A Rare Case of Bochdalek Hernia with Concomitant Para-Esophageal Hernia, Repaired Laparoscopically in an Octogenarian

Abstract

BACKGROUND A Bochdalek hernia (BH) is a rare congenital condition consisting of a posterolateral defect in the diaphragm. A para-esophageal hernia (PEH) is a rare variant of hiatus hernia. BH and PEH may present with gastric volvulus or incarceration, requiring emergency treatment. Minimally invasive surgery is the preferred treatment, particularly for elderly patients and patients with comorbidities. The occurrence of BH with concomitant PEH is a very rare event. We describe a case of an octogenarian patient with BH and concomitant PEH treated laparoscopically. CASE REPORT An 81-year-old male patient, without significant comorbidities, presented with a two-month history of severe chest pain and vomiting after eating. Cardiological investigations ruled out cardiac ischemia, infarction, or other cardiovascular abnormalities. Chest and abdominal computed tomography (CT) imaging demonstrated a large diaphragmatic hernia, with the entire stomach in the left thorax. Laboratory results showed mild anemia and a low iron level. The patient underwent simultaneous laparoscopic repair of a BH and a PEH with mesh reinforcement without antireflux fundoplication. The patient's postoperative recovery was uneventful. CONCLUSIONS We have presented a rare case of BH with concomitant PEH in an octogenarian that was successfully treated with laparoscopic surgery. Although these two forms of hernia are a very rare association, this case report illustrates that the surgical approach should be individualized in each patient's case to ensure a successful surgical outcome. In this case, the decision was made to suture the diaphragmatic crura and reinforce the diaphragm repair with mesh, rather than by fundoplication.

Figure 1.

Computed tomography (CT) axial view of the abdomen. The image shows the whole stomach in the left mediastinum, full of food and air. There is a mesenteric-axial volvulus.

Figure 2.

Laparoscopic surgical treatment of a Bochdalek hernia (BH). The image shows that a laparoscopic approach reduced the stomach from the Bochdalek hernia (BH) from the left chest to the abdominal cavity, following the use of atraumatic graspers.

Figure 3.

Laparoscopic surgical treatment of a Bochdalek hernia (BH). The image shows that the size of the stomach was reduced allowing views the Bochdalek hernia (BH) and the para-esophageal hernia (PEH). The hernia sac was completely reduced and the esophagus released from the soft adhesions in the lower mediastinum to ensure that there is a 3 cm length of lower esophagus in the abdominal cavity.

Figure 4.

Laparoscopic surgical treatment of a Bochdalek hernia (BH). This image was taken following dissection and complete release of the stomach and esophagus, which were disconnected from the diaphragm by cutting the gastrophrenic ligament. The arrows show: 1) the Bochdalek hernia (BH); 2) the para-esophageal hernia (PEH), and 3) the esophagus.

Figure 5.

Laparoscopic surgical treatment of a Bochdalek hernia (BH). The image is taken following the suture of the Bochdalek hernia (BH) and the para-esophageal hernia (PEH) using a composite mesh to reinforce the repair, fastened to the diaphragm with absorbable tackers and sutures. H – hiatus. The Bochdalek foramen was sutured in an anteroposterior direction; the crura were closed posterior to the esophagus in the same way.

Figure 6.

Upper gastrointestinal fluoroscopy performed 24 hours after the operation. On the first postoperative day, an upper gastrointestinal fluoroscopic examination shows a good esophageal passage of the contrast medium, the stomach in place, and there is an adequate duodenojejunal passage.

Figure 7.

The minimally-invasive laparoscopic surgical procedure. The minimally invasive surgery performed through five ports: one port measures 11 mm and four of the ports measure 5 mm. The patient was seen at postoperative day 10 and also at one month after surgery, with no reported symptoms related to reflux, with good healing, and no pain.