Ann Thorac Surg 2005;79:1417-1419
© 2005 The Society of Thoracic Surgeons
Case report
Massive Recurrent Anterior Diaphragmatic Hernia, Coronary Artery Disease, and Valvular Heart Disease
Mark W. Huang, MD*,a,
J. Nilas Young, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, University of California, Davis Medical Center, Sacramento, California, USA
Accepted for publication October 10, 2003.
* Address reprint requests to Dr Huang, University of California, Davis Medical Center, 645 Front St, Suite 808, San Diego, CA, USA 92101
huanger{at}cox.net
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Abstract
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We report the case of a 76-year-old woman found on preoperative evaluation for vaginal prolapse to have coronary artery disease, aortic stenosis, and a large recurrent anterior diaphragmatic hernia. The clinical presentation and surgical management of this case, and the review of the literature are discussed.
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Introduction
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There are no reports of an anterior diaphragmatic hernia found in conjunction with coronary artery disease and aortic stenosis found in the literature. We report the case of an anterior diaphragmatic hernia, coronary artery disease, and aortic stenosis found in 1 patient. The clinical management of this patient and literature search are discussed.
A 76-year-old woman undergoing preoperative evaluation for vaginal prolapse was noted to have a systolic ejection murmur. Initial cardiology evaluation with a transthoracic echocardiogram revealed severe aortic stenosis with an aortic valve area of 0.7 cm2. Cardiac catheterization revealed significant coronary artery disease involving the circumflex and right coronary arteries. An anterior diaphragmatic hernia was found on her preoperative chest roentgenogram (Fig 1) and was confirmed with a computed tomographic scan that demonstrated a large anterior diaphragmatic hernia with loops of transverse colon overlying the pericardium.
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Fig 1. Preoperative chest roentgenogram. Note the abnormal air silhouette anterior to the pericardium.
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The surgical approach used was a median sternotomy. We identified a large 20-cm hernia sac and 20-cm diaphragmatic defect. The colon was noted to be adhered to the right middle and lower lobes of the lung and the anterior pericardium. The contents were mobilized and reduced into the abdominal cavity, and the edges of the diaphragm were dissected. Interrupted horizontal mattress sutures of 0-Prolene (Ethicon, Somerville, NJ) were used to attach an expanded polytetrafluoroethylene mesh to the diaphragm and rectus muscles (Fig 2). After the hernia repair was completed, we opened the pericardium and proceeded with coronary artery bypass grafting in the standard fashion. We placed a 21-mm pericardial bioprosthesis in the aortic position. Routine weaning from cardiopulmonary bypass and wound closure completed the operation.
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Fig 2. The completed repair with expanded polytetraethylfluorene mesh attached to the diaphragm laterally and posteriorly and to the rectus sheath anteriorly.
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The patient's postoperative course was unremarkable. She was discharged on postoperative day 9. The patient was doing well 1 year postoperatively without clinical or radiographic evidence of recurrence (Fig 3).
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Fig 3. Postoperative posteroanterior chest roentgenogram. No evidence of recurrence 1 year postoperatively.
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Comment
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Congenital diaphragmatic hernias typically occur through natural diaphragmatic defects such as Bochdalek's foramen or Morgagni's foramen. In contrast, acquired hernias usually extend from the esophageal hiatus with the exception of traumatic diaphragmatic hernias that can occur anywhere. Rare diaphragmatic hernias have been reported involving defects of the peritoneopericardial membrane [1], which often can be visualized during sternotomy for cardiac surgical procedures. There are no reported cases of anterior diaphragmatic hernias and concomitant surgical coronary artery disease and valvular heart disease in the literature.
Recurrent esophageal hiatal defects are reported in the literature to occur in 5% to 10% of cases [2]. The patient's symptoms may include dyspnea, chest pain, nausea, vomiting, and abdominal pain. The diagnosis is usually made by chest roentgenogram, which reveals gastrointestinal silhouettes above the diaphragm. Computed tomography has been used to identify further anatomic relationships of the diaphragmatic hernia. Occasionally contrast gastrointestinal studies have been used to document the course of the gastrointestinal tract.
Confirmation of the diagnosis of an anterior diaphragmatic defect mandates operative repair to prevent strangulation or obstruction. Several surgical approaches have been described in the literature. The classic repair of diaphragmatic hernias is described as going through a transabdominal incision. This approach is useful for most initial presentations and acute traumatic diaphragmatic injuries because it provides for exposure of herniated contents and allows repair of any hiatal defects and reflux pathology, as well as allowing an assessment of traumatic intraabdominal injuries. Many centers are currently performing laparoscopic repair of diaphragmatic hernias with equivalent success and recurrence rates as open techniques. White and colleagues [3] reported the laparoscopic repair of a Morgagni's hernia in an 85-year-old woman with excellent results.
A series described by Dalton and colleagues [4] involved 68 cardiac surgical patients who underwent concomitant noncardiac procedures. This group described concomitant surgery for thymoma, bronchogenic carcinoma, and hiatal hernia in addition to vascular surgical procedures. Kessler and colleagues [1] reported the incidental finding of a peritoneopericardial diaphragmatic hernia during coronary artery bypass grafting. They describe the repair of the hernia by using expanded polytetraethylfluorene mesh through the median sternotomy exposure.
In our case, we identified the massive recurrent anterior diaphragmatic hernia on preoperative evaluation. We were careful to avoid disruption of the herniated contents during the sternotomy from the xiphoid up to the sternal notch. The use of a standard median sternotomy provided excellent exposure for mobilization of the herniated contents and easy access to repair the hernia with expanded polytetraethylfluorene mesh. Our case illustrates the safety and feasibility of concomitant repair of a massive diaphragmatic hernia combined with coronary artery bypass grafting and an aortic valve replacement.
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References
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- Kessler R, Pett S, Wernly J. Peritoneopericardial diaphragmatic hernia discovered at coronary bypass operation. Ann Thorac Surg. 1991;52:562–563[Abstract]
- Khaitan L, Houston H, Sharp K, Holzman M, Richards W. Laparoscopic paraesophageal hernia repair has an acceptable recurrence rate. Am Surg. 2002;68(6):546–551[Medline]
- White DC, McMahon R, Wright T, Eubanks WS. Laparoscopic repair of a Morgagni hernia presenting with syncope in an 85-year-old woman: case report and update of the literature. J Laparoendosc Adv Surg Tech. 2002;12(3):161–165
- Dalton ML, Parker TM, Mistrot JJ, Bricker DL. Concomitant coronary artery bypass and major noncardiac surgery. J Thorac Cardiovasc Surg. 1978;75(4):621–624[Abstract]
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Abstract
Introduction
