View source for Paper - Pericardio-peritoneal communication, description of a rare type of diaphragmatic hernia (1939)

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=Pericardio-peritoneal communication, description of a rare type of diaphragmatic hernia=

By H. D. O'Brien. 

Department of Anatomy, McGill University, Montreal, Canada


Although cases of diaphragmatic hernia are by no means uncommon, the following specimen is described because of the extreme rarity of the type of which it is an example.

In the course of routine dissection of the body of a 63-year-old Russian, recorded as having died from general paralysis, an aperture in the diaphragm was found forming a communication between the pericardial and peritoneal cavities.


Diaphragm from below. D. defect; Adh. adhesion band between liver and diaphragm. The heavy black line shows the attachment of the anterior parts of the coronary ligament and of the falciform ligament. The posterior parts are omitted for simplicity.

The opening was oval in outline, 3.cm. in transverse, and 2-3 cm. in anteroposterior diameter, lying in the anterior leaf of the centrum tendineum of the diaphragm where this is fused to the floor of the pericardium. It lay just to the left of the middle line, with its anterior border 2 cm. behind the posterior surface of the sternum. Seen from the abdominal aspect, it lay well to the left of the falciform ligament of the liver, and some way anterior to the left part of the coronary ligament. The borders were thin, smooth, and rounded anteriorly and laterally, while the posterior part of the circumference had a thin sharp border. The pericardium was directly continuous with the peritoneum all around the margins of the aperture.


Seen from the pericardial aspect, the posterior two-thirds of the aperture were occupied by a low, smooth, rounded process of the liver projecting not more than 4mm. above the level of the surrounding floor. The anterior part of the aperture exposed some of the great omentum, which, however, had apparently not herniated through the orifice.

The heart was apparently normal externally, but there was a small patent and valvular foramen ovale such as is not uncommonly encountered in the course of routine dissections. The visceral pericardium showed a slight pearly opacity over the area of contact with the exposed liver. The aorta showed evidence of syphilitic aortitis, but otherwise there was no significant abnormality of the heart.

The pericardium, apart from the aperture in the floor, appeared normal in every respect and clothed the heart with the usual accuracy, suggesting that at no time can there have been any significant herniation of abdominal contents into it. There was no sign of a patent pleuro-pericardial canal, and the phrenic nerves ran their usual course.

The diaphragm showed no other abnormality, and the lumbo-costal triangle (foramen of Bochdalek) was closed by muscle tissue.

The liver was slightly smaller than usual, the left lobe in particular being reduced and terminating postero-laterally in a thin sheet which formed the base of the left triangular ligament. Near the anterior border of the diaphragmatic surface of the left lobe there was a low process of liver tissue extending on to the anterior border of the lobe, and accurately fitting the posterior part of the diaphragmatic deficiency, through which it projected into the pericardium for about 4mm. Immediately behind this process, the liver was adherent to the diaphragmatic peritoneum by a narrow, tough adhesion-band running along the posterior periphery of the aperture.

Microscopical examination of the liver in the region of the process revealed evidence of syphilitic cirrhosis of the liver, thickening of the overlying peritoneum, and a narrow band of organized fibrinous exudate at the point of adhesion to the diaphragm. There was no evidence to suggest that the aperture could have been produced by a previous’ gummatous perforation.

No significant abnormality could be detected in the other thoracic and abdominal viscera, there were no scars on the skin to suggest a penetrating injury, and the ribs showed no sign of antecedent fracture. None of the other abdominal viscera showed any evidence to suggest that they might at some time have been herniated into the pericardial cavity.

From lack of evidence of any other possible aetiology, it appears probable that this is a case of hernia diaphragmatica spuria centralis congenita of the liver into the pericardial cavity, in itself a rare condition, but it is further remarkable on account of the very slight degree of herniation present.

A general survey of the literature available revealed that examples of pericardioperitoneal communications have been described in five instances in man, four in the dog, and one in the ass. Of the examples in human subjects, four were of the false variety and were found in males past middle age, as in the present case, while one was a true hernia with sac in a new-born infant of unspecified sex. In all these cases there was a considerable degree of herniation of abdominal contents into the pericardial cavity. Of the examples reported in animals only one, reported by Stoeber (1912), showed evidence of the former existence of a hernial sac.

In the present instance, the lack of herniation of abdominal viscera is probably explicable on the grounds that, although the condition was probably present in some degree at birth, during most of the man’s life it must have been shielded by overlying liver, which only latterly began to retreat and expose the deficiency as the cirrhotic process caused general reduction in size of the liver. This contraction during life would be further increased post-mortem by the method of injection employed in preparing the subject for the dissecting room. That contraction of the liver could effect an enlargement of the aperture is suggested by the firm adhesion of the liver to Author 

(A) In Man: de Cardenal Martland Keith O’Brien

(B) In dog: Antonio* Petit Joest* Stoeber

(C) In donkey: Forgeot*

Date

1903

1909

1910

1939

1901 1902 1904 1912

1903

Age

58

70

50 47

Sex

=

a fe

New-born ?

63

Old

?

=

oo ee Oe Oe

Table I. Pericardio-peritoneal communications

Type

False

False

False False True False

False False False ? True

False

Herniated structures

Great omentum. Loop of transverse colon

Great omentum. Loop of transverse colon

Process of great omentum

Process of liver

Process of liver

Process of liver

Great omentum Coils of small gut Great omentum Process of liver

Process of liver

Associated abnormalities

Omentum adherent to margins of gap. Pericardium large. Heart large and distorted. Loop of colon strangulated

Omentum adherent to margins of gap. Pericardium large, with thick walls

Liver adherent to margin of gap. Passable foramen ovale. Coincident lues

Omentum adherent to heart

No quadrate lobe of liver

Pericardium greatly enlarged

Pericardium greatly enlarged. Lungs reduced :

N.B. Authors marked * are quoted by Joest (1912).

Origin

Congenital

Congenital

Possibly traumatic Possibly traumatic Congenital Congenital

Congenital Congenital Congenital Congenital

Congenital


the posterior margin of the deficiency and by the firm but attenuated appearance of the left lobe and triangular ligament, which doubtless acted as a point of countertraction.

This explanation may account for the lack of herniation in this peculiar example of a rare condition, but there is as yet no satisfactory explanation of the primary embryological aetiology of these curious defects.

==References==

Antonio, A. (1901). Gi. Soc. vet. ital. (Quoted by Joest (1912).) 

DE CaRDENAL, G. & BourpERov (1903). J. Méd. Bordeau, 23, 222. 

Foreeot, M. (1903). J. Méd. vét. (Quoted by Joest (1912).) 

Jorst, E. (1904). Ber. %. das Veterindrswesen im Kénigreich Sachsen. Dresden, 1905. (Quoted by Joest (1912).) 

—— (1912). Frankfurt. Z. Path. 11, 478. 

Kerra, A. (1910). Brit. med. J. 2, 1297. 

Marruanp, H. S. (1909). J. Amer. med Ass. 52, 1574. 

Perit, H. G. (1902). Bull. Mem. Soc. Anat. Paris, T7, p. 306. 

Srorser, H. (1912). Frankfurt. Z. Path. 10, 278.

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