Interactive Cardiovascular and Thoracic Surgery 2:154-155(2003)
© 2003 European Association of Cardio-Thoracic Surgery
A rare case of herniation of omentum into the pericardial cavity after using the right gastro-epiploic artery for coronary bypass grafting
G.F.V. Pandaya,
J.G. Grandjeanb,
K.Y.J.A.M. Hoc and
P.W. Boonstraa,*
a Department of Cardiothoracic Surgery, University Hospital Groningen, Groningen, The Netherlands
b Department of Cardiothoracic Surgery, Ospedale Cisanello Pisa, Pisa, Italy
c Department of Radiology, University Hospital Groningen, Groningen, The Netherlands
* Corresponding author. Tel.: +31-50-3-61-1719; fax: +31-50-3-61-1347
p.w.boonstra{at}thorax.azg.nl
Received October 24, 2002;
received in revised form December 16, 2002;
accepted December 21, 2002
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Abstract
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The right gastro-epiploic artery is frequently used as a conduit in coronary artery bypass grafting. A rare complication after this procedure is herniation of omentum or other gastrointestinal contents into the pericardial cavity. Clinical symptoms of this complications are acute abdominal pain, nausea, angina, dyspnea, vomitting or signs of pericardial compression. In this case-report we present one patient with a herniation of omentum into the pericardial cavity without any clinical symptoms of herniation.
Key Words: Gastro-epiploic artery; Diaphragmatic herniation; Coronary artery bypass grafting
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1. Case report
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Recently we found a diaphragmatic herniation of omentum into the pericardial cavity in a patient that underwent bypass surgery 9 years ago. The left internal thoracic artery (LITA) and right gastro-epiploic artery (RGEA) were used as conduits. This patient was participating in a graft-patency study as a volunteer and had no cardiac complaints at all, nor did he have signs of pericardial compression at physical examination. Furthermore, his ECG was normal. His chest X-ray revealed a slightly enlarged heart contour (Fig. 1). On a coronal projection, a herniation of fat tissue into the pericardial cavity is seen (Fig. 2). The fat tissue appeared to be a slip of the omentum. As the RGEA and LITA were still patent, we started no therapy.
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Fig. 2 A coronal view of the heart taken with a multislice CT-scanner. The low attenuation of the tissue below the heart but within the pericardial cavity indicates the presence of fat tissue that is directly continuous with fat tissue of the abdomen, most likely to be the omentum.
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2. Overview of literature
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Worldwide the RGEA is used in over 10,000 patients. Diaphragmatic herniation after use of the RGEA for coronary artery bypass graft (CABG) is very rare. In literature six other cases of diaphragmatic herniation are described.
The first patient described by Pasic et al., had herniation of small bowel only into the pericardial cavity 6 days after CABG with a retrohepatically routed RGEA [1]. This patient underwent surgery to correct the diaphragmatical defect.
Three other patients had herniation of the stomach into the pericardial cavity [2–4]. The patient described by Caes et al. [2] presented with persisting hiccups, compulsive vomiting and acute abdominal pain 9 months after CABG in which the RGEA was routed posterior to the stomach and liver. Ischaemic changes were found on the ECG. Chest X-Ray revealed a paracardial air shadow on the left side and compression of the lung. During surgery strangulation of almost the whole stomach was found. The RGEA pedicle showed severe congestion and cyanosis. After enlargement of the diaphragmatic orifice and reduction of the hernia, gastropexy was performed to prevent recurrence. The ischaemic changes on the ECG disappeared rapidly after this procedure. The patient described by Verhofste et al. [3] underwent redo-CABG. On day 10 after surgery he presented with vague abdominal pain.
On day 13 after surgery he presented with acute shortness of breath. Chest X-ray revealed a hydropneumothorax. During thoracotomy the fundus of the stomach was found in the left side of the chest. The hernia originated from the incision made to accommodate the RGEA pedicle. The patient described by Manetta et al. [4] presented with post-prandial pain followed by nausea and emesis 3 years after redo-CABG. Chest X-Ray showed an intrapericardial gastric hernia. The RGEA was patent on celiac arteriography. During surgery the stomach and omentum were found in the pericardial sac. The defect was closed with Gore–Tex® after repositioning of the stomach and omentum into the abdominal cavity.
Another patient presented with nausea, vomiting of bile stain fluid, epigastric discomfort and pyrexia of 38 °C 7 days after CABG. Contrast examination showed herniation of the stomach into the pericardial cavity. Laparotomy was performed. The diaphragmatic defect was closed with a Marlex mesh and interrupted prolene sutures.
The last patient described by Ansari et al. [5] had para-umbilical and acute epigastric pain with nausea and vomitting 2 years after a redo-CABG. The computerized tomographic (CT)-scan showed a large transdiaphragmatic hernia with encroachment of nearly all the small intestines, omentum and transverse colon into the thoracic cavity. Surgery was required. The diaphragmatic defect was reduced. Resection of small intestine was not necessary.
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3. Comments
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Many risk factors causing herniation of abdominal content through the surgical aperture have been suggested. Important risk factors are a too large orifice and a retrohepatically routed RGEA. We found no patient who had a RGEA that was routed anteriorly. Probably the liver is protecting the herniation. In only one patient we found long term corticosteroid therapy as a fascilitating factor for herniation. In this case, it is thought that the use of corticosteroids weakens the tissue leading to herniation. In order to prevent herniation three options are suggested. First, minimizing the length of the diapragmatic incision. Second, placing interrupted sutures perpendicular to the musculotendinous fibers of the diaphragm or reinforcing the diaphragmatic incision with a Gore–Tex® surgical membrane. Third, using the RGEA as a free graft, no surgical aperture through the diaphragm has to be made.
In conclusion, patients that undergo coronary artery bypass surgery using a RGEA and who present with complaints of angina, vomiting, acute abdominal pain or nausea should be considered having a diaphragmatic herniation into the pericardial cavity. However, no complaints or physical signs at examination do not preclude this rare complication as is demonstrated in our case.
doi:10.1016/S1569-9293(03)00006-9
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References
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- Pasic M, Carrel T, Von Segesser L, Turina M. Postoperative diaphragmatic hernia after use of the right gastroepiploic artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1994;108(1):189–191[Free Full Text]
- Caes FL, Francois B, Van Nooten GJ. Transdiaphragmatic herniation of the stomach after right gastroepiploic artery grafting. J Thorac Cardiovasc Surg. 1994;108(1):191–193[Free Full Text]
- Verhofste MA, Tam SK. Diaphragmatic hernia after right gastroepiploic artery coronary artery bypass grafting. Ann Thorac Surg. 1995;60(2):458–459[Abstract/Free Full Text]
- Manetta F, Moores DW, Bennett EV, Edwards NM. Intrapericardial herniation of the stomach after use of the right gastroepiploic artery for coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1998;115(2):479–480[Free Full Text]
- Ansari M, Eucher P, De Canniere L. Strangulated giant transdiaphragmatic hernia: a rare complication of coronary artery bypass grafting with the right gastroepiploic artery. J Thorac Cardiovasc Surg. 2002;123(2):358–359[Free Full Text]
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Abstract
1. Case report