© 2014 Wiley Periodicals, Inc.
473
PERIOPERATIVE MANAGEMENT_____________________________________________________
Asymptomatic Traumatic Diaphragmatic Hernia Discovered During an Aortic Valve Replacement Naoto Fukunaga, M.D.,* Hideya Seo, M.D.,y Hiroshi Hamakawa, M.D., Ph.D.,z and Tadaaki Koyama, M.D., Ph.D.* *Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan; yDepartment of Anesthesiology, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan; and zDepartment of Thoracic Surgery, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan ABSTRACT Asymptomatic traumatic diaphragmatic hernia, which presents in an adult, is an extremely rare entity. We discuss the management of a 63-year-old male with an asymptomatic traumatic diaphragmatic hernia discovered during aortic valve replacement. doi: 10.1111/jocs.12341 (J Card Surg 2014;29:473–475) A diaphragmatic hernia is very rarely discovered during cardiac surgery in an adult. Two reports have described simultaneous repair of a diaphragmatic hernia in the setting of cardiac diseases with good outcomes.1,2 We describe an asymptomatic traumatic diaphragmatic hernia that was discovered during valvular surgery and the perioperative management of these defects. PATIENT PROFILE The Institutional Review Board approved this report. A 63-year-old male presented with severe aortic stenosis. He had undergone endoscopic submucosal dissection for gastric cancer 2 years previously and had been involved in a traffic accident at 3 years of age. A chest X-ray showed elevation of the right diaphragm and no pulmonary edema (Fig. 1A). A pulmonary function test showed a vital capacity of 1.78 L and a forced expiratory volume in 1 second of 1.13 L. Computed tomography revealed that the intestinal tract had slightly penetrated the thoracic cavity (Fig. 1B). Transthoracic echocardiography showed a left ventricular ejection fraction of 63% and aortic stenosis with a valve area of 0.5 cm2. Through a standard median sternotomy, we found the right lung at the center of the mediastinum and heart sac deviating into the left thoracic cavity (Fig. 2A). The liver, Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Naoto Fukunaga, M.D., Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 21-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan. Fax: þ81-78-302-7537; e-mail: [email protected]
greater omentum, and small intestine were seen in the right thoracic cavity. There was complete absence of the right diaphragm. The patient underwent aortic valve replacement with an Epic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA). We did not address the absence of the right diaphragm surgically because the patient had been asymptomatic without the diaphragm. He was extubated the following day. Thereafter, his respiratory status gradually deteriorated to the point where reintubation was required. A chest X-ray demonstrated massive herniation of the small intestine into the right thoracic cavity (Fig. 1C), which compressed the lung on computed tomography (Fig. 1D). Conservative intervention was ineffective, so an emergency right thoracotomy was performed, through which the herniated small intestine could be clearly seen protruding from the thoracic cavity (Fig. 2B). The right diaphragm was reconstructed by tightly fixing a Gore-Tex sheet (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) to the vertebral body, sternal wires, and ribs to separate the thoracic and peritoneal space. The abdominal contents were then manually reduced under the sheet. The patient was weaned from the respirator and extubated. Postoperative pulmonary functions of vital capacity, 1.38 L and forced expiratory volume in 1 second of 1.06 L were similar to preoperative functions. He was discharged in good condition and no recurrent hernia has been detected to date (Fig. 1 E). DISCUSSION Congenital diaphragmatic hernias typically occur via natural diaphragmatic defects such as Morgagni’s
474
FUKUNAGA, ET AL. ASYMPTOMATIC TRAUMATIC DIAPHRAGMATIC HERNIA
J CARD SURG 2014;29:473–475
Figure 1. (A) Preoperative X-ray showing elevated right diaphragm. (B) Computed tomography confirming the location of intestinal tract. (C) X-ray taken on postoperative day 1 showing massive herniation of small intestine in right thoracic cavity. (D) Computed tomography of coronal plain confirming massive herniation of small intestine occupying right thoracic cavity and compressing the lung. (E) Chest X-ray at outpatient clinic showing absence of recurrent hernia.
Figure 2. (A) At a standard median sternotomy, the right lung at the center of the mediastinum and heart sac deviating into the left thoracic cavity are shown. (B) View through thoracotomy, herniated small intestine protruding from thoracic cavity where herniated liver is also located.
J CARD SURG 2014;29:473–475
foramen or Bochdaleck’s foramen. With the exception of traumatic diaphragmatic hernias that mostly involve the left dome of the diaphragm, acquired hernias usually extend from the esophageal hiatus. Only two case reports have described repair of a diaphragmatic hernia together with simultaneous cardiac surgery,1,2 and one of them describes a diaphragmatic hernia which was accidentally discovered during cardiac surgery. We assumed that the present diaphragmatic hernia was due to trauma because our patient had been involved in a traffic accident and the abnormality was not detected when he was born. The patient had been asymptomatic for 60 years despite the complete absence of a diaphragm, and having abdominal vital organs located in the thoracic cavity. One reason might have been due to protection offered by the liver on the right side.3 In retrospect, we should have reconstructed the diaphragm during aortic valve replacement as both published reports describe good postoperative outcomes with such procedures.
FUKUNAGA, ET AL. ASYMPTOMATIC TRAUMATIC DIAPHRAGMATIC HERNIA
475
Huang et al.2 advocated a median sternotomy to allow the mobilization of herniated contents and repair diaphragmatic hernias. Rather than a median sternotomy for our patient, we considered that a thoracotomy would provide better exposure of the herniated contents and surrounding structures on which to fix the artificial sheet. This experience provides further evidence to suggest that cardiac conditions and diaphragmatic hernias should be simultaneously repaired. REFERENCES 1. Kessler R, Pett S, Wernly J: Peritoneopericardial diaphragmatic hernia discovered at coronary bypass operation. Ann Thorac Surg 1991;52:562–563. 2. Huang MW, Young JN: Massive recurrent anterior diaphragmatic hernia, coronary artery disease, and valvular heart disease. Ann Thorac Surg 2005;79:1417–1419. 3. Mullins ME, Stein J, Saini SS, et al: Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR, 2001; 177:363–366.
473
PERIOPERATIVE MANAGEMENT_____________________________________________________
Asymptomatic Traumatic Diaphragmatic Hernia Discovered During an Aortic Valve Replacement Naoto Fukunaga, M.D.,* Hideya Seo, M.D.,y Hiroshi Hamakawa, M.D., Ph.D.,z and Tadaaki Koyama, M.D., Ph.D.* *Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan; yDepartment of Anesthesiology, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan; and zDepartment of Thoracic Surgery, Kobe City Medical Center General Hospital, Chuo-ku, Kobe, Japan ABSTRACT Asymptomatic traumatic diaphragmatic hernia, which presents in an adult, is an extremely rare entity. We discuss the management of a 63-year-old male with an asymptomatic traumatic diaphragmatic hernia discovered during aortic valve replacement. doi: 10.1111/jocs.12341 (J Card Surg 2014;29:473–475) A diaphragmatic hernia is very rarely discovered during cardiac surgery in an adult. Two reports have described simultaneous repair of a diaphragmatic hernia in the setting of cardiac diseases with good outcomes.1,2 We describe an asymptomatic traumatic diaphragmatic hernia that was discovered during valvular surgery and the perioperative management of these defects. PATIENT PROFILE The Institutional Review Board approved this report. A 63-year-old male presented with severe aortic stenosis. He had undergone endoscopic submucosal dissection for gastric cancer 2 years previously and had been involved in a traffic accident at 3 years of age. A chest X-ray showed elevation of the right diaphragm and no pulmonary edema (Fig. 1A). A pulmonary function test showed a vital capacity of 1.78 L and a forced expiratory volume in 1 second of 1.13 L. Computed tomography revealed that the intestinal tract had slightly penetrated the thoracic cavity (Fig. 1B). Transthoracic echocardiography showed a left ventricular ejection fraction of 63% and aortic stenosis with a valve area of 0.5 cm2. Through a standard median sternotomy, we found the right lung at the center of the mediastinum and heart sac deviating into the left thoracic cavity (Fig. 2A). The liver, Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Naoto Fukunaga, M.D., Department of Cardiovascular Surgery, Kobe City Medical Center General Hospital, 21-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan. Fax: þ81-78-302-7537; e-mail: [email protected]
greater omentum, and small intestine were seen in the right thoracic cavity. There was complete absence of the right diaphragm. The patient underwent aortic valve replacement with an Epic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA). We did not address the absence of the right diaphragm surgically because the patient had been asymptomatic without the diaphragm. He was extubated the following day. Thereafter, his respiratory status gradually deteriorated to the point where reintubation was required. A chest X-ray demonstrated massive herniation of the small intestine into the right thoracic cavity (Fig. 1C), which compressed the lung on computed tomography (Fig. 1D). Conservative intervention was ineffective, so an emergency right thoracotomy was performed, through which the herniated small intestine could be clearly seen protruding from the thoracic cavity (Fig. 2B). The right diaphragm was reconstructed by tightly fixing a Gore-Tex sheet (W.L. Gore & Associates, Inc., Flagstaff, AZ, USA) to the vertebral body, sternal wires, and ribs to separate the thoracic and peritoneal space. The abdominal contents were then manually reduced under the sheet. The patient was weaned from the respirator and extubated. Postoperative pulmonary functions of vital capacity, 1.38 L and forced expiratory volume in 1 second of 1.06 L were similar to preoperative functions. He was discharged in good condition and no recurrent hernia has been detected to date (Fig. 1 E). DISCUSSION Congenital diaphragmatic hernias typically occur via natural diaphragmatic defects such as Morgagni’s
474
FUKUNAGA, ET AL. ASYMPTOMATIC TRAUMATIC DIAPHRAGMATIC HERNIA
J CARD SURG 2014;29:473–475
Figure 1. (A) Preoperative X-ray showing elevated right diaphragm. (B) Computed tomography confirming the location of intestinal tract. (C) X-ray taken on postoperative day 1 showing massive herniation of small intestine in right thoracic cavity. (D) Computed tomography of coronal plain confirming massive herniation of small intestine occupying right thoracic cavity and compressing the lung. (E) Chest X-ray at outpatient clinic showing absence of recurrent hernia.
Figure 2. (A) At a standard median sternotomy, the right lung at the center of the mediastinum and heart sac deviating into the left thoracic cavity are shown. (B) View through thoracotomy, herniated small intestine protruding from thoracic cavity where herniated liver is also located.
J CARD SURG 2014;29:473–475
foramen or Bochdaleck’s foramen. With the exception of traumatic diaphragmatic hernias that mostly involve the left dome of the diaphragm, acquired hernias usually extend from the esophageal hiatus. Only two case reports have described repair of a diaphragmatic hernia together with simultaneous cardiac surgery,1,2 and one of them describes a diaphragmatic hernia which was accidentally discovered during cardiac surgery. We assumed that the present diaphragmatic hernia was due to trauma because our patient had been involved in a traffic accident and the abnormality was not detected when he was born. The patient had been asymptomatic for 60 years despite the complete absence of a diaphragm, and having abdominal vital organs located in the thoracic cavity. One reason might have been due to protection offered by the liver on the right side.3 In retrospect, we should have reconstructed the diaphragm during aortic valve replacement as both published reports describe good postoperative outcomes with such procedures.
FUKUNAGA, ET AL. ASYMPTOMATIC TRAUMATIC DIAPHRAGMATIC HERNIA
475
Huang et al.2 advocated a median sternotomy to allow the mobilization of herniated contents and repair diaphragmatic hernias. Rather than a median sternotomy for our patient, we considered that a thoracotomy would provide better exposure of the herniated contents and surrounding structures on which to fix the artificial sheet. This experience provides further evidence to suggest that cardiac conditions and diaphragmatic hernias should be simultaneously repaired. REFERENCES 1. Kessler R, Pett S, Wernly J: Peritoneopericardial diaphragmatic hernia discovered at coronary bypass operation. Ann Thorac Surg 1991;52:562–563. 2. Huang MW, Young JN: Massive recurrent anterior diaphragmatic hernia, coronary artery disease, and valvular heart disease. Ann Thorac Surg 2005;79:1417–1419. 3. Mullins ME, Stein J, Saini SS, et al: Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR, 2001; 177:363–366.
