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Ann Thorac Surg 2004;77:340
© 2004 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Traumatic intrapericardial herniation of the stomach

Evaristo Castedo, MDa*, Andres Varela, MDa,b,c,d, Ana Villasclaras, MDa,b,c,d, Concha Gonzalez, MDa,b,c,d, Felix Arrieta, MDa,b,c,d

a Department of Cardiothoracic Surgery, Hospital Clinica Puerta de Hierro, Universidad Autonoma de Madrid, Madrid, Spain
b Department of Radiology, Hospital Clinica Puerta de Hierro, Universidad Autonoma de Madrid, Madrid, Spain
c Department of General Surgery, Hospital Clinica Puerta de Hierro, Universidad Autonoma de Madrid, Madrid, Spain
d Department of Intensive Care Unit, Hospital Clinica Puerta de Hierro, Universidad Autonoma de Madrid, Madrid, Spain

* Address reprint requests to Dr Castedo, Department of Cardiothoracic Surgery, Clinica Puerta de Hierro, C/ San Martín de Porres, 4, E-28035 Madrid, Spain.
e-mail: evaristocm{at}terra.es

A 66-year-old man was referred to our hospital after a traffic accident. On admission, he complained of thoracic and pelvic pain and was in a hemodynamically stable condition. Physical examination revealed subcutaneous emphysema on the left side of the thorax and abdominal tenderness. Chest roentgenogram showed fractured ribs (second to seventh) on the left side and an air bubble over the cardiac silhouette (Fig 1, arrows). Spiral computed tomographic scan demonstrated pelvic and costal fractures, left apical pneumothorax, pulmonary contusion, and posterior displacement of the heart by an intrapericardial air-filled mass (Fig 2, arrows). Pneumothorax was evacuated, and the patient was operated on through an upper midline laparotomy. The stomach was found to be herniated into the pericardial cavity. The hernia was reduced, and the diaphragmatic tear was repaired. The postoperative course was uneventful.



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  		Fig 1.
 


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  		Fig 2.
 
Intrapericardial diaphragmatic hernia is a very rare entity. Since the first reported case by DeCardinal in 1903 [1], less than 90 cases have been described worldwide [2]. Although most of them were caused by blunt trauma sustained in a vehicular crash, use of the right gastroepiploic artery for coronary artery bypass grafting has recently emerged as an important cause of iatrogenic intrathoracic herniation of abdominal contents [3]. The stomach is the viscera most frequently involved (40%) after the transverse colon. Early diagnosis is achieved in only 48% of cases. Clinical symptoms vary from nonspecific abdominal or respiratory signs to cardiac tamponade, but asymptomatic cases are not rare. Surgical correction is mandatory in the prevention of gastric and cardiac complications. An upper midline laparotomy is the preferred approach; sternotomy should be reserved for cases of delayed diagnosis in which division of adhesions between the stomach and the pericardium is necessary.

References

  1. De Cardinal, Grenier, Bourderov Hernie diaphragmatique du colon transverse dans le pericarde chez un adulte. J Med Bordeaux 1903;23:22
  2. Reina A., Vidaña E., Soriano P., et al. Traumatic intrapericardial diaphragmatic hernia: case report and literature review. Injury 2001;32:153-156.[Medline]
  3. Manetta F., Moores D.W.O., Bennett E.V., Edwards N.M. Intrapericardial herniation of the stomach after the use of the right gastroepiploic artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1998;115:479-480.[Free Full Text]



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