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Case reports
Traumatic herniation into the pericardial sac
PATRICK W. DAVIS*F.R.C.S.
Hammersmith Hospital
TRAUMATIC rupture of the diaphragm may beassociated with
herniation into the chest ofabdominal viscera. The nature of the
injury maybe direct (penetrating), or indirect (blunt or
crushtrauma). Rupture occurs more commonly on theleft side: the
right side is said to be protectedby the liver. This report
describes a case of apure intrapericardial hernia of traumatic
origin.
Case reportS.P. a 17-year-old Jamaican boy was knocked
off his bicycle and run over by a lorry 25 July1967.On
admission. Preliminary examination showed
that he had a fractured right clavicle, fracturedpelvis and
injuries to the chest wall anteriorly.Surgical emphysema was
palpated over the frontof his chest and an immediate chest X-ray
showedevidence of pulmonary contusion. About 4 hrlater another
chest X-ray (Fig. 1) was takenbecause of increasing dyspnoea. This
showed apneumothorax on the left side and a gas shadowabove the
diaphragm.The next day further views of the chest (Figs. 2
and 3) and a gastrografin swallow were per-formed. The
impression gained was that thebowel, probably colon, was situated
in theanterior mediastinum, possibly in the pericardium.On this day
the patient complained of increas-ing upper abdominal pain, and an
electrocardio-gram showed a sinus tachycardia of 140/min.Laparotomy
was performed through a midlineepigastric incision and a dilated
loop of trans-verse colon was found lying in front of and abovethe
liver. This was withdrawn easily and revealeda large transverse
tear in the central tendon ofthe diaphragm leading directly into
the pericard-ial cavity. The tear was between 4 and 5 in. longand
the margins, which were ragged, werestretched apart. There was no
hernial sac. Accessfrom below was inadequate to allow a
satisfactoryrepair so a left thoracotomy was performedthrough the
fifth intercostal space and the peri-
*Present address: Liandough Hospital, Cardiff.
cardial sac was opened. With retraction of thelower border of
the heart this gave good ex-posure of the margins of the defect
(Fig. 4).Repair was performed with horizontal mattresssutures of
No. 1 Ethicon. Apart from a pelvichaematoma no other abnormality
was foundwithin the abdomen. The patient made a goodrecovery.
DiscussionPilcher (1965) points out that congenital or
acquired herniae may occur into the pericardium.More
specifically Guthrie (1855) recorded thecase of a soldier who died
some months afterreceiving a penetrating wound of the chest atthe
battle of Waterloo. Autopsy revealed a holein the central tendon of
the diaphragm and therewere signs of pericarditis. Guthrie stated
'if thisman had lived long enough he might have furn-ished evidence
of hernia of the stomach or ofintestine into the pericardium'. In
1921 Bryanin a Hunterian lecture on injuries of thediaphragm, based
mainly on his experiences inWorld War I, discussed the morbid
anatomy ofdiaphragmatic herniae and noted that 'very rarelyhernia
through the central tendon into the peri-cardium has happened'.
O'Brien (1939) describeda pericardio-peritoneal communication found
inthe course of anatomical dissection. He surveyedthe literature
and found that pericardio-peritoneal communications had been
describedin five instances in man, four in the dog and onein the
ass. All were considered congenital excepttwo occurring in adult
males: these were listedas 'possibly traumatic'. No satisfactory
explana-tion of the primary embryological aetiology ofthese defects
was offered.A review of American literature dealing with
large numbers of traumatic diaphragmaticherniae does not include
a description of hernia-tion of abdominal viscera into the
pericardialsac (Harrington, 1948, 1951 ; Hill, 1964; Noon,Beall
& De Bakey, 1966; Waldhausen et al., 1966).
Similarly the British literature does not des-cribe such an
occurrence (Marsden, 1947; Evans
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876 Case reportsF"
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FIG. 1. Chest X-ray (erect) 4 hr later. Note sub-cutaneous
emphysema, the large left pneumothorax andthe gas shadow above the
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FIG. 2. Chest X-ray, AP view in left lateral decubitus.The gas
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FIG. 3. Chest X-ray (erect, right lateral). A gas-filledviscus
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FIG. 4. Left thoracotomy: view of ruptured centraltendon of
diaphragm after opening pericardium.
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Case reports
& Simpson, 1950; Probert & Harvard, 1961).Robb (1963)
reviewed five cases of traumaticdiaphragmatic hernia involving the
pericardium;of these only two were confined to the pericar-dium.
The case he added was a purely intra-pericardial hernia, as was
that described byHerman & Goldstein (1965) and Nelson
(1966).
All six cases, which include the subject of thisreport, have
been related to blunt trauma; fivewere males, and three of these
were negroes.The contents of the pericardial sac have beenreported
as stomach, omentum, colon and leftlobe of the liver. The
disposition of the tear hasbeen reported as oblique anteroposterior
in threecases and transverse in two.
DiagnosisIt is well recognized that traumatic diaphrag-
matic hernia may be obvious immediately orbecome evident later,
perhaps as a result of ratherbizarre alimentary symptoms. Lastly it
mayremain silent and undetected for a number ofyears and manifest
itself by sudden obstructionor strangulation (Carter, Giuseffi
& Felson,1951). Nelson's case (1966) was diagnosed somemonths
following a road accident. Thoracotomyrevealed no paraoesophageal
or intrathoracichernia though this had been outlined by
plainradiography and barium studies prior to opera-tion. Further
films taken after the negative ex-ploration showed persistence of
the hernia andat a second operation stomach was found in
thepericardial sac.The diagnosis might be suspected in cases of
multiple injuries which are becoming morecommon. In 1965, 1510
patients died with'internal injury of the chest, abdomen and
pelvis',showing an increase on the preceding year when1442 patients
died from the same injuries (Regis-trar General 1965). In the case
described here,the possibility of herniation of a viscus into
thepericardial sac might have been raised on accountof
breathlessness, upper abdominal pain and sinustachycardia. The
diagnosis was suggested on plainX-ray examination in the erect
position, and thedecubitus film in the 'left side down' position
wasparticularly helpful in defining the limits of thestructures
involved (Fig. 2). The gastrografinswallow was not helpful in this
case. Bariummeal with follow through and barium enema ex-amination
may be of assistance and the use ofpneumoperitoneum has been
recommendedthough Pilcher (1965) warns against the possibil-ity of
producing cardiac tamponade.
ManagementThe fact that 90% of strangulated diaphrag-
matic herniae are traumatic in origin and mostof these occur
within 3 years of injury is goodreason for early surgical treatment
(Carter et al.,1951). Because rupture of the diaphragm is
asso-ciated often with other injuries especially of theabdominal
organs, an initial approach throughthe abdomen is advisable. This
case was notablefor the absence of injury to any of the
abdominalviscera.
Repair of the diaphragm is performed mosteasily from above, and
as in this case, throughthe pericardium. Non-absorbable suture
material,placed in one or two layers, is used to obliteratethe
defect. Rarely small defects may heal spon-taneously (Greig, 1919),
but since these are morelikely to be associated with obstruction or
strang-ulation it would be foolhardy to wait for thisto happen. If
there is difficulty in apposing themargins of the defect, skin,
fascia or man-madefibre may be used to bridge the gap, or
itsmargins may be sutured to the liver (Sandford &Stafford,
1956; Waldhaussen et al., 1966). Othersuggestions have included the
use of a pedicledpericardial flap (Desforges et al., 1957). Owingto
the site of the tear in this case the question of'splinting' the
diaphragm by phrenic nerve crushor use of a ventilator did not
arise.
MechanismSince Ambroise Pare (1579) first described
traumatic rupture of the diaphragm no satisfac-tory explanation
has been found to account forthe forces involved, their manner of
transmis-sion to the diaphragm and the consequent loca-tion and
direction of any tear. If the term trau-matic rupture is taken to
include iatrogeniccauses, then incision and repair of the
diaphragmfor the purpose of surgical access, and sub-phrenic
abscess may be borne in mind. A medicalhistory which includes these
events may help toexplain unusual alimentary symptoms at a
laterdate in the life of the patient. With regard toaccidental
trauma, it is tempting to consider rup-ture of the diaphragm as a
local event analogousto the tearing of muscle fibres that will
occurunder conditions of stress in the rectusabdominis, the biceps
and quadriceps femorisand the musculo-tendinous region of the
calfmuscles. As a result of sudden and intense con-traction the
diaphragm might tear; the intrinsicforces involved, asymmetrically
distributed andpossibly modified by external factors will
accountfor the location and disposition of a tear. In thecase
presented, there was no contusion of theherniated colon: the X-rays
demonstrate that ittravelled through the diaphragm some 4 hr
afterthe accident. This suggests that the tear in the
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878 Case reports
diaphragm might have been the result of isolatedlocal stress
rather than the consequence of muchraised intra-abdominal
pressure.
AcknowledgmentsThe patient was admitted under the care of Mr R.
H.
Franklin to whom I am grateful for advice in managementand for
permission to publish this case. Dr F. Doyle andDr J. Taubman were
responsible for the radiology and MrBracknell reproduced the X-rays
for publication. Miss S.Barker of the Department of Medical
Illustration providedFig. 4.
ReferencesBRYAN, C.W.G. (1921) Injuries of the diaphragm. Brit.
J.
Surg. 9, 117.CARTER, B.N., GIUSEFFI, J. & FELSON, B. (1951)
Traumatic
diaphragmatic hernia. Amer. J. Roentgenol. 65, 56.DESFORGES, G.,
STREIDER, J.W. LYNCH, J.P. & MADOFF, I.M.
(1957) Traumatic rupture of the diaphragm. J. Thorac.Surg. 34,
779.
EVANS, C.J. & SIMPSON, J.A. (1950) Fify-seven cases
ofdiaphragmatic hernia and eventuation. Thorax, 5, 343.
GREIG, D.M. (1919) A case ofdiaphragmatic hernia followinga
gunshot wound. Edinb. med. J. 22, 357.
GUTHRIE, G.J. (1855) Commentaries on the Surgery of theWar,
etc., 6th edn, p. 513. Henry Renshaw, London.
HARRINGTON, S.W. (1948) Various types of diaphragmatichernia
treated surgically. Surg. Gynec. Obstet. 86, 735.
HARRINGTON, S.W. (1951) Clinical manifestations of hiatushernia.
Rev. Gastroent. 18, 243.
HERMAN, P.G. & GOLDSTEIN, J.E. (1965) Traumatic
intra-pericardial diaphragmatic hernia. Brit. J. Radiol. 38,
631.
HILL, G.C. (1964) Some unusual cases of traumatic diaphrag-matic
hernia. J. nat. med. Ass. (N. Y.), 56, 401.
MARSDEN, C.M. (1947) Traumatic diaphragmatic hernia.J. roy. Army
med. Corps. 89, 71.
NELSON, J.F. (1966) The roentgenologic evaluation ofabdominal
trauma. Rad. Clin. N. Amer. 4, 429.
NOON, G.P., BEALL, A.C. & DE BAKEY, M.E. (1966)
Surgicalmanagement of traumatic rupture of the diaphragm.J. Trauma,
6, 344.
O'BIUEN, H.D. (1939) Pericardio-peritoneal
communication:description of a rare type of diaphragmatic hernia.
J. Anat.(Lond.), 74, 131.
PILCHER, R.S. (1965) Thorax. Clinical Surgery (Ed. byA.L.
d'Abreu, C. Robb and R. Smith), Vol. 5, p. 385.Butterworths,
London.
PROBERT, W.R. & HARVARD, C. (1961) Traumatic diaphrag-matic
hernia. Thorax, 16, 99.
REGISTRAR GENERAL (1965) Statistical Review, Part 1,
Tables,Medical, pp. 175 and 176. H.M.S.O., London.
ROBB, D. (1963) Traumatic diaphragmatic hernia into
thepericardium. Brit. J. Surg. 50, 664.
SANDFORD, M.C. & STAFFORD, E.S. (1956) Diaphragmatichernia
caused by trauma; diagnosis and treatment. Post-grad. Med. 19,
60.
WALDHAUSEN, J.A., KILMAN, J.W., HELMAN, C.H. &BATTERSBY,
J.S. (1966) Diagnosis and treatment of trau-matic injuries of the
diaphragm. J. Trauma, 6, 332.
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