INTRODUCTION

Lindenmann et al. [1] stated that pericardial rupture resulting in cardiac herniation is an uncommon traumatic injury, with an incidence of 0.4% to 3% following blunt chest trauma. This condition is most frequently observed in high-speed impact scenarios, such as motor vehicle or motorcycle accidents, and is associated with a notably high mortality rate. Guenther et al. [2] reported that diagnosing this condition through radiologic imaging is challenging due to the lack of specificity in the results, and echocardiography may be limited by visibility issues. Typically, a definitive diagnosis is made through surgical intervention. Standard treatment involves surgically repositioning the heart to its normal anatomical position and repairing the pericardium, either through primary suturing or using a patch if there is tissue loss [3,4].

In this case report, we present the case of a 51-year-old polytrauma patient who experienced concomitant pericardial rupture followed by cardiac herniation and left diaphragmatic rupture with visceral herniation, secondary to blunt trauma from a collapsing wall. We also explore the considerations and complexities involved in the successful repair of this condition. The main objective of this case report is to share our experience managing concomitant pericardial rupture with cardiac herniation and diaphragmatic rupture with visceral herniation using minimal access surgery.

CASE REPORT

A 51-year-old man was admitted to the emergency department after being injured by a collapsing wall. He reported general body discomfort, breathlessness, chest pain, and abdominal discomfort as his primary symptoms.

The patient was evaluated using the principles of advanced trauma life support. He was able to maintain his own airway and his cervical spine was clinically cleared. Decreased breath sounds were observed on the left side of his chest. The shock index was recorded at 0.864, with a pulse rate of 108 beats per minute and a blood pressure of 125/60 mmHg. His Glasgow Coma Scale score was 15 (eye response, 4; vocal response, 5; motor response, 6). During the secondary examination, abrasions were noted on the left side of the patient's abdomen and thorax. The abdominal area was soft, exhibiting slight tenderness in the epigastric and left hypochondriac regions. Notably, there were no indications of peritonitis. The pelvic compression test was positive, and the patient experienced tenderness at the left sacroiliac joint. To manage this, a circumferential pelvic sheet (binder) was applied around the greater trochanters and securely tightened.

Following the initial assessment and stabilization, the patient's condition stabilized and he was transported for radiological imaging studies. A plain x-ray revealed haziness in the left thoracic cavity, elevation of the left hemidiaphragm, and collapse of the left lung. Additionally, a gastric shadow was visible within the left hemithorax, accompanied by a mediastinal shift to the right (Fig. 1). The pelvic x-ray displayed a fracture at the right sacroiliac joint, fractures of both the left superior and inferior pubic ramus, and comminuted, displaced fractures of the left anterior acetabulum (Fig. 2). A computed tomographic (CT) scan of the thorax, abdomen, and pelvis was performed as the patient remained hemodynamically stable. The scan revealed herniation of the stomach, splenic flexure, and spleen through a rupture in the posteromedial left hemidiaphragm, along with an air column at the epicardial fat pocket (Fig. 3). Additionally, there was evidence of hemoperitoneum and bilateral hemopneumothorax. No pericardial tear was reported, and the CT scan showed no clear evidence of pericardial laceration.

The patient underwent an emergency exploratory laparoscopy in a supine position and a thoracoscopy in a semilateral position. For the laparoscopic access, the initial port was inserted infraumbilically using the open Hassan technique for the 30° laparoscope. Two working ports were then placed in a triangular pattern under endoscopic guidance in the right and left upper quadrants, along the midclavicular line at the para rectus region, following the establishment of pneumoperitoneum. Two additional working ports were inserted in the right and left lower quadrants, midclavicular line in the para rectus region, to assist and ensure a comprehensive assessment of the entire abdominal cavity, aiming to prevent any missed injuries. During the procedure, a minimal hemoperitoneum was discovered, along with a significant defect in the left hemidiaphragm, categorized as a grade IV laceration (Fig. 4), and a pericardial rupture that led to cardiac herniation (Fig. 5). Additionally, there was visceral herniation of the stomach, splenic flexure, and spleen through the diaphragmatic rent. No other organ or bowel injuries were noted. The abdominal visceral organs were repositioned into the abdomen, and the diaphragm was primarily closed without tension (Fig. 6). Subsequently, a left thoracoscopic exploration was performed in a semilateral position using a three-port approach. The first port (10 mm) was placed under the tip of the scapula for the 30° laparoscope, followed by two working ports in a triangular pattern: a 5-mm port in the fourth intercostal space and another 5-mm port in the sixth intercostal space (Fig. 7). The heart was carefully repositioned to its normal anatomical location, and the pericardial defect was closed using thoracoscopic techniques with a polypropylene suture (Fig. 8). A left-sided tube thoracostomy was then inserted under direct visualization through the sixth intercostal port site incision, followed by the placement of a second intercostal drain on the right side. Postoperatively, the patient showed improvement without any complications and was co-managed in collaboration with orthopedic surgeons. The patient was discharged from general surgery after a few days.

Ethics statement

Written informed consent for publication of the research details and clinical images was obtained from both the patient and the Clinical Executive Director of Mankweng Academic Hospital (Sovenga, South Africa).

DISCUSSION

Pericardial rupture resulting in cardiac herniation is a rare consequence of blunt trauma [1]. Even more uncommon is a pericardial tear accompanied by diaphragmatic injury following such trauma [5]. The literature indicates that traumatic pericardial rupture leading to cardiac herniation is a severe injury, and there have been only a few reported cases of pericardial tear with diaphragmatic hernia [5]. Diagnosing this condition is exceptionally challenging when relying solely on radiographic studies, due to the pericardium's thin nature, even with the use of advanced imaging techniques [5], as demonstrated in our case. However, certain direct signs, such as the heart protruding into the thoracic cavity, strongly suggest pericardial rupture. Indirect imaging signs, like pneumopericardium or hemopericardium, may offer helpful hints but are not conclusively diagnostic [5,6]. Typically, a definitive diagnosis is obtained surgically, either through open surgery or laparoscopically, depending on the patient's stability.

The usual surgical method for addressing pericardial ruptures has traditionally been an open unilateral thoracotomy. In this case, however, we have demonstrated that hemodynamically stable patients can be treated with thoracoscopic techniques. Initially, our patient's symptoms suggested a left diaphragmatic rupture rather than a pericardial rupture. This case underscores the diagnostic challenges of pericardial ruptures, which often require a high level of clinical suspicion unless the patient presents with characteristic symptoms. Timely treatment involves repositioning the heart to its normal anatomical position and repairing the pericardium, either through primary repair with a nonabsorbable suture or by using a patch in cases of tissue loss [3,4]. In this instance, the patient was both hemodynamically and metabolically stable, with the majority of injuries originating from the abdominal cavity, as determined by preoperative assessments. The surgical goal was to reduce and assess the herniated contents, inspect the bowel, rule out any missed injuries associated with high morbidity, and subsequently repair the diaphragm. It was discovered intraoperatively that both body cavities were involved, as evidenced by a pericardial rupture with cardiac herniation, which presented a significant challenge. In conclusion, diagnosing pericardial rupture with radiologic imaging is challenging. Clinicians must maintain a heightened level of suspicion when treating patients who have sustained severe blunt trauma. Laparoscopy can be employed to diagnose pericardial ruptures when the diaphragm is also injured, and thoracoscopic techniques should be considered for repairing pericardial ruptures. Minimally invasive surgery can play a crucial role in managing pericardial ruptures in stable patients.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Methodology: all authors; Project administration: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Chest x-ray showing a gastric shadow within the left hemithorax (arrow), accompanied by a mediastinal shift towards the right (arrowhead).

Fig. 2.

Pelvic x-ray showing comminuted left anterior acetabular displaced fractures, comminuted left superior and inferior pubic rami fractures, and left iliac bone and left sacral alar fractures.

Fig. 3.

Thoracic, abdominal, and pelvic coronal views of computed tomography showing herniation of the stomach, splenic flexure, and spleen in the chest cavity.

Fig. 4.

Intraoperative laparoscopic images showing the diaphragmatic rent (arrow) and cardiac herniation through the pericardium (arrowhead).

Fig. 5.

Intraoperative thoracoscopic images showing a pericardial rupture measuring approximately 20 cm with cardiac herniation and heart exposed within the chest cavity (arrow).

Fig. 6.

Diaphragm repaired by laparoscopic approach (arrow).

Fig. 7.

Access and placement of port sites. (A) Laparoscopic port insertion. The schematic diagram of the anterior view of the abdomen shows the placement of five laparoscopic ports. (B) Thoracoscopic port insertion. The schematic diagram of the left lateral view of the chest wall shows the placement of three thoracoscopic ports.

Fig. 8.

Sutured pericardium using a nonabsorbable suture by thoracoscopic approach (arrow).

REFERENCES

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