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Herniation of the left auricle
HERNIATION OF THE LEFT AURICLE* COMDR.
WESLEY
FRY, M.C.
Oakland, Calijornia
A
N interesting case of herniation of the Ieft auricIe through a defect in the pericardium is presented because of the un-
FIG. I. Postero-anterior roentgenogram of chest showing mass in the vicinity of puImonary conus which at operation was proved to be a herniated Ieft auricle.
usua1 nature of this condition and because of the diffrcuIty in making an accurate evaIuation of the condition before operation. CASE
REPORT
A white man, twenty years of age, was referred to this hospital with a diagnosis of “mediastina1 mass” after an x-ray of the chest
an abnormal shadow in the region of the conus arteriosus. The patient was asymptomatic. Studies in the hospita1 confirmed the roentgenographic finding. (Fig. I.) The history and physical examination provided no Iead as to the diagnosis. The usua1 Iaboratory examinations yieIded resuIts within norma limits. Cardiac Auoroscopy was performed with barium swaIIow. By this examination it was not possibIe to separate the mass in the vicinity of the Ieft puImonary artery from the cardiac siIhouette. In fact the mass was observed to puIsate. The roentgenoIogist believed that the mass probabIy represented hiiar Iymph nodes and, possibIy, Iymphoma. LateraI views of the chest were of no heIp in IocaIizing the mass visibIe in the postero-anterior fiIm. Pursuant to our poIicy that necessity exists for expIoration and surgical remova of mediastinal masses when they cannot be proved to be innocuous, a Ieft thoracotomy was performed upon this patient. A preoperative diagnosis of mediastina1 tumor was made. At operation when the Ieft Iung had been retracted posteriorIy, exposing the anterior mediastinum, the auricuIar appendage of the Ieft atrium was found to be in the pleural cavity. (Fig. 2.) There was a smaI1 defect in the pericardium through which the auric!e protruded. The auricIe appeared to be somewhat Iarger than average size. It was extremely irritabIe as evidenced by the fact that touching it resuIted in arrhythmia of short duration. Bathing the auricIe with I per cent procaine soIution rendered the auricIe Iess irritabIe and it was possibIe to explore the pericardial defect digitaIIy. A finger passed readiIy into the pericardia1 sac through the abnorma1 hiatus with-
* From the Surgical Service, United States NavaI Hospital, Oakland, CaIif. The opinions expressed are those of the author and are not to be construed as olIicia1 or reffecting the views of the Navy Department or the Naval Service at Iarge.
736
American
Journal
of Surgery
Fry-Herniation out constricting the auricIe unduly. The heart was free from the periiardium all around the defect. There was no evidence of thrombosis on inspection and paIpation of the auricle. The question of replacing the auricular appendage and closing the pericardium then
of Left
COMMENTS
AND
CONCLUSION
The abnorma1 hiatus through which the auricle herniated probabIy resuIted from a faiIure of the pIeuropericardia1 membrane to cIose compIeteIy the space between the pleura and pericardium in fetal Iife. The embryonic ceIom is partitioned by the pIeuropericardia1 foIds, the pIeuroperitonea1 foIds and the septum transversum.2 These foIds arise from the dorsoIateraI mesoderm of the body waI1 of the embryo. The pIeuropericardia1 foIds grow cephaIad and mesially to form the pleuropericardial December,
1953
737
membrane which fuses with the primitive mediastinum. The diaphragm is formed from the septum transversum and pIeuroperitonea1 membrane in a similar ingrowth toward the mid-axis of the body but its cIosure is somewhat Iater than that of the pericardium.
FIG. 2. Drawing of appearance of herniated auricle: B. Dericardium over Ieft ventricle; E, left puiionary artery; F, Ieft lung. arose. It was decided that inasmuch as the defect was probabIy congenita1 and the patient had not experienced symptoms because of it no repair of the pericardium was indicated. Recovery was unremarkabIe.
AuricIe
left auricIe at operation. A, left C, phrenic nerve; D, aortic arch;
Failure of the pIeuroperitonea1 sinus to cIose resuIts in a diaphragmatic hernia of the foramen of BochdaIek. SimiIarIy, a faiIure of the pIeuroperitonea1 foId to compIete its growth resuIts in a defect of the pericardium. Arey’ refers to such a deveIopmenta1 faiIure as “incomplete pericardium.” Potter3 in reference to this situation stated, “AbnormaIities of the pericardium and pericardial cavity are uncommon except when other malformations affect the mediastinum. The pericardium is seIdom partially or compIeteIy absent in any of our cases except in association with defects of the anterior body waI1.” In the absence of any history or evidence of trauma the IogicaI concIusion is that the herniation of the Ieft auricle occurred through a smaI1, congenital defect which resuIted from failure of the pIeuropericardia1 foId to cIose
Fry-Herniation
of Left
comdetelv.
This concIusion is drawn notwithLand;ng the fact that no anomaly of the anterior body waI1 existed. This case of hernia of the auricIe through the pericardium, causing an abnorma1 roentgenogram, is unique in our experience and no reference to a similar case has been found.
AuricIe REFERENCES *
I. AREY, L. B. DeveIopment 2. 3.
Anatomy. Philadelphia and London, 1949. W. B. Saunders Co. PATTEN, B. M. Human Embryology. PhiIadelphia and Toronto, 1947. The Blakiston Co. POTTER,E. L. Pathology of the Fetus and Newborn. Chicago. The Year Book PubIishers.
VERY rareIy is it indicated to do more than a simpIe cIosure in patients with an acuteIy perforated peptic ulcer. Operative results are exceIIent if the opening is sealed off within six to eight hours, mortaIity being onIy 4 per cent, whereas in patients operated upon Iater the mortality may be 20 per cent or more. Patients unsuitable for surgery suffered a 40 per cent mortaIity according to the studies of Burbank and Roe. Intravenous fluids and transfusions, improved anesthesia, gastric suction and chemotherapy have a11 contributed to reduce mortaIity in these cases as compared to years ago. (Richard A. Leonardo, M.D.)
American
Journal
of Surgery
WESLEY
FRY, M.C.
Oakland, Calijornia
A
N interesting case of herniation of the Ieft auricIe through a defect in the pericardium is presented because of the un-
FIG. I. Postero-anterior roentgenogram of chest showing mass in the vicinity of puImonary conus which at operation was proved to be a herniated Ieft auricle.
usua1 nature of this condition and because of the diffrcuIty in making an accurate evaIuation of the condition before operation. CASE
REPORT
A white man, twenty years of age, was referred to this hospital with a diagnosis of “mediastina1 mass” after an x-ray of the chest
an abnormal shadow in the region of the conus arteriosus. The patient was asymptomatic. Studies in the hospita1 confirmed the roentgenographic finding. (Fig. I.) The history and physical examination provided no Iead as to the diagnosis. The usua1 Iaboratory examinations yieIded resuIts within norma limits. Cardiac Auoroscopy was performed with barium swaIIow. By this examination it was not possibIe to separate the mass in the vicinity of the Ieft puImonary artery from the cardiac siIhouette. In fact the mass was observed to puIsate. The roentgenoIogist believed that the mass probabIy represented hiiar Iymph nodes and, possibIy, Iymphoma. LateraI views of the chest were of no heIp in IocaIizing the mass visibIe in the postero-anterior fiIm. Pursuant to our poIicy that necessity exists for expIoration and surgical remova of mediastinal masses when they cannot be proved to be innocuous, a Ieft thoracotomy was performed upon this patient. A preoperative diagnosis of mediastina1 tumor was made. At operation when the Ieft Iung had been retracted posteriorIy, exposing the anterior mediastinum, the auricuIar appendage of the Ieft atrium was found to be in the pleural cavity. (Fig. 2.) There was a smaI1 defect in the pericardium through which the auric!e protruded. The auricIe appeared to be somewhat Iarger than average size. It was extremely irritabIe as evidenced by the fact that touching it resuIted in arrhythmia of short duration. Bathing the auricIe with I per cent procaine soIution rendered the auricIe Iess irritabIe and it was possibIe to explore the pericardial defect digitaIIy. A finger passed readiIy into the pericardia1 sac through the abnorma1 hiatus with-
* From the Surgical Service, United States NavaI Hospital, Oakland, CaIif. The opinions expressed are those of the author and are not to be construed as olIicia1 or reffecting the views of the Navy Department or the Naval Service at Iarge.
736
American
Journal
of Surgery
Fry-Herniation out constricting the auricIe unduly. The heart was free from the periiardium all around the defect. There was no evidence of thrombosis on inspection and paIpation of the auricle. The question of replacing the auricular appendage and closing the pericardium then
of Left
COMMENTS
AND
CONCLUSION
The abnorma1 hiatus through which the auricle herniated probabIy resuIted from a faiIure of the pIeuropericardia1 membrane to cIose compIeteIy the space between the pleura and pericardium in fetal Iife. The embryonic ceIom is partitioned by the pIeuropericardia1 foIds, the pIeuroperitonea1 foIds and the septum transversum.2 These foIds arise from the dorsoIateraI mesoderm of the body waI1 of the embryo. The pIeuropericardia1 foIds grow cephaIad and mesially to form the pleuropericardial December,
1953
737
membrane which fuses with the primitive mediastinum. The diaphragm is formed from the septum transversum and pIeuroperitonea1 membrane in a similar ingrowth toward the mid-axis of the body but its cIosure is somewhat Iater than that of the pericardium.
FIG. 2. Drawing of appearance of herniated auricle: B. Dericardium over Ieft ventricle; E, left puiionary artery; F, Ieft lung. arose. It was decided that inasmuch as the defect was probabIy congenita1 and the patient had not experienced symptoms because of it no repair of the pericardium was indicated. Recovery was unremarkabIe.
AuricIe
left auricIe at operation. A, left C, phrenic nerve; D, aortic arch;
Failure of the pIeuroperitonea1 sinus to cIose resuIts in a diaphragmatic hernia of the foramen of BochdaIek. SimiIarIy, a faiIure of the pIeuroperitonea1 foId to compIete its growth resuIts in a defect of the pericardium. Arey’ refers to such a deveIopmenta1 faiIure as “incomplete pericardium.” Potter3 in reference to this situation stated, “AbnormaIities of the pericardium and pericardial cavity are uncommon except when other malformations affect the mediastinum. The pericardium is seIdom partially or compIeteIy absent in any of our cases except in association with defects of the anterior body waI1.” In the absence of any history or evidence of trauma the IogicaI concIusion is that the herniation of the Ieft auricle occurred through a smaI1, congenital defect which resuIted from failure of the pIeuropericardia1 foId to cIose
Fry-Herniation
of Left
comdetelv.
This concIusion is drawn notwithLand;ng the fact that no anomaly of the anterior body waI1 existed. This case of hernia of the auricIe through the pericardium, causing an abnorma1 roentgenogram, is unique in our experience and no reference to a similar case has been found.
AuricIe REFERENCES *
I. AREY, L. B. DeveIopment 2. 3.
Anatomy. Philadelphia and London, 1949. W. B. Saunders Co. PATTEN, B. M. Human Embryology. PhiIadelphia and Toronto, 1947. The Blakiston Co. POTTER,E. L. Pathology of the Fetus and Newborn. Chicago. The Year Book PubIishers.
VERY rareIy is it indicated to do more than a simpIe cIosure in patients with an acuteIy perforated peptic ulcer. Operative results are exceIIent if the opening is sealed off within six to eight hours, mortaIity being onIy 4 per cent, whereas in patients operated upon Iater the mortality may be 20 per cent or more. Patients unsuitable for surgery suffered a 40 per cent mortaIity according to the studies of Burbank and Roe. Intravenous fluids and transfusions, improved anesthesia, gastric suction and chemotherapy have a11 contributed to reduce mortaIity in these cases as compared to years ago. (Richard A. Leonardo, M.D.)
American
Journal
of Surgery