Iatrogenic intrapericardial diaphragmatic hernia associated with cardiac tamponade

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.

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

Background

Intrapericardial 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 presentation

A 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.

Conclusions

This 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.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation

BACKGROUND

Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft.

CASE REPORT

We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.

Getting a better look: Outcomes of laparoscopic versus transdiaphragmatic pericardial window for penetrating thoracoabdominal trauma at a Level I trauma center

BACKGROUND

In penetrating thoracoabdominal trauma, it is necessary to evaluate both the pericardial fluid and the diaphragm directly. Transdiaphragmatic pericardial windows (TDWs) provide direct access to the pericardium and diaphragm but expose the patient to the risks of laparotomy. We hypothesize that transabdominal laparoscopic pericardial windows (LPWs) are a safe and effective alternative to TDWs in stable patients.

METHODS

This is a retrospective observational study of stable patients with thoracoabdominal penetrating trauma at a level I trauma center between January 2007 and June 2015, comparing outcomes after TDW versus LPW.

RESULTS

A total of 99 patients with penetrating trauma had a diagnostic pericardial window, 33 of which were laparoscopic. Stab wounds were most common (80, 80.8%) compared with gunshot wounds (19, 19.2%). Of 11 patients who had a positive pericardial window, 10 (90.9%) were associated with a cardiac injury. There was no difference in the ratio of positive pericardial windows for patients who had TDW versus LPW (8/66, 12.1% vs. 3/33, 9.1%; p = 0.651). One patient had a complication related to a negative pericardial window in the laparoscopic group. There was no difference in complication rates between TDW and LPW (p = 0.155). Mean length of stay was longer in TDW compared with LPW (12 vs. 5 days, p = 0.046). One patient died during index admission in the TDW group, but there was no difference in mortality rates between TDW and LPW during the index admission (p = 0.477). Median length of follow-up was 29 days (range, 0-2,709). On long-term follow-up, there was also no difference in mortality rates between TDW and LPW (2/66, 3.0% vs. 2/33, 6.1%; p = 0.470).

CONCLUSION

In hemodynamically stable patients with thoracoabdominal injuries, LPW is a safe and effective technique in evaluating both pericardial fluid and the diaphragm. LPW is a viable alternative to exploratory laparotomy and TDWs.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Laparoscopic repair of an iatrogenic intrapericardial diaphragmatic hernia using the falciform ligament flap

Iatrogenic intrapericardial diaphragmatic hernia after creation of a pericardial-peritoneal window is a very rare entity. We present the clinical case of an acute intestinal bowel obstruction due to herniation of small bowel into the pericardial sac. After laparoscopic reduction of the herniated small bowel, the diaphragmatic defect was successfully repaired using the hepatic falciform ligament.

Outside the box: extra-pericardial tamponade due to acute recurrence of hiatus hernia

Cardiac tamponade is defined as a life-threatening, slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, thrombus or gas as a result of effusion, trauma, or myocardial rupture. We describe the case of a lady who developed classic signs of cardiac tamponade immediately after an open hiatus hernia repair. Computed tomographic imaging revealed extrapericardial hernia recurrence causing cardiac compression. We believe this is the first such reported case. We conclude that cardiac tamponade from acute recurrence of hiatus hernia must be considered in the unstable postoperative patient and that the definition of cardiac tamponade is expanded to include extrapericardial pathologies.

Iatrogenic intrapericardial diaphragmatic hernia diagnosed by cardiovascular magnetic resonance

Intrapericardial diaphragmatic hernias are very uncommon and are most typically caused by high-force blunt trauma. Other iatrogenic causes such as prior surgical formation of a pericardial window have been described, but are exceedingly rare. We present a case of an intrapericardial diaphragmatic hernia in a patient with a prior pericardial window in which the diagnosis was unclear using conventional imaging modalities, but was established using cardiovascular magnetic resonance.

[Cardiac arrest following blunt chest injury. Emergency thoracotomy without ifs or buts?]

In German-speaking countries, most serious thoracic injuries are attributable to the impact of blunt force; they are the second most frequent result of injury after head injury in polytrauma patients with multiple injuries. Almost one in every three polytraumatized patients with significant chest injury develops acute lung failure, and one in every four, acute circulatory failure. The acute circulatory arrest following serious chest injury involves a high mortality rate, and in most cases it reflects a tension pneumothorax, cardiac tamponade, or hemorrhagic shock resulting from injury to the heart or one of the large vessels close to it. Brisk drainage of tension pneumothorax and adequate volume restoration are therefore particularly important in resuscitation of multiply traumatized patients, as are rapid resuscitative thoracotomy to allow direct heart massage, drainage of pericardial tamponade, and control of hemorrhage. However the probability of survival described in the literature is very low for patients sustaining severe chest trauma with acute cardiac arrest. The case report presented here describes a female polytrauma patient who suffered an acute cardiac arrest following cardiac tamponade after admission in the emergency department and who survived without neurological deficits after an emergency thoracotomy. Selections from the topical literature can help the treating physician in the emergency department in making decisions on whether an emergency thoracotomy is indicated after a blunt chest injury and on the procedure itself.

Sectional Neuroanatomy of the Middle Thoracic Spine (T5-T8) and Chest

This is the third in a series of articles on the spine. The first reviewed the anatomy of the neck. The second reviewed the upper thoracic spine and chest (T1-T4). A fourth article is planned for the lower thoracic spine. Procedures in the midthoracic spine include chest tube placement, trigger point injections, chemodenervation with botulinum toxin, video-assisted thoroscopic surgery, and spinal injections. Complications include pneumothorax, hemothorax, diaphragmatic irritation, sympathetic trunk irritation, postthoracotomy pain, and intradural abscesses. This article provides anatomically accurate schematics of innervations of the middle thoracic chest and spine (T5-T8) that can be used to interpret magnetic resonance images of the muscles and nerves. Cross-sectional schematics of the middle thoracic chest and spine were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of the middle thoracic chest and spine allows the physician to increase the accuracy and efficacy of interventional procedures. This could also assist the electromyographer in correlating the clinical and electrophysiologic findings with magnetic resonance images.

Massive intrapericardial herniation of stomach following pericardial window

Herniation of intra-abdominal contents into the pericardial cavity is rare. We describe one such case occurring after creation of a pericardioperitoneal window for drainage of a pericardial effusion. The diagnosis of an intrapericardial hernia should be considered in patients presenting with gastrointestinal and/or cardiorespiratory symptoms following surgical procedures involving the diaphragm.