we present a case of an intrapericardial diaphragmatic hernia from blunt trauma . in this report we will review the current literature and also describe the first report of a primary laparoscopic repair of the defect .
a 38-year - old unrestrained male passenger had blunt chest and abdominal trauma from a motor vehicle collision .
two months later , on a computed tomography scan , he was found to have an intrapericardial diaphragmatic hernia .
symptoms of intrapericardial diaphragmatic hernia are chest pain , upper abdominal pain , dysphagia , and dyspnea .
even when the injury is diagnosed late , laparoscopy can be used for primary and patch repair .
the diaphragm is a dome - shaped septum , composed of muscular portions surrounding the central tendon , which is a clover leaf  shaped fascial aponeurosis with one anterior leaf and two lateral leaves .
the 3 components of the muscular portions of the diaphragm ( costal , sternal , and lumbar components ) attach to the circumference of the thoracic inlet ( lower 6 ribs , sternum and xiphoid process , and upper 3 lumbar vertebrae ) and attach to the central tendon .
the central tendon is attached to the pericardial sac and lies anterior to the esophageal hiatus . in an animal model ,
the central tendon is subject to higher tension than the other muscles of the diaphragm .
intrapericardial diaphragmatic hernias occur when this central tendon of the diaphragm ruptures with herniation of abdominal viscera into the pericardium from blunt trauma .
this is opposed to a tear of the pericardium into the thorax , which has also been described .
the literature on this rare injury was last reviewed in 2001 by reina et al .
we present an additional case of an intrapericardial diaphragmatic injury along with an updated review of the published english - language literature focusing on diagnosis , treatment , and outcome .
a 38-year - old male unrestrained passenger was involved in a motor vehicle collision and had blunt chest and abdominal trauma .
his initial imaging included radiographs of the chest and pelvis and computed tomography ( ct ) imaging of the head , cervical spine , abdomen , and pelvis .
he was found to have a left grade 4 renal laceration , multiple bilateral rib fractures , bilateral pulmonary contusions , and 2 tiny foci of pneumoperitoneum that were not attributable to any hollow viscous injury ( figure 1 ) .
he was initially resuscitated in the surgical intensive care unit and then underwent selective renal angioembolization on hospital day 1 . on hospital day 4 , the patient had a ct urogram that showed a urine leak and subsequently underwent placement of a left ureteral stent . on hospital day 6 , he was discharged home with a foley catheter .
he was then seen in the trauma surgery clinic on postinjury day 19 for follow - up and was having regular bowel movements without nausea or vomiting , but he was noted to be eating small meals because of abdominal bloating .
he was seen by his primary care provider 1 month later with complaints of worsening epigastric pain , lower chest discomfort , and abdominal cramps but was again noted to be having regular bowel movements .
an abdominal radiograph was obtained at the time and showed a moderate stool burden but no other apparent abnormalities .
his next visit was to our urology clinic 2 months after injury for removal of his ureteral stents .
his ct urogram showed no evidence of urinary extravasation , but we visualized an intrapericardial diaphragmatic defect with herniation of the abdominal viscera into the pericardial sac ( figure 2 ) .
a retrospective review of the ct scan from the patient 's initial presentation showed an intrapericardial defect in the anterior diaphragm ( figure 1 ) .
a total of 3 trocars were used ( a camera port above the umbilicus and 2 working ports at the epigastrium and left subcostal margin ) .
pneumoperitoneum was maintained at 10 to 12 cm h2o to avoid any potential tamponade effect on the heart .
the transverse colon and omentum were reduced from the pericardial sac through the diaphragmatic defect , with adhesiolysis of attachments of the omentum at the rim of the pericardium and diaphragm ( figures 3 and 4 ) . the intrapericardial diaphragm defect measured 8 cm long  4.5 cm wide .
0 prolene suture ( ethicon , somerville , new jersey ) ( figure 5 ) .
the patient had an uneventful postoperative course and was discharged home on postoperative day 2 .
van loenhout et al were the first authors to review the literature on traumatic intrapericardial diaphragmatic hernia .
reina et al reviewed the literature from 1986 through 1999 and found 22 cases in addition to the case they reported .
rodriguez - morales et al described an additional two cases in 1986 that were not described by reina et al . since 1999 , there have been 11 additional cases of traumatic intrapericardial diaphragmatic hernias reported in the english - language literature . including our case , there are 96 published occurrences of traumatic intrapericardial diaphragmatic hernias .
a blunt mechanism is most common , including car crashes , pedestrians being struck by cars , or falls , with one case in which the exact mechanism was unknown .
there are a variety of associated injuries that are common in blunt trauma without any one being specifically associated with intrapericardial diaphragmatic hernia .
the longest time interval to presentation was 38 years , and the defect length ranged from 6 to 16 cm .
reina et al reported an average interval between injury and diagnosis of 4.8 years and average defect length of 10.3 cm .
half of the cases of blunt traumatic intrapericardial diaphragmatic hernias ( 6 of 12 ) were diagnosed remotely ( > 30 days ) from the initial trauma injury .
diaphragmatic hernia in general should be maintained in the differential of a patient with blunt trauma who does not progress appropriately and in whom dysphagia , dyspnea , new - onset gastroesophageal reflux disease symptoms , or abdominal or chest discomfort persists without an adequate explanation from another abdominal or thoracic process .
chest radiography was a common initial imaging study followed by ct to confirm the diagnosis .
the initial trauma imaging workup missed the diagnosis of intrapericardial diaphragmatic injury in all cases described in the past decade , including our case .
interestingly , our patient had a chest ct scan on initial presentation that was read as normal , but in retrospect , there was a small defect present .
as the quality of ct imaging improves , there is potential that these rare injuries will be more commonly diagnosed on initial imaging .
the principles of the operation are to reduce the herniated organs ( most commonly the transverse colon , omentum , and stomach ) , define the edges of the diaphragm , and close the diaphragmatic defect either primarily or with a patch .
a variety of surgical approaches are described for repair of intrapericardial hernias , including thoracotomy with either primary or patch repair , laparotomy with primary or patch repair , and abdominal laparoscopy with patch repair .
the laparoscopic approach using a patch was described by mccutcheon et al as a safe and feasible repair method .
we describe the first case of an intrapericardial diaphragmatic hernia successfully repaired primarily through an abdominal laparoscopic approach .
although the central tendon portion of the diaphragm may seem to be less compliant than the dome of the diaphragm , our case  along with most of the literature  suggests that primary repair can be performed . just as in the repair of diaphragmatic hernias ,
both absorbable and nonabsorbable sutures have been described , as has a running versus interrupted suture technique .
we advocate that a blunt traumatic intrapericardial diaphragmatic defect can be fixed primarily , similar to most other blunt diaphragmatic injuries . if primary repair is not feasible , use of an expanded polytetraflouroethylene patch as a bridge seems appropriate because it presents a smooth surface for both the cardiac and intra - abdominal sides .
a biologic patch may also have a role in repairing this injury but has not yet been described .
a laparoscopic approach should be considered because avoiding an upper abdominal incision may translate into a significantly shorter hospital stay as has been shown with laparoscopic cholecystectomy .
although successful reports of primary and patch repair are present in the literature , long - term outcomes are lacking .
only 3 reports have any follow - up , which ranged from 6 to 48 months .
our patient has been followed up for 8 months postoperatively and has no signs of recurrence either clinically or on chest and abdominal radiographs . in conclusion , half of the cases of blunt traumatic intrapericardial diaphragmatic hernias present remote from the initial traumatic injury , with the most common symptoms being chest pain , upper abdominal pain , dysphagia , and dyspnea .
even when the injury is diagnosed late , laparoscopy can be used for primary and patch repair and should be attempted first before an immediate open approach .
 introduction : intrapericardial diaphragmatic hernia is a rare injury . we present a case of an intrapericardial diaphragmatic hernia from blunt trauma . in this report we will review the current literature and also describe the first report of a primary laparoscopic repair of the defect.case description : a 38-year - old unrestrained male passenger had blunt chest and abdominal trauma from a motor vehicle collision . 
 two months later , on a computed tomography scan , he was found to have an intrapericardial diaphragmatic hernia . 
 the defect was repaired primarily through a laparoscopic approach.discussion:symptoms of intrapericardial diaphragmatic hernia are chest pain , upper abdominal pain , dysphagia , and dyspnea . 
 chest computed tomography is the most useful diagnostic test to define the defect . 
 even when the injury is diagnosed late , laparoscopy can be used for primary and patch repair . 
Introduction:
Case Description:
Discussion:
INTRODUCTION
CASE REPORT
LITERATURE REVIEW
DISCUSSION