Laparoscopic repair of a Bochdalek hernia in an elderly patient: a case report with a review from 1999 to 2019 in Japan

Abstract

Background: A Bochdalek hernia (BH) is a congenital defect of the diaphragm that generally presents in the newborn as life-threatening cardiorespiratory distress. In contrast, the diagnosis of a BH in adults is rare. Surgical repair for adult BH is recommended, but the optimal surgical method remains unclear.

Case presentation: A 75-year-old woman presented with progressive dyspnea and back pain, and a diagnosis of BH was made based on chest X-ray and computed tomography. Laparoscopic evaluation revealed a defect in the left posterior attachment of the diaphragm, and a left-sided BH without hernia sac was diagnosed. Parts of the stomach, small intestine, colon, pancreas, and spleen had prolapsed into the left thoracic cavity, without ischemic change, and these herniated organs were reduced to the abdominal cavity. A direct closure of the hernia orifice was possible by the laparoscopic suture technique using a mesh reinforcement. The patient made an uneventful recovery, and no recurrence was found in the 2-year follow-up.

Conclusion: A recently published study reviewing detailed cases of repair of adult BH from 1999 to 2019 identified 96 cases, including the present case. The number of reports on laparoscopic and/or thoracoscopic surgery for BH in adults has recently increased, and the approach for repairing BH should be selected carefully on a case-by-case basis.

Keywords: Adult diaphragmatic hernia; Bochdalek hernia; Surgery.

Fig. 1

a Preoperative images of the Bochdalek hernia. The chest radiography on admission shows a lesion containing bowel gas in the left thoracic cavity. b Axial view images of the CT scan showing prolapse of the stomach, small intestine, colon, pancreas, and spleen into the left thoracic cavity. c Coronal view images of the CT scan showing same as above

Fig. 2

a Intraoperative views obtained upon laparotomy and port positions for abdominal access. b A large hernial orifice is observed in the left diaphragm, and the prolapsed stomach, small intestine, colon, and pancreas, are seen in the left thoracic cavity. c The spleen is entirely contained within the thoracic cavity due to adhesions. d Upon complete exposure, the hernial orifice is found to be 10 × 8 cm, without hernia sac. e The diaphragmatic defect is closed with interrupted nonabsorbable sutures. f The sutured site was reinforced with Ventralight™ ST mesh

Fig. 3

Trends in the numbers of surgeries for adult Bochdalek hernia from 1999 to 2019 grouped by operative method (endoscopic versus conventional surgery)