Laparoscopic Repair of Diaphragmatic Pericardial Hernia Following Blunt Trauma: A Case Report

Introduction

Traumatic diaphragmatic hernias occur when intra-abdominal structures herniate into the thoracic cavity following blunt or penetrating trauma to the abdomen or chest [1]. Although not always recognized as such, diaphragmatic pericardial hernias (DPH) can be considered a rare disease, often with an unusual clinical course that remains undiagnosed if the initial injury is overlooked [2,3]. Congenital defects or anatomical variations may also predispose certain patients to this condition. DPH is a subset of diaphragmatic hernias characterized by a defect that permits abdominal contents to enter the pericardial sac [4], frequently resulting from highimpact events such as motor vehicle collisions [4].

Diagnosing DPH poses substantial challenges because symptoms are often nonspecific, ranging from mild chest discomfort to severe respiratory distress, potentially leading clinicians to misdiagnose or delay accurate identification [2,5]. Presentations can be nonspecific – ranging from mild abdominal pain to respiratory distress – and DPH may go unrecognized until significant complications, such as strangulation or perforation, arise [2,3]. Diagnostic tools such as chest radiographs, computed tomography (CT), and magnetic resonance imaging (MRI), while valuable, may still overlook subtle diaphragmatic disruptions or early visceral herniation, emphasizing the limitations of current imaging modalities [6,7]. Consequently, there is an essential need for heightened suspicion and vigilance in clinical practice. Fair et al analyzed 833 309 cases from the National Trauma Data Bank in 2012 and found that 3873 patients (0.46%) had traumatic diaphragmatic injuries. Of these, 67% were due to penetrating mechanisms, while 33% were caused by blunt trauma [8].

Recognizing and reporting unique presentations of DPH is crucial to improving clinical decisionmaking and patient outcomes. This case underscores the importance of early suspicion, rapid identification, and timely surgical intervention, potentially guiding clinicians in refining current trauma and surgical protocols. By documenting the specific clinical trajectory and surgical management strategies employed, this report aims to inform broader clinical guidelines and enhance future diagnostic and therapeutic approaches, thereby improving patient safety and reducing morbidity.

Case Report

A 63-year-old Eritrean man presented with a 2-day history of upper-abdominal pain, nausea, and intermittent vomiting. He had a history of end-stage renal disease, hypertension, gout, and bronchial asthma. Two years ago, he experienced a significant blunt trauma as a result of a car accident. This incident has led to the development of a subgaleal hematoma; imaging and clinical evaluations conducted at the time indicated that there was no evidence of diaphragmatic injury.

During the initial clinical examination, the patient exhibited stable vital signs, with blood pressure measured at 130/85 mmHg, a heart rate of 82 beats per minute, a respiratory rate of 16 breaths per minute, a body temperature of 37.2°C, and an oxygen saturation level of 98% while breathing room air. Table 1 shows the initial lab results for the patient. A thorough abdominal examination revealed tenderness localized to the upper abdomen, although there was no evidence of guarding or rebound tenderness, suggesting that there may not be an acute abdominal condition. The chest examination yielded normal findings, with clear lung fields and no audible crackles or wheezes, indicating the absence of respiratory distress or infection. Similarly, the cardiac examination was unremarkable, with no discernible murmurs or irregular heart rhythms noted upon auscultation.

The patient underwent a computed tomography (CT) scan directly due to clinical suspicion of significant pathology and he did not undergo ultrasound imaging. Echocardiography showed no clear evidence of cardiac compression, the left ventricular ejection fraction was 60%, and there were no regional wall motion abnormalities. Computed tomography (CT) of the abdomen and chest identified a ~5 cm defect in the central diaphragm with herniation of the transverse colon and omentum into the pericardial space (Figure 1).

Laparoscopic exploration confirmed an incarcerated segment of transverse colon and omentum within the pericardium, with the omentum showing signs of early strangulation. The herniated contents were reduced, and the defect was repaired using a bridging technique. A biological mesh was placed first to promote tissue ingrowth and reduce cardiac irritation, followed by an overlapping composite synthetic mesh to provide permanent reinforcement. Non-absorbable 3-0 V-lock sutures and tissue adhesive were used to secure both meshes. An intrapericardial drain was inserted and routed through the abdominal cavity to the outside, mitigating risk of pericardial tamponade postoperatively.

Postoperative recovery was uneventful. The patient resumed scheduled hemodialysis sessions without complication, and an echocardiogram showed no significant pericardial effusion. The drain was removed after confirming minimal output. At 1-month follow-up, he was asymptomatic with no evidence of recurrence.

Discussion

Traumatic diaphragmatic hernias (TDH) are infrequent but serious outcomes of blunt or penetrating thoracoabdominal trauma [1]. Delays in diagnosis commonly occur due to initial imaging limitations, concomitant injuries, or the insidious nature of diaphragmatic tears. One review of 58 cases of traumatic intrapericardial diaphragmatic hernia reported delayed diagnosis in 37 patients, with intervals ranging from 23 days to 23 years [2]. This emphasizes the need for heightened clinical suspicion, even when initial studies do not indicate a diaphragmatic tear [2,3].

Keith first documented DPH in autopsy findings in 1910, highlighting the potential for these injuries to go unnoticed [3]. Further literature reviews (Table 2) and case series consistently show that when patients present with unexplained thoracic or upper-abdominal concerns after trauma, clinicians should consider DPH [2,4,5]. While diaphragmatic pericardial hernia (DPH) is rare and often overlooked, several diagnoses should be considered during evaluation, especially in patients with blunt thoracoabdominal trauma presenting with nonspecific symptoms. The differential diagnosis for a suspected diaphragmatic pericardial hernia encompasses a variety of thoracoabdominal injuries and conditions. First, traumatic diaphragmatic rupture without pericardial involvement – by far the more common entity – can present with signs of visceral herniation but generally lacks any direct cardiac or pericardial compromise [9]. Second, pericardial tamponade or effusion – in which fluid or blood accumulates within the pericardial sac – can mimic many of the cardiopulmonary symptoms seen in DPH; however, echocardiography or contrast-enhanced CT readily distinguishes these by demonstrating pericardial fluid collections and diastolic collapse of cardiac chambers [6]. Third, one must exclude primary cardiac injury such as contusion or even myocardial rupture after blunt trauma; elevated cardiac biomarkers coupled with targeted cardiac imaging (eg, MRI or dedicated CT protocols) can identify myocardial bruising or frank wall rupture [10]. Finally, acute pulmonary pathology – specifically, massive pulmonary embolism or tension pneumothorax – can induce abrupt respiratory distress and hemodynamic instability; prompt chest radiography or CT will reveal intravascular filling defects in embolism or free air in the pleural space in pneumothorax, guiding urgent management [11].

Surgical intervention remains mandatory to prevent organ strangulation, perforation, and other serious complications [5,12]. Open surgical repair without mesh reinforcement is often the preferred option when there is an elevated risk of infection. However, it tends to be linked to higher recurrence rates, particularly for larger defects [13]. Primary suture repair, which excludes mesh, may be considered for smaller defects but carries a considerable risk of recurrence [14]. Non-operative management, while sometimes necessary, is reserved for those who cannot undergo surgery due to severe comorbidities; outcomes often involve ongoing morbidity and high mortality risk [10].

Delliturri et al described laparoscopic bridging with synthetic mesh [6], while Aborajooh et al employed a composite mesh approach [7]. Laparoscopic repairs can offer superior visualization and reduced morbidity [12,15–17]. Okamoto and Maeyama recently performed a laparotomy for acute traumatic diaphragmatic hernia repair [12]. In large defects or instances where primary closure would cause excessive tension, mesh reinforcement is recommended to reduce the risk of recurrence [8,12,15,18,19]. Primary closure may be feasible for smaller defects, as seen in certain case reports [15,16].

Conclusions

This case demonstrates the successful laparoscopic repair of a post-traumatic diaphragmatic pericardial hernia in a high-risk patient with multiple medical diseases. Traumatic diaphragmatic pericardial hernia is an uncommon but serious sequela of blunt or penetrating thoracoabdominal trauma that often eludes early detection due to imaging limitations and nonspecific symptoms [1,2]. A high index of suspicion – coupled with thorough evaluation to exclude alternative diagnoses such as isolated diaphragmatic rupture, pericardial effusion, cardiac contusion, or pulmonary pathology – is essential for timely recognition [6,9,10,19]. Definitive management requires surgical repair tailored to defect size and patient comorbidities; large or high-risk defects benefit most from tension-free mesh reinforcement, while smaller tears may be amenable to primary suture closure [8,12–15,19]. This case demonstrates that a laparoscopic approach with combined biological and composite synthetic mesh can provide a durable, low-morbidity repair even in a high-risk patient with end-stage renal disease – highlighting the value of minimally invasive techniques and vigilant postoperative monitoring in optimizing outcomes.