Thoracoscopic-assisted repair of a bochdalek hernia in an adult: a case report

Abstract

Introduction: Bochdalek hernia is a congenital defect of the diaphragm that usually presents in the neonatal period with life-threatening cardiorespiratory distress. It is rare for Bochdalek hernias to remain silent until adulthood. Once a Bochdalek hernia has been diagnosed, surgical treatment is necessary to avoid complications such as perforation and necrosis.

Case presentation: We present a 17-year-old Japanese boy with left-upper-quadrant pain for two months. Chest radiography showed an elevated left hemidiaphragm. Computed tomography revealed a congenital diaphragmatic hernia. The spleen and left colon had been displaced into the left thoracic cavity through a left posterior diaphragmatic defect. We diagnosed a Bochdalek hernia. Surgical treatment was performed via a thoracoscopic approach. The boy was placed in the reverse Trendelenburg position and intrathoracic pressure was increased by CO2 gas insufflations. This is a very useful procedure for reducing herniated contents and we were able to place the herniated organs safely back in the peritoneal cavity. The diaphragmatic defect was too large to close with thoracoscopic surgery alone. Small incision thoracotomy was required and primary closure was performed. His postoperative course was uneventful and there has been no recurrence of the diaphragmatic hernia to date.

Conclusion: Thoracoscopic surgery, performed with the boy in the reverse Trendelenburg position and using CO2 gas insufflations in the thoracic cavity, was shown to be useful for Bochdalek hernia repair.

Figure 1

Preoperative chest radiograph. The chest radiograph shows elevation of the left diaphragm. In this case, the lateral chest radiography was important for the detection of an abnormality in the thoracic cavity.

Figure 2

Preoperative enhanced chest and abdominal computed tomography (CT) scans. The chest CT shows a diaphragmatic hernia. The spleen and left colon have herniated into the left thoracic space through a left posterior diaphragmatic defect.

Figure 3

Surgical findings with thoracoscopy. A) The left colon and spleen were identified in the left thoracic cavity under thoracoscopy. No hernia sac was found. B) The left colon and spleen appeared to have herniated through a left posterior diaphragmatic defect, as indicated by the preoperative chest computed tomography. C) The diaphragmatic defect, 5 cm × 6 cm in size, had a smooth circular edge and showed gradual expansion at the thoracic wall. D) The defect was closed using a single layer primary closure method with interrupted non-absorbable sutures.

Figure 4

Postoperative chest radiography. There were no abnormalities on postoperative chest radiography.

Figure 5

Postoperative enhanced chest and abdominal computed tomography (CT) scans. Two months postoperatively, an outpatient chest CT was performed. There was no recurrence of diaphragmatic hernia