Laparoscopic Repair of Giant Bochdalek Hernia in Adults

Incidental discovery of a giant congenital diaphragmatic hernia in an adult: A case report and literature review

INTRODUCTION AND IMPORTANCE

Congenital diaphragmatic hernia (CDH) is rare, occurring in 1 in 2000 to 4000 live births, and is typically diagnosed in neonates. Bochdalek hernia is the most common type, usually presenting as a left-sided posterolateral defect. Adult presentations of CDH are uncommon and often incidental. This report discusses a young adult with an undiagnosed CDH, emphasizing the importance of clinical awareness.

CASE PRESENTATION

A 26-year-old man presented with flu-like symptoms and stable vital signs. He reported chronic postprandial shortness of breath that improved with standing. Physical examination revealed decreased breath sounds on the left side. A chest X-ray identified a left diaphragmatic hernia, confirmed by spiral chest computed tomography. Although advised to undergo surgery, the patient opted for discharge against medical advice.

CLINICAL DISCUSSION

Bochdalek hernia, comprising over 95 % of CDH cases, is usually left-sided due to a defect in the pleuroperitoneal membrane. Adults with CDH often present with nonspecific symptoms or the condition is discovered incidentally. Our patient adapted to his symptoms by standing after meals, which provided relief. Surgical intervention is recommended to prevent organ damage, with various techniques available, including open and endoscopic surgery. This case highlights the necessity of clinical vigilance in diagnosing CDH in adults.

CONCLUSION

Adult congenital diaphragmatic hernia, though rare, requires prompt surgical treatment to prevent organ damage. Recognizing subtle symptoms is crucial for diagnosis. This report contributes to the limited literature on adult-diagnosed CDH, stressing the need for clinical awareness and timely management.

ACR Appropriateness Criteria® Hernia

Abdominopelvic hernias are common clinical entities composed of a wide variety of congenital, traumatic, and iatrogenic etiologies. Any weakness in the body wall may result in hernia of cavity contents with concomitant risks of morbidity and mortality. Presentations may be specific, palpable body wall mass/bulge, or vague, nonspecific pain through bowel obstruction. This document focuses on initial imaging of the adult population with signs of symptoms prompting suspicion of abdominopelvic hernia. Imaging of the abdomen and pelvis to evaluate defects is essential for prompt diagnosis and treatment. Often CT and ultrasound are the first-line modalities to quickly evaluate the abdomen and pelvis, providing for accurate diagnoses and management of patients. MRI protocols may be useful as first-line imaging studies, especially in patients with orthopedic instrumentation. Although often performed, abdominal radiographs and fluorographic procedures may provide indirect evidence of hernias but are usually not indicated for initial diagnosis of hernia. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

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

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.

Bochdalek hernia in an adult: two case reports and a review of perioperative cardiopulmonary complications

Background

Bochdalek hernia in an adult is very rare and often needs an immediate surgical repair for the herniation. Although its etiology and surgical techniques have frequently been reported, perioperative complications, especially cardiopulmonary problems, remain unknown. We reported two adults with Bochdalek hernia and reviewed the published literatures with a focus on these issues.

Case presentation

We experienced two adult cases of Bochdalek hernia with gastrointestinal strangulation. One case had massive herniation of the stomach, colon, spleen, and pancreas in the left chest, causing repeated vomiting. The other had a right-side hernia with strangulation of the colon. We successfully performed emergency repairs of these diaphragmatic hernias without any postoperative complications.

Conclusions

Our literature review revealed that life-threatening cardiopulmonary complications, such as empyema or cardiac arrest caused by the tamponade effect of the herniated viscera, sometimes occurred in patients with Bochdalek hernia. These complications were found in Bochdalek hernia with gastrointestinal strangulation.

A Lady with Severe Abdominal Pain Following a Zumba Dance Session: A Rare Presentation of Bochdalek Hernia

A Bochdalek hernia is a congenital diaphragmatic hernia that results from a failure of closure of the pleuroperitoneal folds during embryologic development. While it is most often diagnosed in neonates and infants, Bochdalek hernias can rarely present in adulthood for the first time. We describe the case of a 42-year-old lady who presented with sudden onset of severe abdominal pain following a Zumba dance session. Her chest radiograph showed an elevated left hemi-diaphragm with visualization of a gastric bubble in the thorax. A computed tomography (CT) scan of the abdomen showed a defect in the left hemi-diaphragm with herniation of the stomach and abdominal viscera through the defect. The patient was taken for diagnostic laparoscopy, and the diaphragmatic defect was repaired with a synthetic mesh. Perioperatively, perforation of the anterior wall of the stomach was noted, and a diagnosis of Bochdalek hernia with gastric strangulation was made. This case demonstrates a rare presentation of Bochdalek hernia in an adult with strangulation and perforation of the stomach. Clinicians need to be aware of this rare but life-threatening clinical entity in order to secure a timely diagnosis and institute appropriate management.