Strangulated intrapericardial herniation of the stomach after use of the right gastroepiploic artery for coronary artery bypass grafting.

A 74-year-old woman with coronary artery disease had undergone coronary artery bypass grafting (CABG) with autologous vein grafts in 1999. She subsequently had recurrenct angina and underwent a second CABG in 2001 with the right gastroepiploic artery (GEA). The GEA pedicle was placed anterior to the stomach. In November 2004, the patient was admitted to the emergency room for back pain with nausea and vomiting. A repeat electrocardiogram did not show transient myocardial ischemia. A plain radiograph of the chest revealed the gas-filled dilatation of the stomach with fluid levels in the left base of the thorax. An upper gastrointestinal radiographic series using stomach tube revealed a strangulated intrapericardial gastric hernia. A computed tomographic scan with sagittal plane showed an intrapericardial hernia above the left lobe of the liver. Although herniation of the abdominal contents is a rare complication, it may be preventable. Techniques such as keeping the GEA pedicle small, minimizing the length of the diaphragmatic incision, placing interrupted sutures perpendicular to the musculotendinous fibers of the diaphragm, performing a gastropexy, and reinforcing the diaphragmatic incision with mesh may prevent this complication.