Repair of Intrapericardial Diaphragmatic Hernia during Aortic Surgery in a 78-Year-Old Woman

Abstract

Intrapericardial diaphragmatic hernias are reported very rarely. Those of congenital origin are most often diagnosed in neonates, and those caused by indirect blunt trauma occur chiefly in adults. The latter type can be asymptomatic; however, the results of a computed tomographic scan can yield a definitive diagnosis. Once discovered, these hernias should be corrected to avoid severe sequelae such as bowel strangulation and necrosis, peritonitis, mediastinitis, and cardiac tamponade. We report the case of a 78-year-old woman who presented for elective ascending aortic aneurysm repair. Computed tomographic angiograms incidentally revealed a large intrapericardial diaphragmatic hernia, which had probably developed years earlier, after a traffic accident. The patient underwent a median sternotomy and repair of the intrapericardial diaphragmatic hernia with use of a bovine pericardial patch, followed by ascending aortic and hemiarch repair, aortic valve repair, and aorto–right coronary artery bypass grafting. We discuss the details of these procedures and alternative treatment options. To our knowledge, this is the first report of concomitant aortic surgery and repair of a trauma-induced intrapericardial diaphragmatic hernia in an adult.

Patient Characteristics and Outcomes Following Operative Repair of Acute versus Chronic Traumatic Diaphragmatic Hernia

“…Given these results, we suspect that a significant portion of our chronic TDH patients were identified and repaired through an incidental finding or as a complication following another procedure. These phenomena have been previously described by others [24][25][26]. Furthermore, prior literature has suggested that obesity itself may cause herniation via enlargement of the normal anatomical diaphragmatic esophageal hiatus or formation of acquired hernia defects [27].…”

Treatment of Chronic Traumatic Diaphragmatic Hernia Based on Laparoscopic Repair: Experiences From 23 Cases

“…As diaphragmatic defect edges were weak, thin and fragile (17), there was usually a large tension when suturing the diaphragm, especially the part adjacent to the central of the hiatus. Thus, mesh repair was required for these cases (18). According to our experiences, for the hernia ring with a diameter of <5 cm, mesh may not be necessary if the diaphragmatic defect could be easily sutured.…”

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

“…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].…”

“…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].…”