Injury, Int. J. Care Injured 32 (2001) 153–156

Case report

Traumatic intrapericardial diaphragmatic hernia: case report andliterature review

A. Reina *, E. Vidana, P. Soriano, A. Orte, M. Ferrer, E. Herrera, M. Lorenzo,J. Torres, R. Belda

Department of General and Digesti6e Surgery. Hospital Torrecardenas, Paraje Torrecardenas s/n., 04009 Almerıa, Spain

Accepted 12 July 2000

www.elsevier.com/locate/injury

1. Introduction

A traumatic rupture of the diaphragm, with hernia-tion of the abdominal viscera into the thoracic cavity, isrelatively rare, being observed in �3–7% of all ab-dominal or thoracic traumas [1]. Herniation into thepericardium is very rare [2]. We have reviewed thepost-traumatic intrapericardial diaphragmatic hernias(TIPDH) published in the world literature within ourreach and, as it was already stated in the review carriedout by Van Loenhout et al. [3] in 1986, approximatelyone post-traumatic intrapericardial hernia is reportedevery year. The patient that we present makes case 82of those published until October of 1999.

2. Case report

A 65 year old man had a road traffic crash in May1990 that caused him a double left costal fracture —sixth and seventh ribs — and a pelvic fracture. In

January 1991, he had another road traffic crash with ablunt abdominal trauma. An emergency midline laparo-tomy revealed a mesentery laceration, and a 60 cmresection was performed in the small bowel.

Throughout 1995 and 1996, the patient reportedminimal and sporadic abdominal pain without anyother clinical symptoms. In November 1996, the patientreported moderate, diffuse abdominal pain without aclear location and nausea/vomiting. The analyses andECG were normal. CT scan (Fig. 1) demonstratedmediastinic and intrabdominal masses. A midline la-parotomy showed a 7 cm defect in the central portion

of the diaphragm into which the greater omentum washerniated. Adhesiolysis between omentum and peri-cardium was done, whereafter the contents of the her-nia could be reduced. The central tendon defect wasrepaired with polyglactin interrupted sutures. The in-traperitoneal masses were biopsied and reported aslipomathosis.

The postoperative course was uneventful. In the lastfollow-up evaluation, 29 months after the operation,there was no recurrence.

3. Literature review

According to some authors [1,3], most diaphragmaticruptures are caused by the conjunction of two factors:the most important — and sometimes the only one —is, obviously, a severe thoracic or abdominal trauma-tism during which the abdominal pressure — usuallybetween 2 and 10 cm H2O — rises to at least 1000 cmH2O. The second factor would be a failure duringembryologic development with a potential defectivemembranous area of the diaphragm [3].

In 1903, DeCardinal et al. [4] reported the firstintrapericardial diaphragmatic hernia — of congenitalorigin — while Keith [5] made the first report of trau-matic intrapericardial diaphragmatic hernia in 1910 asautopsy findings in two cases. Since that time, ananalysis of reported cases has only shown a few refer-ences to TIPDH. Hence, in the review carried out byLarrieu et al. 1980 [6] — 70 years after Keith — only27 cases are documented, out of which only 17 werepericardiophrenic hernias with a traumatic etiology. Sixyears later, in 1986 Lohenhout et al. [3] found andreviewed 58 TIPDH descriptions, and they also con-* Corresponding author. Tel.: +34-50016000, ext, 6855.

0020-1383/01/$ - see front matter © 2001 Elsevier Science Ltd. All rights reserved.PII: S 0020 -1383 (00 )00151 -0

A. Reina et al. / Injury, Int. J. Care Injured 32 (2001) 153–156154

Fig. 1. CT scan shows an apparent mediastinic lipomathosis.

tributed a case. After that paper, we have revised all thecases of TIPDH published until October 1999. We havefound 19 papers, with 22 new cases reported [1–3,7–23]. The references by year are listed in Table 1.

Therefore, as a whole, there have been 81 cases ofTIPDH reported in the world literature, and our pa-tient is the 82nd case published. We have reviewed theepidemiologic, clinical, diagnostic and therapeutic dataof all these cases, but we have not included fourpatients, since we have not had access to their refer-ences [8,11,14,22]. TIPDH is more frequent in malepatients: 52 patient were male, 22 were female and, infour, sex was not reported. In general, the acceptedmale predominance ratio is 3:1. A total of 60% of thepatients were between 30 and 60 years old [3]; meanage, 48.4 years.

Most TIPDH were caused by blunt trauma to chest,abdomen or both. Road traffic crashes (71.4%) was themost usual mode of injury, and the remaining 30% hadanother origin: Eight patients suffered some type ofheavy blow to the chest or abdomen, four patients fellfrom a height and two were stabbed. In eight cases, thecause was unknown. The diagnosis was immediate(during the traumatic phase) in 37 patients (48.05%)and delayed in 37 (48.05%) with an interval time from23 days to 23 years. Three references did not contributethat data [3]. In the patients who presented in thedelayed phase, the average interval between injury anddiagnosis was 4.8 years. The clinical symptoms arelisted in Table 2. In these patients, associated injuriesare frequent (Table 3). There was a predominance ofrib fractures (36 patients), fractured pelvis (19 patients)and head injury (12 patients).

In 25 patients [2,3,6,8–10,13,16,17,19], the diagnosisof TIPDH was considered on the basis of chest X-ray.Additional diagnostic tools were CT scan [20], contraststudies [9,15,23] or echocardiography [6,17,18], al-though, in many cases, as in ours, TIPDH was recog-nized as incidental findings at surgery [1,2,21].

Table 1Reported cases by year

Year ReferencesNumber

59 [3]Until 1986–1987 –

1988 2 [7,8]11989 [9]

1990 ––1991 [10–13]51992 4 [2,14]1993 2 [15,16]

[1]11994[17]1995 1

31997 [18–20]1998 2 [21,22]1999 [23]1

81Total

Table 2Clinical symptoms

Clinical symptoms Number

Hypovolemic 9Cardiac Tamponade 6

28Abdominal signs33Respiratory signs

Cardiac signs 11Nausea/vomiting 7No symptoms 9Unknown 5

A. Reina et al. / Injury, Int. J. Care Injured 32 (2001) 153–156 155

Table 3Associated injuries

Injury Number

Rib fractures 36Fractured pelvis 20Head injury 12

16Leg fracturesSpleen 9

6Urologic injuries10Arm/ Clavicle

Vertebral fracture 34Pneumotorax3Lung injury

Cardiac luxation 1Other 15

postoperative complications, cardiac tamponade, is arare condition, which has just been reported in one case[24]. Other complications may be the adult respiratorydistress syndrome or pericardial effusion [9,23]. Sevendeaths have been reported (9.4%).

4. Conclusion

TIPDH imply significant trauma and are associatedwith other injuries, mainly rib fractures, pelvic fracturesor head injuries. Clinical symptoms vary from cardiactamponade to non specific abdominal or respiratorysymptoms. Plain chest radiography may be helpful inestablishing the diagnosis although in many cases, as inours, TIPDH can be an incidental finding at surgery. Ahigh index of suspicion with the appropriate investiga-tions is the mainstay of management. A trans-abdomi-nal approach id s preferred for surgical closure in theacute phase as it provides good access to the tear in thediaphragm. Most authors recommend thoracotomy inmost cases of delayed TIPDH where divisions of adhe-sions in the pericardium is necessary. Treatment con-sists of closing the defect with nonabsorbable sutures orwith the use of a patch. Primary repair generally resultsin a good prognosis.

References

[1] Fleyfel M, Ferreira JF, Gonzalez De Linares H, et al. Cardiactamponade after intrapericardial diaphragmatic hernia. Br JAnaesthesiol 1994;73:249.

[2] Aldhoheyan A, Jain SK, Hamdy M, et al. Traumatic intraperi-cardial diaphragmatic hernia. Injury 1992;23:331.

[3] Van Loenhout RMM, Schiphorst TJMJ, Wittens CHA, et al.Traumatic intrapericardial diaphragmatic hernia. J Trauma1986;26:271.

[4] DeCardinal, Grenier, Bourderou. Hernie diaphragmatique ducolon transverse dans le pericarde chez un adulte. J MedBourdeaux 1903; 23:22.

[5] Keith A. Remarks on diaphragmatic hernias. Br Med J1990;2:1297.

[6] Larrieu AJ, Wiener I, Alexander R, et al. Pericardiodiaphrag-matic hernia. Am J Surg 1980;139:436.

[7] Bellakhdar A, Abi F, Khalidi A, et al. Un case de hernie intrapericardique post-traumatique chez l’enfant. Chir Pediatr1988;29:47.

[8] Bourdeaud%hui A, Roques X, Laborde N, et al. Hernie diaphrag-matique intrapericardique. Revue de la litterature. A propposd’un cas. Ann Chir 1988;42:118.

[9] Laric MJ, Roger M, Broude HB. Intrapericardial diaphragmatichernia. A case report. S Afr J Surg 1989;27:100.

[10] Girzadas DV, Fligner DJ. Delayed traumatic intrapericardialdiaphragmatic hernia associated with cardiac tamponade. AnnEmerg Med 1991;20:1246.

[11] Mayor-Davis JA, Britz RS, Soares MJ. Intrapericardial hernia-tion. A report of 2 cases. S Afr J Surg 1991;29:55.

[12] Beless DJ, Organ BC. Delayed presentation of intrapericardialdiaphragmatic hernia, an unusual cause of colon obstruction.Ann Emerg Med 1991;20:415.

Table 4Herniated organs

Organ Number

39Transverse colonStomach 33

31Greater omentumLiver 9Small intestine 9Spleen 2None/unknown 4

The surgical approach was abdominal in 35 patients,most of whom (25 cases) were diagnosed during theimmediate post-traumatic period [1–3,9,17–20]. Thethoracic approach was used in 24 patients, 18 of whomwere diagnosed in the delayed phase [3,15]. In ninepatients, the approach was a combined thoracoabdomi-nal procedure [3,8,13] and in nine it was unknown[3,12]. The thoracic approach is preferred in patientswith delayed TIPDH, since adhesions in the peri-cardium can be freed more easily. In our case, due tothe intraoperatory diagnosis of TIPDH, an abdominalapproach was used. The division of the pericardiumadhesions and the reduction of the hernia were per-formed without difficulties.

The mean length of the diaphragmatic laceration was10.3 cm, although in 21 patients this data was notreported. In one case, there was an associated injury inthe left diaphragm [17]. The organ most frequentlyinvolved in TIPDH was (Table 4) the transverse colon,found in 39 patients [3,6,8,10,12,13,15,19,20,23], fol-lowed by the stomach [1–3,9,15,16,18,19,21] in 33 casesand the greater omentum [3,8,10,12,13,18] with 31cases, including our patient.

Most authors recommend the closing of the hernialdefect with nonabsorbable sutures [2,6,13,18,19] al-though the use of absorbable sutures [3,21] or a patchfor the appropriate closing of the diafragmatic lacera-tion has also been reported [8,9,23]. The most feared

A. Reina et al. / Injury, Int. J. Care Injured 32 (2001) 153–156156

[13] Letessier E, Loubersac P, Gibaud H, et al. Hernie phreno-peri-cardique post.traumatique. Rapport d’un cas. J Chir1991;128:101.

[14] Buinebich GA. Ushchemlenie postravmaticheskoi diafrag-moperikardial%noi gryzhi. Khirurgiia 1992;4:89.

[15] Sugio K, Fukushima Y, Akasu I, et al. A case of a traumaticdiaphragmatic true hernia manifesting itself 12 years after theaccident. Nippon Kyobu Geka Gakkai Zasshi 1993;41:1229.

[16] De Rooij PD, Haarman HJ. Herniation of the stomach intopericardial sac combined with cardiac luxation caused by blunttrauma: a case report. J Trauma 1993;34:453.

[17] Ikeda E, Kawakami S, Otsuka K, et al. Nippon Kyobu GekaGakkai Zasshi 1995;43:1234.

[18] Colliver C, Oller DW, Rose G, et al. Traumatic intrapericar-dial diaphragmatic hernia diagnosed by echocardiography. JTrauma 1997;42:115.

[19] Muysoms F, Verhelst H, Schroe H. Traumatic Intrapericardialdiaphragmatic hernia. J Accid Emerg Med 1997;14:156.

[20] Barker JA, Gavant ML, Hughes CB. Posttraumatic intra-pericardial diaphragmatic hernia. Am J Roentgenol1997;169:315.

[21] Stefani A, Brandi L, Ruggiero C, Lodi R. A case of traumaticpericardiophrenic rupture. J Cardiovasc Surg (Torino)1998;39:859.

[22] Glasser DL, Shanmuganathan K, Mirvis SE. General case ofthe day. Acute intrapericardial diaphragmatic hernia. Radio-graphics 1998;18:799.

[23] Valestaqui R, Mehran RJ. Traumatic hernia of the peri-cardium. J Trauma 1999;46:513.

[24] Le Treut YP, Herve L, Cardon JM, et al. Blunt traumaticrupture of the right ventricle with intrapericardial rupture ofthe diaphragm: Successful surgical repair. Injury 1981;13:66.

.