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J Thorac Cardiovasc Surg 1998;115:479-480
© 1998 Mosby, Inc.
BRIEF COMMUNICATIONS |
Albany, N.Y.
From the Albany Medical Centera and St. Peter'sHospital,b Albany, N.Y.
Address for reprints: Darroch W. O. Moores, MD, 319 South ManningBlvd., Suite 301, Albany, NY 12208.
The right gastroepiploic artery (GEA) is frequently used asconduit for coronary artery bypass grafting (CABG). Intrathoracic herniation ofthe stomach has been reported when the GEA pedicle has been routedposterior to the stomach.
1-3Recently, a transdiaphragmatic,intrapericardial herniation of the stomach developed in one of our patientsafter the right GEA pedicle was routed anterior to the stomach. To ourknowledge, this is the first report of this complication.
Case report. A 56-year-old man withcoronary artery disease had undergone CABG with autologous vein grafts to theleft anterior descending, diagonal, obtuse marginal, and posterior descendingcoronary arteries in 1984. He subsequently had recurrent angina and underwent asecond CABG in 1994 with the left and right internal thoracic arteries and theGEA to the left anterior descending, circumflex, and distal right coronaryarteries, respectively. The GEA pedicle was placed anterior to the stomach.
In April 1997, the patient started to have postprandial epigastric painfollowed by nausea and emesis. An upper gastrointestinal radiographic seriesrevealed a intrapericardial gastric hernia (Fig. 1). He subsequently underwent celiacarteriography, which demonstrated a patent right GEA supplying his rightcoronary artery. The patient underwent exploration through a subxiphoid, uppermidline laparotomy. Two thirds of the patient's stomach and omentum were foundin the pericardial sac. A plane of dissection was developed between theepicardium and stomach wall. Adhesions continued to the level of the innominateartery. These were lysed, and the stomach and omentum were reduced into theabdominal cavity. There was no hernia sac. The 8 cm diaphragmatic defect wasrepaired with a 10 cm polytetrafluoroethylene surgical membrane patch,* leaving adequate space for the GEA pedicle. A sternotomy wasnot performed. The patient was discharged home 4 days after the operationwithout sequelae.
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4Subsequent studies have shown it to be a safe and effective conduit. 5 There is debate regarding the bestroute for the GEA pedicle. When the pedicle is placed posterior to the stomachand the liver, a greater length of pedicle is available for conduit to completethe coronary anastomosis. The retrogastric route also minimizes the risk ofinjury during a subsequent laparotomy, whereas the antegastric, antehepaticroute has advantages such as ease of handling, ease of visual inspection forbleeding along the pedicle, and theoretic prevention of transdiaphragmaticherniation of the stomach because the GEA pedicle passes through the diaphragmabove the left lobe of the liver. Reported complications of using the GEA havebeen few. Transdiaphragmatic herniations of the stomach and small bowel with theretrogastric route have been reported in both the early and late postoperativeperiods. 1-3 The most likely cause of transdiaphragmatic herniation of the stomach inthis patient was an overly large window for the GEA pedicle. Risk factors fordiaphragmatic hernia, such as chronic cough, obesity, pregnancy, blunt trauma,and ascites, were not present in our patient and can probably be excluded.
We report here the first case of transdiaphragmatic herniation of thestomach after CABG with the GEA placed anterior to the stomach and liver.Although herniation of the abdominal contents is a rare complication, it may bepreventable. Techniques such as keeping the GEA pedicle small, minimizing thelength of the diaphragmatic incision, placing interrupted sutures perpendicularto the musculotendinous fibers of the diaphragm, 2 performing a gastropexy, 3 and reinforcing the diaphragmaticincision with polytetrafluoroethylene mesh may prevent this complication.
Footnotes
*Gore-Tex surgical membrane, registered
trademark of W.L. Gore & Associates, Inc., Newark, Del. 
References
This article has been cited by other articles:
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  Y. Ikeda, S. Tobari, N. Morita, and K. Okinaga Strangulated intrapericardial herniation of the stomach after use of the right gastroepiploic artery for coronary artery bypass grafting Interactive CardioVascular and Thoracic Surgery, June 1, 2005; 4(3): 168 - 169. [Abstract] [Full Text] [PDF]
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 E. Castedo, A. Varela, A. Villasclaras, C. Gonzalez, and F. Arrieta Traumatic intrapericardial herniation of the stomach Ann. Thorac. Surg., January 1, 2004; 77(1): 340 - 340. [Full Text] [PDF]
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G.F.V. Panday, J.G. Grandjean, K.Y.J.A.M. Ho, and P.W. Boonstra A rare case of herniation of omentum into the pericardial cavity after using the right gastro-epiploic artery for coronary bypass grafting Interactive CardioVascular and Thoracic Surgery, June 1, 2003; 2(2): 154 - 155. [Abstract] [Full Text] [PDF]
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 M. Ansari, P. Eucher, and L. De Canniere Strangulated giant transdiaphragmatic hernia: A rare complication of coronary artery bypass grafting with the right gastroepiploic artery J. Thorac. Cardiovasc. Surg., February 1, 2002; 123(2): 358 - 359. [Full Text] [PDF]
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