A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Intrapericardial Diaphragmatic Hernia Following the Convergence Procedure for Atrial Fibrillation

This case report highlights a very rare variant of diaphragmatic hernia, namely, an intrapericardial diaphragmatic hernia, which can arise as a complication of the convergence procedure. A 77-year-old man, presenting with chronic shortness of breath and fatigue, was unexpectedly found to have herniation of the transverse colon into the pericardial cavity through a diaphragmatic-pericardial defect. The diaphragmatic defect was repaired with mesh via robotic surgery. The patient reported resolution of his symptoms at the six-month follow-up.

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

Transdiaphragmatic hernia via the central tendon in the pericardium is a rare entity. Most often, these hernias are acquired and related to the iatrogenic creation of a transdiaphragmatic-pericardial defect. We would like to present a case of a 62-year-old male who presented with acute chest pain and was diagnosed to have a transdiaphragmatic-pericardial hernia on computed tomography. He has a history of cardiac intervention via an abdominal approach 12 years earlier. A segment of jejunum was found strangulated in the defect. We used DaVinci Xi® (Intuitive Surgical, Sunnyvale, CA) robot and were able to successfully reduce the hernia, repair the defect, and resect a short segment of jejunum which was non-viable. The utilization of a minimally invasive approach may be feasible, and the use of a robotic surgical system may enhance the surgeon’s ability to repair the defect.

Iatrogenic Incarcerated Diaphragmatic Hernia after Nissen Fundoplication

Postoperative iatrogenic diaphragmatic hernias have been reported sparingly after several thoracic and abdominal surgeries. Although rare, a delay in diagnosis can lead to life-threatening cases of strangulation or perforation, as well as cardiovascular and respiratory insufficiency. This is a case of a 78-year-old female who developed acute obstructive symptoms secondary to herniation of the distal stomach through a defect in the central tendon of the diaphragm. The diaphragmatic defect was presumed to be iatrogenically acquired after Nissen fundoplication one year prior. Other etiologies were not as likely considering that she had never had any trauma to her chest or abdomen and had no history suggestive of a congenital nature for the diaphragmatic hernia. The hernia was successfully decompressed laparoscopically with the stomach having ischemic changes along the greater curvature, necessitating gastric wedge resection. The diaphragmatic defect, which was lengthened to reduce the edematous incarcerated stomach, was repaired primarily. The patient had an uneventful postoperative course. This case highlights the potential complication of incarcerated diaphragmatic hernia after Nissen fundoplication. Late diagnosis of iatrogenic diaphragmatic hernias is frequent because of nonspecific symptoms and surgery is indicated at the time of diagnosis.

Laparoscopic Repair of an Intrapericardial Diaphragmatic Hernia After Convergent Maze Procedure

The convergent maze procedure (CMP) is a new minimally invasive technique for the surgical treatment of atrial fibrillation (AF). Recently, multiple groups have published excellent results and few adverse events with CMP. However, we now report the second case of an intrapericardial diaphragmatic hernia with small bowel obstruction that resulted from CMP. This adverse event was managed successfully by laparoscopic repair of the hernia and the use of a polytetrafluoroethylene mesh closure with hepatic buttress, achieving an excellent result. With the expanding use of CMP for the treatment of AF, awareness of this adverse event and its appropriate management are increasingly important.

Differential diagnostic value of small bowel wall thickness and density changes measured by computed tomography in small bowel obstruction

AIM: To investigate the diagnostic value of small bowel wall thickness and density measured by computed tomography (CT) in differentiating simple small bowel obstruction (SI) from strangulated small bowel obstruction (ST).

METHODS: Forty-two patients with SI and 38 patients with ST were included. All patients underwent plain and contrast-enhanced CT scans. The density of bowel wall thickening was recorded and compared.

RESULTS: The percentage of patients with normal inner density measured by plain CT was significantly higher in the SI group than in the ST group, and the percentage of patients with decreased whole density was significantly lower in the SI group than in the ST group (P < 0.05). The percentage of patients with decreased whole density measured by contrast-enhanced CT was significantly lower in the SI group than in the ST group (P < 0.05). The sensitivity and specificity of normal inner density measured by plain CT for diagnosis of ST were 34.2% and 33.3%, respectively. The sensitivity and specificity of decreased whole density measured by plain CT were 73.7% and 71.4%, respectively. The sensitivity and specificity of decreased whole density measured by contrast-enhanced CT were 84.2% and 73.8%, respectively.

CONCLUSION: Small bowel wall thickness and density changes measured by computed tomography can help differentiate between SI and ST.