustrates the possibility of IPDH after esophagectomy with antethoracic alimentary reconstruction, although such hernias are extremely rare. IPDH often presents with symptoms of bowel obstruction such as abdominal discomfort or vomiting. If not properly treated, life-threatening necrosis and/or perforation of the herniated contents may occur.Case presentationA 68-year-old Japanese man underwent subtotal esophagectomy with three-field lymph node dissection for treatment of esophageal cancer. Completion gastrectomy with perigastric lymph node dissection was also performed because the patient had previously undergone distal partial gastrectomy for treatment of gastric cancer. The alimentary continuity was reconstructed using the pedicled jejunal limb through the antethoracic route. When we separated the diaphragm from the esophagus and removed xiphoid surgically to prevent a pedicled jejunal limb injury, the pericardium was opened. The patient was readmitted to our hospital because of abdominal discomfort and vomiting 6 months after the esophagectomy. A diagnosis of IPDH after esophagectomy was made. The patient was treated by primary closure of the diaphragmatic defect using vertical mattress sutures and additional reinforcement of the closing defect using a graft harvested from the rectus abdominis posterior sheath. The postoperative course was uneventful, and he was discharged on the seventh day after hernia repair.ConclusionsThis patient’s clinical course provides two important clinical suggestions. First, we must be aware of the possibility of iatrogenic IPHD after esophagectomy with antethoracic alimentary reconstruction. Second, a graft from the rectus abdominis posterior sheath is beneficial in the treatment of IPDH.

Transdiaphragmatic-pericardial Hernia: Case Report of an Unusual Condition Managed by Utilization of a Robotic Surgical System

“…Iatrogenic defects most often follow coronary bypass surgery, particularly when using a right gastroepiploic artery graft, following subxiphoid procedures, including pericardial window or procedures for atrial fibrillation or after esophagectomy [1][2][3]. The herniation of abdominal contents is a result of pressure differences between the abdomen and thoracic cavity and may involve any of the abdominal hollow viscus organs [7][8][9] The clinical presentation of TDPH may be variable. Patients can present with symptoms of chest pain, mimicking cardiac ischemia or abdominal pain, indigestion and nausea with or without vomiting, or can be asymptomatic.…”

“…This makes the clinical diagnosis at times difficult [4][5][6][7][8][9]. The physical examination is often not helpful but can include the findings of bowel sounds over the mid-chest, decreased breath sounds over the left anterior lung fields, and the absence of a cardiac apex impulse [6][7][8][9][10][11]. Imaging is key in the diagnosis of TDPH: plain-film chest radiography may demonstrate an enlarged cardiac silhouette and/or what appears to be a pneumopericardium, but is often not diagnostic [8].…”

“…Once the diagnosis is made, urgent or emergent surgical repair is indicated to prevent secondary complications of bowel incarceration, strangulation, or the physiologic effects of cardiac tamponade. Both open and laparoscopic surgical repairs have been reported for TDPH, using both abdominal and thoracic approaches [4][5][6][7][8][9]12]. When utilizing a thoracic approach, individual case reports have described using a median sternotomy, but most successfully utilized a left anterior lateral thoracotomy or minimally invasive approach, avoiding the added morbidity associated with median sternotomy [4,5,8].…”

“…Primary repair of the diaphragmatic defect with non-absorbable or slowly absorbable monofilament suture may be feasible for smaller defects; a mesh repair is most often used for larger defects. Most surgeons seem to use composite mesh; however, there is no clear consensus on the type of mesh most appropriate for diaphragmatic hernia repair [3][4][5][6][7][8][9][10][11][12][13]. Robotic-assisted surgical approaches are becoming increasingly popular, as they can provide added ability for visualization and dexterity while mobilizing the herniated contents and repairing the TDPH defect [14].…”

“…Diaphragmatic hernias can be acquired or congenital [4,5]. Acquired TDPH is unusual and usually secondary to a prior iatrogenic procedure [4][5][6][7][8][9].…”