Minimally invasive repair of a congenital right-sided diaphragmatic hernia in an adult

A Tale of Two Congenital Lesions: A Case Report of Congenital Diaphragmatic Hernia and Congenital Heart Disease Managed by Successful Surgical Outcome With Review of the Literature (Bhende-Pathak Hernia)

Congenital diaphragmatic hernia (CDH) is a diaphragmatic defect that is usually situated on the left side in the posterolateral region, named a Bochdalek hernia (BH), which allows abdominal organs to herniate into the thoracic cavity. BH is a prevalently observed birth anomaly in infants but is rare in adults. Right-sided BH that involves the colon is exceptionally rare, and no prior cases have described ileocecal appendix involvement. Here, we present a case of a preschooler with a right-sided BH and patent ductus arteriosus (PDA), requiring distinct surgical approaches: left open thoracotomy for PDA ligation and right open thoracotomy for CDH repair. Surgical intervention is associated with reduced morbidity and mortality, favorable long-term outcomes, and a low recurrence rate, irrespective of the selected approach. Reinforcement through suture repair with mesh application, as well as PDA ligation, reinforced with metallic clips as the preferred surgical operation in this case. To the best of our knowledge, this is the first reported instance of a pediatric patient with right-sided BH that involves the appendix, alongside concurrent congenital heart disease (CHD). We propose the term Bhende-Pathak hernia for this pediatric variant.

Right-sided Bochdalek hernia in an adult with hepatic malformation and intestinal malrotation

BACKGROUND

Bochdalek hernia is a common congenital diaphragmatic defect that usually manifests with cardiopulmonary insufficiency in neonates. It is very rare in adults, and symptomatic cases are mostly left-sided. Diaphragmatic defects generally warrant immediate surgical intervention to reduce the risk of incarceration or strangulation of the displaced viscera.

CASE PRESENTATION

A 47-year-old woman presented with dyspnea on exertion. Computed tomography revealed that a large part of the intestinal loop with superior mesenteric vessels and the right kidney were displaced into the right thoracic cavity. Preoperative three-dimensional (3D) simulation software visualized detailed anatomy of displaced viscera and the precise location and size of the diaphragmatic defect. She underwent elective surgery after concomitant pulmonary hypertension was stabilized preoperatively. The laparotomic approach was adopted. Malformation of the liver and the presence of intestinal malrotation were confirmed during the operation. The distal part of the duodenum, jejunum, ileum, colon, and right kidney were reduced into the abdominal cavity consecutively. A large-sized oval defect was closed with monofilament polypropylene mesh. No complications occurred postoperatively.

CONCLUSION

Symptomatic right-sided Bochdalek hernia in adults is exceedingly rare and is frequently accompanied by various visceral anomalies. Accurate diagnosis and appropriate surgical repair are crucial to prevent possible incarceration or strangulation. The preoperative 3D simulation provided comprehensive information on anatomy and concomitant anomalies and helped surgeons plan the operation meticulously and perform procedures safely.

A systematic review on diagnostics and surgical treatment of adult right-sided Bochdalek hernias and presentation of the current management pathway

Purpose

Bochdalek hernia is a congenital diaphragmatic hernia. The incidence in adults is estimated around 0.17%. Right-sided hernias are much more seldom than left-sided ones because of faster closure of the right pleuroperitoneal canal and the protective effect of the liver. Due to its rarity, there have been no large prospective or retrospective studies following great need for evidence-based diagnostics and treatment strategies. In this systematic review, we evaluated the current evidence of diagnostics, treatment, and follow-up of adult right-sided Bochdalek hernias.

Methods

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines a systematic literature review was conducted in PubMed and Cochrane library from 2004 to January 2021. The literature search included all studies with non-traumatic right-sided Bochdalek hernias. Literature on left- or both-sided, pregnancy-associated, pediatric, and other types of hernias were explicitly excluded. Quality assessment of the included studies was performed.

Results

Database search identified 401 records. After eligibility screening 41 studies describing 44 cases of right-sided non-traumatic Bochdalek hernias in adulthood were included for final analysis. Based upon the systematic literature review, the current diagnostic, therapeutic, and follow-up management pathway for this rare surgical emergency is presented.

Conclusion

This systematic review underlined that most studies investigating management of adult non-traumatic right-sided Bochdalek hernias are of moderate to low methodological quality. Hernias tend to occur more frequently in middle-aged and older women presenting with abdominal pain and dyspnea. A rapid and accurate diagnosis following surgical repair and regular follow-up is mandatory. High-quality studies focusing on the management of this rare entity are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02445-1.

Surgical management of symptomatic right-sided Bochdalek hernias in adults: when is a minimally invasive approach appropriate?

BACKGROUND

Right-sided Bochdalek hernias are uncommon congenital diaphragmatic hernias that can be challenging to manage because they can contain bowel, omentum, kidney or liver.

METHODS

We describe our experience at a single centre and integrate this with all reported cases in the literature to evaluate how this rare problem has been managed and when a minimally invasive approach is appropriate.

RESULTS

A total of 31 patients were identified, four patients from our institution and 27 case reports from the literature. A minimally invasive approach was utilized in 15 of 31 patients (including two of four at our institution) and was more common if the operation was performed in the elective setting (10/12 versus 4/19). If a bowel resection was required, an open approach was more common (9/17 versus 1/14). The commonest method of repair was a primary suture repair (18/31), and the mesh was used in 13 cases, particularly in the elective setting (9/12 versus 4/19).

CONCLUSION

Right-sided Bochdalek hernias are an uncommon and challenging problem. These hernias can contain bowel, kidney and even liver but can still be successfully repaired using minimally invasive techniques, especially in the elective setting and when an emergency bowel resection is not required.

Complicated adult right-sided Bochdalek hernia with Chilaiditi's syndrome: a case report

An extremely rare adult case that underwent surgery for ileus caused by Bochdalek hernia associated with Chilaiditi’s syndrome is presented. A 65-year-old woman complaining of upper abdominal pain presented to our hospital. Abdominal plain radiography showed increased intestinal gas, and computed tomography (CT) showed the transverse colon located above the right lobe of the liver, representing Chilaiditi’s sign. She was diagnosed as having ileus and treated with decompression therapy by a nasoenteric tube. After hospitalization, the patient developed dyspnea, and CT showed intestinal herniation into the right thoracic cavity. She was diagnosed as having strangulated ileus caused by Bochdalek hernia. An emergent laparotomy was performed, and it showed a hole of 5 cm in diameter at the right hemi-diaphragm. The transverse colon was incarcerated through the hole, it was pulled back to the abdominal cavity, and a right hemicolectomy was performed because of necrotic changes. A small part of the liver was also herniated into the right thoracic cavity, and it was returned to the abdominal cavity. The defect in the diaphragm was closed by direct suture. Although the patient developed an abscess in the thoracic cavity postoperatively, she improved with antibiotic therapy and was discharged 2 months after the operation.

Rare case report - congenital diaphragmatic hernia presentation in adult

Congenital diaphragmatic hernia (CDH) which mainly occurs in the newborn or in childhood with severe respiratory distress and high mortality, is rarely found in adults (Yamaguchi et al. Ann Thorac Cardiovasc Surg 8:106-108, 2002; Dalencourt and Katlic Ann Thorac Surg 82:721-722, 2006; Fraser et al. Endosc Percutan Tech 19: e5-e7, 2009; Kanazawa et al. Surg Today 32:812-815, 2002). These patients are been accustomed to adjust their lifestyle to manage symptoms associated with frank herniation of the large bowel and liver inside the diaphragmatic hernial sac. Bowel above the liver surface especially the transverse colon is suggestive of a Chilaiditi's syndrome in these group of patients. Diagnostic laparoscopy plays an important role for diagnosis of diaphragmatic hernia in some cases over other investigations like CT scan and ultrasonography. Chilaiditi's syndrome has no surgical line of treatment but a symptomatic diaphragmatic hernia requires surgical correction. Liver as the main hernial content has been reported only in three cases throughout the world (Goh et al. Am J Surg 194: 390-391, 2007; Luo et al. Hepatobiliary Pancreat Dis Int 6: 219-221, 2007; Bosenberg and Brown RA Curr Opin Anaesthesiol 21: 323-331, 2008). A case of a 27 year old female patient presenting with a symptomatic congenital diaphragmatic hernia is reported.