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Triple Diaphragmatic Rupture with Disruption of the Pericardium: Pericardial Reconstruction by Lyophilized Dura Allograft
Triple Diaphra natic Rupture with Disruption of trle Pericardium: Pericardial Recorkmction by Lyophilized Dura Allograft Freya Juttner, M.D., Hans Pinter, M.D., Dieter Kampler, M.D., Karlheinz Tscheliessnigg, M.D., and Gerhard Friehs, M.D. ABSTRACT A patient is described with the unusual findings of intrapericardial diaphragmatic rupture combined with total disruption of the pericardium and partial abruption of the diaphragm from its costal origin. Through a third traumatic diaphragmal leak, the small intestine had prolapsed intercostally without contact to the pleural space. Surgical repair was done by direct diaphragmatic suturing and lyophilized dura allograft reconstruction of the left pericardial circumference. Postoperatively, atrioventricular block secondary to myocardial contusion necessitated pacemaker implantation. The patient left the hospital five weeks after the injury. Although rupture of the diaphragm due to blunt chest trauma is frequently seen, intrapericardial diaphragmatic rupture is a rare clinical finding [l-71. As most of these patients are seen with cardiac contusion and other severe associated injuries, death often occurs rapidly before clinical diagnosis. Immediate surgical exploration in any patient suspected of having ihis condition is necessary because definitive diagnosis is only possible intraoperatively in 50% of all patients with pericardiophrenic rupture who survive [8].Surgical repair of such lesions may require grafting of the diaphragm or pericardium in some instances. We describe a patient with the unusual finding of a triple diaphragmatic rupture involving the pericardium and the left diaphragm with transdiaphragmatic extrapleural herniation of the small intestine. A 42-year-old patient was admitted to our institution after blunt thoracoabdominal trauma. Initial chest roentgenogram showed bilateral rib fractures and a left hemopneumothorax, which was d.rained by an intercostal tube. On the control roentgenogram an enlarged cardiac shadow and an irregular circumference of the left diaphragm became obvious. At the left hemithorax some subcutaneous blebs were visible radiographically. There was an increasing tonic defense in the upper epigastrium. Peristaltic murmurs could be auscultated at the left hemithorax. Measurement o:f hemodynamic variFrom the Department of Thoracic and Hyperbaric Surgery, University Clinic for Surgery, Graz, Austria. Accepted for publication Feb 3, 1984. Address reprint requests to Dr.Jiittner, Thoracic Surgery, A-8036 LKH, Graz, Aushia.
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ables suggested progressive shock and cardiac tamponade. An emergency left-sided thoracotomy was performed in the seventh intercostal space. Through a large pericardial tear extending from the left pulmonary veins down to the diaphragm, the greater omentum had prolapsed into the pleural space. By palpation of the pericardial cavity, the corpus of the stomach, which also was prolapsed, was found intrapericardially and pushed back into the abdomen, along with the greater omentum. Hemodynamic variables improved rapidly after this maneuver. A median laparotomy was performed. There was a pericardiophrenic rupture with transverse extent parallel to the anterior thoracic wall 1 to 2 cm from the sternum. The cardiac apex had dislocated intraabdominally and was reduced into the thorax. By the abdominal approach, a right-sided rupture of the pericardium extending from the diaphragm up to the ascending aorta was exposed (Fig 1).Laterally to the pericardiophrenic rupture and separated by a bridging segment of intact diaphragm, there was an abruption of the diaphragm from its insertion at the seventh and eighth ribs, causing another communication to the pleural space. A third rupture of the left diaphragm was found between the ninth and tenth ribs. Through the gap a loop of small intestine had prolapsed intercostally without opening the pleura (Fig 2). The loop proved to be necrotic and was resected. The right pericardial tear was closed directly with running suture after insertion of an intercostal tube into the right pleural cavity. The pericardiophrenic rupture was also closed directly using interrupted Teflon patchsupported sutures. The diaphragm was reinserted to its costal origins and the lateral rupture closed. After the pancreatic region was drained because of massive contusion and drainage of a retroperitoneal hematoma, the abdomen was closed. The large pericardial defect at its left circumference caused dislocation of the heart into the left pleural cavity. We closed the defect using two patches of lyophilized dura allograft that were shaped into stripes and sutured to the pericardial border. Cranially a pericardial window was left (Fig 3). After positioning of one upper and one lower intercostal tube, the chest was closed. The respiratory situation of the patient required controlled ventilation for two weeks postoperatively. Although there had not been any signs suggesting myocardial contusion intraoperatively or in the early postoperative period, severe tachycardia developed on
527 Case Report: Jiittner et al: Diaphragmatic Rupture with Disruption of Pericardium
Fig I. Combined diaphragmatic and pericardial trauma.
Fig 3 . Reconstruction .
postoperative day 7, changing 5 days later into bradycardia with electrocardiographic signs of first degree atrioventricular block. After gradual weaning from artificial ventilation, the patient became mobile the third week after operation. Sudden occurrence of third degree atrioventricular block necessitated implantation of a permanent cardiac pacemaker. Five weeks after the trauma, the patient left the hospital.
Comment
Fig 2 . Transdiaphragmatic-transcostal herniation of the small bowel.
Central diaphragmatic ruptures or abruptions of the diaphragm from its costal origin are common sequelae of blunt thoracoabdominal trauma [3-5, 91. Only a few cases of isolated rupture of the pericardium [8, 101 or combined pericardiophrenic ruptures [l,2, 4, 6, 7] have been reported. As these types of injury are due to violent thoracoabdominal trauma, cardiac contusion or even myocardial rupture is frequently seen along with diaphragmatic rupture [ll, 121. Traumatic herniation of intrathoracic or intraabdominal structures through the abdominal or chest wall may also occur after blunt trauma. The combination of these injuries found in the patient we have described has not been reported, to our knowledge. The intrapericardial prolapse of greater omentum and stomach combined with luxation of the cardiac apex into the abdomen caused an impairment of venous inflow similar to cardiac tamponade. The irregular circumference of the left diaphragm and auscultation of the extraabdominally prolapsed small intestine suggested diaphragmatic rupture. Diagnosis was made intraoperatively. During operation and the initial postoperative course, no sign of cardiac contusion was obvious. After a symptom-free interval of 7 days, the typical signs of
528 The Annals of Thoracic Surgery Vol 38 No 5 November 1984
heart contusion developed, necessitating implantation of a permanent pacemaker three weeks postoperatively for third degree atrioventricular block. Prosthetic closure of pericardial defects is more common in cancer patients after 'extended resections. For this purpose, glutaraldehyde-prepared pericardial xenograft, polyglactin 910 net, and lyophilized dura allograft have been used experimentally and clinically [13-151. In our patient traumatic disruption had caused a loss of almost the entire left pericardial wall, requiring prosthetic replacement. The smooth consistency of the lyophilized dura facilitated exact adaptation of the prosthetic "bag" to the myocardial surface, preventing dislocation of the heart without narrowing of the pericardial cavity. Two months after operation, the patient had no cardiac sensations and there were no clinical signs of shrinking or rejection of the graft. Successful treatment of severe combined thoracoabdominal injuries is effected only by immediate surgical intervention [5, 91. Decision for thoracotomy or laparotomy should be made as soon as possible.
References Cranshaw GR Herniation of the stomach, transverse colon, and a portion of the jejunum into the pericardium. Br J Surg 39:364, 1952 Kubo G: Traumatische Herzbeutel und Diaphragmaruptur mit Luxation der Herzspite in das Abdomen. Monatsschr Unfallheilk 70259, 1967 Lombard0 C, Da Ros D, Loll0 G, Sala A: Rupture of the
diaphragm caused by closed thoraco-abdominal trauma: presentation of 14 cases. Minerva Chir 38:527, 1983 4. Pinter H, Reschauer R Problematik der nicht erkannten Zwerchfellruptur. Zentralbl Chir 104:1045,1979 5. Pinter H, Trnoska R Management of blunt chest trauma. Zentralbl Chir 1061049,1981 6. Proye C Rupture of the diaphragmatic dome and pericardiotomy. Ann Chir 34:512, 1980 7. Santy P, Duroux PE: Hemie diaphragmatique: 6ctopie abdominale du coeur. Lyon Chir 46356, 1951 8. Christides C, Laskar M, Kim M, et al: Post-traumatic rupture of the pericardium with cardiac luxation associated with myocardial infarction, and a rupture of the aortic isthmus. J Chir 118505,1981 9. Mulder DS: Symposium on trauma: 11. Chest trauma: current concepts. Can J Surg 23:340, 1980 10. Cham B, Baehrel B, Etievent P, et a1 Isolated rupture of the pericardium after closed trauma of the thorax. J Chir 115:507, 1978 11. Steinbach K, Domanig E, Weissenhofer W Totaler AVBlock nach stumpfem Thoraxtrauma. Monatsschr Unfallheilk 75275, 1972 12. Symbas PN: Cardiac trauma. Am Heart J 92387, 1976 13. Gallo JI, Pomar JL, Artiriano E, Duran CMG: Heterologous pericardium for the closure of pericardial defects. Ann Thorac Surg 26:149, 1978 14. Hofmann A Beitrag zur Anwendung von lyophilisierter Dura bei thoraxchirurgischen Eingriffen. Med Mitt (Melsungen) 43:171, 1969 15. Toty L, Bakdach H: Repair of thoracic and pericardial loss of substance using a net of absorbable material. Nouv Press Med 11:3265, 1982
526
ables suggested progressive shock and cardiac tamponade. An emergency left-sided thoracotomy was performed in the seventh intercostal space. Through a large pericardial tear extending from the left pulmonary veins down to the diaphragm, the greater omentum had prolapsed into the pleural space. By palpation of the pericardial cavity, the corpus of the stomach, which also was prolapsed, was found intrapericardially and pushed back into the abdomen, along with the greater omentum. Hemodynamic variables improved rapidly after this maneuver. A median laparotomy was performed. There was a pericardiophrenic rupture with transverse extent parallel to the anterior thoracic wall 1 to 2 cm from the sternum. The cardiac apex had dislocated intraabdominally and was reduced into the thorax. By the abdominal approach, a right-sided rupture of the pericardium extending from the diaphragm up to the ascending aorta was exposed (Fig 1).Laterally to the pericardiophrenic rupture and separated by a bridging segment of intact diaphragm, there was an abruption of the diaphragm from its insertion at the seventh and eighth ribs, causing another communication to the pleural space. A third rupture of the left diaphragm was found between the ninth and tenth ribs. Through the gap a loop of small intestine had prolapsed intercostally without opening the pleura (Fig 2). The loop proved to be necrotic and was resected. The right pericardial tear was closed directly with running suture after insertion of an intercostal tube into the right pleural cavity. The pericardiophrenic rupture was also closed directly using interrupted Teflon patchsupported sutures. The diaphragm was reinserted to its costal origins and the lateral rupture closed. After the pancreatic region was drained because of massive contusion and drainage of a retroperitoneal hematoma, the abdomen was closed. The large pericardial defect at its left circumference caused dislocation of the heart into the left pleural cavity. We closed the defect using two patches of lyophilized dura allograft that were shaped into stripes and sutured to the pericardial border. Cranially a pericardial window was left (Fig 3). After positioning of one upper and one lower intercostal tube, the chest was closed. The respiratory situation of the patient required controlled ventilation for two weeks postoperatively. Although there had not been any signs suggesting myocardial contusion intraoperatively or in the early postoperative period, severe tachycardia developed on
527 Case Report: Jiittner et al: Diaphragmatic Rupture with Disruption of Pericardium
Fig I. Combined diaphragmatic and pericardial trauma.
Fig 3 . Reconstruction .
postoperative day 7, changing 5 days later into bradycardia with electrocardiographic signs of first degree atrioventricular block. After gradual weaning from artificial ventilation, the patient became mobile the third week after operation. Sudden occurrence of third degree atrioventricular block necessitated implantation of a permanent cardiac pacemaker. Five weeks after the trauma, the patient left the hospital.
Comment
Fig 2 . Transdiaphragmatic-transcostal herniation of the small bowel.
Central diaphragmatic ruptures or abruptions of the diaphragm from its costal origin are common sequelae of blunt thoracoabdominal trauma [3-5, 91. Only a few cases of isolated rupture of the pericardium [8, 101 or combined pericardiophrenic ruptures [l,2, 4, 6, 7] have been reported. As these types of injury are due to violent thoracoabdominal trauma, cardiac contusion or even myocardial rupture is frequently seen along with diaphragmatic rupture [ll, 121. Traumatic herniation of intrathoracic or intraabdominal structures through the abdominal or chest wall may also occur after blunt trauma. The combination of these injuries found in the patient we have described has not been reported, to our knowledge. The intrapericardial prolapse of greater omentum and stomach combined with luxation of the cardiac apex into the abdomen caused an impairment of venous inflow similar to cardiac tamponade. The irregular circumference of the left diaphragm and auscultation of the extraabdominally prolapsed small intestine suggested diaphragmatic rupture. Diagnosis was made intraoperatively. During operation and the initial postoperative course, no sign of cardiac contusion was obvious. After a symptom-free interval of 7 days, the typical signs of
528 The Annals of Thoracic Surgery Vol 38 No 5 November 1984
heart contusion developed, necessitating implantation of a permanent pacemaker three weeks postoperatively for third degree atrioventricular block. Prosthetic closure of pericardial defects is more common in cancer patients after 'extended resections. For this purpose, glutaraldehyde-prepared pericardial xenograft, polyglactin 910 net, and lyophilized dura allograft have been used experimentally and clinically [13-151. In our patient traumatic disruption had caused a loss of almost the entire left pericardial wall, requiring prosthetic replacement. The smooth consistency of the lyophilized dura facilitated exact adaptation of the prosthetic "bag" to the myocardial surface, preventing dislocation of the heart without narrowing of the pericardial cavity. Two months after operation, the patient had no cardiac sensations and there were no clinical signs of shrinking or rejection of the graft. Successful treatment of severe combined thoracoabdominal injuries is effected only by immediate surgical intervention [5, 91. Decision for thoracotomy or laparotomy should be made as soon as possible.
References Cranshaw GR Herniation of the stomach, transverse colon, and a portion of the jejunum into the pericardium. Br J Surg 39:364, 1952 Kubo G: Traumatische Herzbeutel und Diaphragmaruptur mit Luxation der Herzspite in das Abdomen. Monatsschr Unfallheilk 70259, 1967 Lombard0 C, Da Ros D, Loll0 G, Sala A: Rupture of the
diaphragm caused by closed thoraco-abdominal trauma: presentation of 14 cases. Minerva Chir 38:527, 1983 4. Pinter H, Reschauer R Problematik der nicht erkannten Zwerchfellruptur. Zentralbl Chir 104:1045,1979 5. Pinter H, Trnoska R Management of blunt chest trauma. Zentralbl Chir 1061049,1981 6. Proye C Rupture of the diaphragmatic dome and pericardiotomy. Ann Chir 34:512, 1980 7. Santy P, Duroux PE: Hemie diaphragmatique: 6ctopie abdominale du coeur. Lyon Chir 46356, 1951 8. Christides C, Laskar M, Kim M, et al: Post-traumatic rupture of the pericardium with cardiac luxation associated with myocardial infarction, and a rupture of the aortic isthmus. J Chir 118505,1981 9. Mulder DS: Symposium on trauma: 11. Chest trauma: current concepts. Can J Surg 23:340, 1980 10. Cham B, Baehrel B, Etievent P, et a1 Isolated rupture of the pericardium after closed trauma of the thorax. J Chir 115:507, 1978 11. Steinbach K, Domanig E, Weissenhofer W Totaler AVBlock nach stumpfem Thoraxtrauma. Monatsschr Unfallheilk 75275, 1972 12. Symbas PN: Cardiac trauma. Am Heart J 92387, 1976 13. Gallo JI, Pomar JL, Artiriano E, Duran CMG: Heterologous pericardium for the closure of pericardial defects. Ann Thorac Surg 26:149, 1978 14. Hofmann A Beitrag zur Anwendung von lyophilisierter Dura bei thoraxchirurgischen Eingriffen. Med Mitt (Melsungen) 43:171, 1969 15. Toty L, Bakdach H: Repair of thoracic and pericardial loss of substance using a net of absorbable material. Nouv Press Med 11:3265, 1982