Traumatic diaphragmatic hernia into the pericardium

Traumatic intrapericardial diaphragmatic hernia

Traumatic intrapericardinal diaphragmatic hernia is a rare occurrence following blunt thoracoabdominal injuries. We have reviewed 59 cases reported in the literature and added three. Emphasis is placed on the diagnostic difficulties encountered, with some discussion regarding the management and surgical approach.

Traumatic pericardiophrenic hernia: a report of 3 cases

Three cases of traumatic intrapericardial diaphragmatic hernia are reported. The defect was limited to the central tendon of the diaphragm in all 3 cases with herniation of the transverse colon (n = 2) or small bowel (n = 1) into the pericardial sac. A correct preoperative diagnosis was made in all 3, using a dilute barium meal in 2 patients, and from the chest X-ray examination alone in 1. Successful operative repair was performed. Previous reports suggest that barium studies of the gastrointestinal tract are the most accurate method of diagnosis but should be used with caution as they may precipitate cardiac tamponade through distension of herniated bowel.

Pericardiodiaphragmatic hernia

Twenty-seven reported cases of pericardial diaphragmatic hernia are reviewed and another case is added. This entity may be congenital or traumatic in origin, the latter being more frequent at a ratio of 2:1. All patients except one were male and the mean age at diagnosis was 40 years. The patients were usually symptomatic, the most frequent complaints being of cardiac or respiratory origin. Pneumoperitoneum may be diagnostic although chest roentgenograms and contrast studies may suggest the diagnosis. Computed axial tomography and echocardiography may prove useful in the future. We believe the anterior abdominal approach is preferable to the transthoracic approach in reducing the hernia and repairing the defect because it affords better exposure and easier accessibility to other intraabdominal disease and can easily be converted into a median sternotomy if needed. The stomach and transverse colon became herniated most frequently and in only three cases was a sac found. The defect involves the central leaflet of the diaphragm and primary repair generally results in a good prognosis.

Blunt traumatic rupture of the diaphragm

Blunt traumatic rupture of the diaphragm must be suspected in all patients with massive trauma and especially in those whose chest roentgenogram reveals an abnormal or obscured diaphragmatic shadow. Regular reevaluation is most important. A diagnostic pneumoperitoneum is the most accurate preoperative test available. Transthoracic approach is the operation of choice.

A case report of surgical repair of traumatic rupture of the pericardium and diaphragm

A 55 year-old male with traumatic rupture of the pericardium, diaphragm and spleen, and with crush of the pancreas was successfully operated upon. The diagnosis of rupture of the diaphragm was done on the chest X ray on admission, and the rupture of the pericardium was diagnosed at the time of laparotomy and thoracotomy. The ruptured spleen and the crushed pancreas tail were removed, and the ruptured pericardium and diaphragm were closed successively.

Diaphragmatic rupture with cardiac tamponade

Intrapericardial herniation of abdominal viscera following blunt abdominal trauma is rare. We have been able to find only nine reported cases. Six of these were finally diagnosed after a long delay, ranging from a year to 23 years. Three were diagnosed within three months of the original injury, but in these patients, the investigations were initiated following an abnormal chest skiagram. We wish to report a unique case in which a traumatic intrapericardial hernia presented as an acute cardiac tamponade within 48 hours of injury.

Pericardial rupture from blunt chest trauma

Borrie, J. and Lichter, I. (1974).Thorax, 29, 329-337. Pericardial rupture from blunt chest trauma. Pericardial rupture may occur in two distinct anatomical sites, namely the diaphragmatic pericardium and the pleuropericardium. They may be combined. The problems in each type are different.

In ruptured diaphragmatic pericardium the rent may involve the pericardial cavity alone, or may extend into one or both adjoining pleural cavities. Upward herniation of abdominal viscera can occur, with or without strangulation. The presence of a pericardial rent may be suggested by diagnostic pneumoperitoneum, and chest films showing displaced abdominal viscera; its extent may be fully revealed only by thoracotomy. If the rent involves only the diaphragmatic pericardium without lateral spread into a pleural cavity, the presence of a rent may be revealed only by exploratory thoracotomy with pericardiotomy.

In ruptured pleuropericardium the rent is usually vertical and may occur on either side, more usually on the left. It may be recognized on chest films in its early stages by the presence of intrapericardial air arising from associated lung trauma. There is serious risk of heart dislocation with or without strangulation. The defect must be surgically repaired and, because of pericardial retraction, it may require a fabric patch. Teflon fabric has proved to be a long-term satisfactory pericardial substitute.

Two cases of each type of pericardial rupture are described and illustrate these points.

Late appearance of Bochdalek hernia

Images

Traumatic diaphragmatic transpericardial hernia

Images

Traumatic herniation into the pericardial sac

Images

An improved technic for vascular isolation of the liver: experimental study and case reports

Images