Title : Intrapericardial diaphragmatric hernia with central tendon deficiency in a case of triple vessel coronary artery disease. An intraoperative revelation
Abstract:
Introduction: Intrapericardial diaphragmatic hernia with central tendon deficiency is extremely rare, usually presenting in infancy. Only 28 adult cases have been reported, and one such incidental case is described here.
Case- A 46-year-old male presented with intermittent chest pain and was diagnosed with triple-vessel coronary artery disease, for which coronary artery bypass grafting was planned. Following median sternotomy and pericardial incision, omentum was unexpectedly seen encasing the anterior and inferior aspects of the heart, moving freely with respiration. Inferior tracing revealed a 10 × 10 cm diaphragmatic defect with absence of the central tendon. After adhesiolysis and reduction of the omentum, primary closure was performed using non-absorbable polypropylene interrupted sutures, followed by off-pump coronary artery bypass grafting.
Discussion: Intrapericardial diaphragmatic hernia with pericardioperitoneal communication is an exceedingly rare entity. CT and MRI are the definitive diagnostic tools; however, in our case, preoperative imaging was not performed as the patient was asymptomatic and the chest X-ray was normal. This emphasizes that even subtle abnormalities in preliminary investigations should prompt further evaluation. Surgical repair is recommended at diagnosis due to the risk of intestinal obstruction and strangulation. A sternal incision was chosen as it provided excellent exposure, allowed abdominal extension, and enabled tension-free primary closure of the diaphragmatic defect. The absence of gastrointestinal or cardiac symptoms and any history of trauma suggests a congenital etiology. The presence of pericardioperitoneal communication with a deficient central tendon and well-defined surrounding structures further supports this conclusion.
