INTRAPERICARDIAL DIAPHRAGMATIC HERNIA WITH CENTRAL TENDON DEFICIENCY IN A CASE OF TRIPLE VESSEL CORONARY ARTERY DISEASE- AN INTRAOPERATIVE REVELATION nischit27@gmail.com

 

INTRAPERICARDIAL DIAPHRAGMATIC HERNIA WITH CENTRAL TENDON DEFICIENCY IN A CASE OF TRIPLE VESSEL CORONARY ARTERY DISEASE- AN INTRAOPERATIVE REVELATION

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India

Oral only

Intrapericardial diaphragmatic hernia (IPDH) with central tendon deficiency accounts for a very small percentage of all diaphragmatic hernias, either congenital or acquired.Most of them usually present in infancy with typical gastrointestinal symptoms. However, some patients remain asymptomatic and are detected incidentally. In adults, only 28 cases have been reported.

A middle aged male presented to our institute with angina and was diagnosed with severe triple vessel coronary artery disease, following which, he was scheduled for coronary artery bypass grafting.

After Median sternotomy and incision of pericardium, omentum was unusually seen encasing the heart on anterior and inferior aspect. On tracing inferiorly a large defect of size 10 x 10 cm was present in the diaphragm with absence of central tendon. Hernial sac and bowel were absent in the pericardium. After reducing the omentum into the abdomen, primary closure of the defect was done with polypropylene interrupted sutures followed by Off Pump Coronary artery bypass grafting.

IPDH are a very uncommon in adults and can remain asymptomatic until encountered with dangerous gastrointestinal complications. Studies recommend that all diaphragmatic herniae be repaired at the time of diagnosis. Since the chest x ray of the patient was normal, further imaging was not performed. In this case, hernia was of congenital origin as there was no history of trauma. Pericardioperitoneal communication and a deficient central tendon with clear surrounding structures further corroborates our credence. In asymptomatic individuals, slightest hint in preliminary investigations should evoke enough suspicion to probe further and rule out such abnormality.