An Adult Case of Bochdalek Hernia with Incarcerated Transverse Colon Successfully Treated by Hand-Assisted Laparoscopic Surgery

Abstract

Introduction: Bochdalek hernia (BH) is a congenital diaphragmatic hernia that is rare among adults. It is difficult to treat especially with an incarcerated abdominal organ. Although surgery via laparotomy or thoracotomy to repair the hernia with or without mesh reinforcement is the gold standard of treatment for BH, conversion to open surgery is performed to obtain a good surgical view and sufficient working space. Herein, we describe a rare case of BH with incarcerated distal transverse colon treated by hand-assisted laparoscopic surgery (HALS).

Case presentation: A 74-year-old man visited the outpatient clinic with the chief complaints of anorexia and abdominal distension. Contrast-enhanced computed tomography scan showed incarcerated left diaphragmatic hernia, with the distal transverse colon trapped in the left hemithorax with ischemic change. The patient was diagnosed with large bowel obstruction because of BH. Thus, emergency laparoscopic surgery was performed. However, it was converted to HALS because the colon could not be easily pulled back to the abdominal cavity. The transverse colon was carefully removed without perforation. The surgical course was uneventful, and the patient was discharged 1 week after surgery.

Conclusions: HALS can be used when laparoscopic surgery is difficult.

Keywords: diaphragmatic; hernias; laparoscopy.

Fig. 1. Chest X-ray showing an abnormal gas-filled mass in the left thoracic cavity.

Fig. 2. Computed tomography before surgery. (A) Coronal image showing a hernia defect (white arrow). The oral colon was dilated under the diaphragm (white arrow head). (B) Sagittal image showing the distal transverse colon herniating into the left thoracic space (white arrow).

Fig. 3. Port arrangement. A small incision was made for HALS.

HALS, hand-assisted laparoscopic surgery

Fig. 4. Surgical findings. (A) The incarcerated transverse colon (surrounded in the dotted line) was carefully pulled from the hernia orifice (white arrow) toward the abdominal cavity. (B) The size of the hernia orifice was 5 × 2.5 cm. The left lung was observed through the defect (white arrow). (C) The hernia defect was repaired using non-absorbable sutures.