Thoracoscopic approach to congenital diaphragmatic hernias in adults: Southampton approach and review of the literature

Abstract

Congenital diaphragmatic hernias (CDH) are likely to present in early postnatal or infancy and are associated with significant morbidity and mortality due to associated pulmonary hypoplasia, pulmonary hypertension and heart failure. Symptomatic adult congenital Bochdalek hernia, on the other hand, is extremely rare with a prevalence of 0.17-6% of all diaphragmatic hernias. They present with recurrent abdominal pain and shortness of breath. Acute presentations could be life threatening especially if there is incarcerated or threatened bowel in the chest. Repair of symptomatic Bochdalek hernia is recommended in the adult population. We present two cases of right and left symptomatic Bochdalek hernias in adults, encountered over 15 years of practice in a tertiary referral centre in the UK. We discuss their presentation and surgical management and review the literature of similar cases treated by video-assisted thoracoscopic surgery (VATS). Thoracic surgeons are increasingly becoming involved in these cases, which used to be the domain of upper gastrointestinal surgeons. A synthetic patch may be required to close the defect, therefore; the thoracic surgeon must be familiar with such techniques. The recent expansion in video format publishing in the internet and social media has revolutionized the way knowledge and how-to-do-it expertise is distributed around the world. It has the advantage of reaching far more viewer than subscription paper-printed format journals and has a rising significance in encouraging thoracic surgeons to do things they were not used to do. Finally; Symptomatic Bochdalek hernia, and possibly Morgagni hernia in the adult population could be safely repaired by VATS with good and lasting results.

Keywords: Bochdalek hernia; Congenital diaphragmatic hernia (CDH); Morgagni hernia; diaphragmatic approach; video assisted thoracoscopic surgery (VATS).

Figure 1

VATS repair of right Bockdalek hernia and diaphragmatic plication (1). [Reproduced with permission from CTSnet.org previously published at https://www.ctsnet.org/article/vats-repair-right-bockdalek-hernia-and-diaphragmatic-plication. 4th May 2015]. Available online: http://www.asvide.com/articles/1841

Figure 2

Preoperative diagnostic imaging in case 1. (A) Plain postero-anterior chest X-ray showing abnormal profile of the right hemidiaphragm. (B) The CT scan shows herniation of the liver into the right chest, and no evidence of interstitial lung disease.

Figure 3

Postoperative imaging in case 1. (A) Plain chest X-ray in the immediate postoperative period showing the low and flat position of the right hemidiaphragm. (B) Chest X-ray taken six month postoperatively showing sustainable low position of right diaphragm.

Figure 4

VATS repair of left Bochdalek hernia (2). [Reproduced with permission from CTSnet.org previously published at https://www.ctsnet.org/article/vats-repair-left-bochdalek-hernia. 3rd October 2016]. Available online: http://www.asvide.com/articles/1842

Figure 5

Axial and frontal MPR computed tomography of patient in case 2. Fat is seen in the left chest, suggesting omental hernia through a diaphragmatic defect. MPR, multiplanar reconstruction.

Figure 6

Plain postero-anterior chest radiographs in case 2. (A) Day one postoperatively after removal of chest drain; (B) one year later.

Figure 7

Frontal MPR of CT of patient in case 2 one year post operatively. Reported as “minor non-specific elevation of left diaphragm and no cause for shortness of breath identified. There was no recurrence of hernia”. MPR, multiplanar reconstruction; CT, computed tomography.

Figure 8

Potential sites of congenital hernias. IVC, inferior vena cava; Oes, oesophagus; Ao, aorta.

Figure 9

MPR of computed tomography showing greater omentum herniating via a Morgagni hernia into the right chest. MPR, multiplanar reconstruction.

Figure 10

Morgagni hernia seen from laparoscopic abdominal view, same patient as in Figure 7.