Robert A Grossman, MD, Daniela Treitl, MD, Michael Hurtado, MD, Irvin Willis, MD. Mount Sinai Medical Center
Background: The minimally invasive maze procedure can be performed to attain sinus rhythm in patients with atrial fibrillation. We present a case in which a patient presented eight days after a minimally invasive hybrid maze procedure with epigastric pain, obstipation, nausea, and vomiting as well as tachycardia of two days’ duration. He was found to an intrapericardial diaphragmatic hernia containing small bowel causing both small bowel obstruction and cardiac tamponade.
Methods: The decision was made to attempt laparoscopic reduction of small bowel, with possible sternotomy if unsuccessful. After insufflation and entry to the abdomen, four trocars were inserted in a semi-circle triangulated upon the central tendon of the diaphragm. The bowel was found to have herniated through the diaphragmatic incision, and had become incarcerated and necrotic. The bowel was reduced with gentle traction, and a large volume of dark blood was expelled through the defect. After reducing the bowel out of the pericardial sac, the pericardium was copiously irrigated. The diaphragmatic defect was closed with three figure-of-eight sutures and subsequently buttressed with a falciform flap secured in place with simple interrupted sutures. The necrotic bowel was subsequently removed and small bowel reanastomosed via a small midline incision. The patient recovered well post-operatively without any significant events and postoperative imaging demonstrated resolution of the pericardial hernia.
Conclusions: Intrapericardial diaphragmatic hernia is a rare event typically occurring after trauma. In the setting of prior surgery, small bowel obstruction and cardiac tamponade can occur when the hernia contains small bowel. Laparoscopic reduction of the small bowel and closure of the defect with buttressing of the falciform ligament obviates the risk of mesh infection in this contaminated field, suggesting a feasible and safe surgical option.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 79844
Program Number: V080
Presentation Session: Friday Exhibit Hall Video Presentations Session 2 (Non CME)
Presentation Type: EHVideo