Case report: anaesthetic and surgical management of a diaphragmatic rupture with tension pneumothorax and iatrogenic bowel perforation in an undiagnosed Bochdalek hernia patient

Abstract

Background: Congenital diaphragmatic defects are rare, with most cases presenting in childhood. Diagnosis in adulthood is usually incidental or when symptoms develop. We present a case of a strangulated Bochdalek hernia complicated by possible tension pneumothorax and iatrogenic bowel injury in a healthy young male.

Case presentation: A 23-year-old Chinese man initially presented with complaints of mild back pain and was discharged with symptomatic treatment. He presented again 3 days later, with dyspnea and left upper back pain and was haemodynamically unstable and hypoxic. A chest x-ray was reported as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax. Needle decompression resulted in feculent fluid being aspirated with no resolution of symptoms. The patient required an immediate transfer to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and left tension pneumothorax, with accidental puncture of the herniated bowel. He underwent an emergent laparotomy with requirements for rapid lung isolation and continued aggressive resuscitation.

Conclusions: Patients with congenital diaphragmatic hernias may present in adulthood, either incidentally or emergently. In the well adult patient with good reserves, these initial symptoms may be mild, and may be symptomatically treated with no further workup. However, patients may deteriorate rapidly once their compensatory mechanisms are exhausted. This is the first reported case of a patient with diaphragmatic rupture and bowel herniation, complicated by iatrogenic tension pneumothorax. This rare case illustrates the speed at which a diaphragmatic rupture may progress, possible pitfalls and offers insights on how a misdiagnosis may be avoided.

Keywords: Abdominal surgery; Airway management; Critical care; Diaphragmatic hernia; Emergency surgery.

Fig. 1

Chest X-ray images. a On admission showing a large left sided pneumothorax with tracheal deviation and herniation of bowel into the left hemithorax. b After attempted needle decompression showing a persistent left pneumothorax, with further elevation of the bowel loop superiorly in the left hemithorax. The mediastinum is slightly less deviated but still shifted to the right. c After the first surgery showing reduction of left diaphragmatic hernia and temporary closure of defect with surgical towels, There was also re-expansion of the left lung with airspace opacities in the mid and lower zones. d After discharge from ICU showing improvement of airspace opacities