Right posterior diaphragmatic hernia (Bochdalek) with liver involvement and alteration of hepatic outflow in adult: a case report

Combined laparoscopic and thoracoscopic repair of adult right-sided Bochdalek hernia with massive liver prolapse: A case report

BACKGROUND

A Bochdalek hernia (BH) is a congenital diaphragmatic hernia that often develops in the neonatal period. BH typically occurs on the left side of the diaphragm. A right-sided BH in an adult is rare.

CASE SUMMARY

A 45-year-old man was referred to our hospital because of an abnormal shadow seen on chest radiography during a medical check-up. A chest radiograph showed elevation of the right hemidiaphragm. Computed tomography showed prolapse of multiple intraabdominal organs into the right thoracic cavity, corresponding to a right-sided BH. The herniated contents included the stomach, transverse colon, and left lobe of the liver. The left lobe of the liver was enlarged, particularly the medial segment. Laparoscopic surgery was performed. However, the left lobe of the liver was completely trapped in the thoracic cavity. Therefore, thoracoscopic manipulation had to be performed to return the liver to the abdominal cavity. The hernia was repaired with interrupted nonabsorbable sutures and reinforced with mesh.

CONCLUSION

Combined laparoscopic and thoracoscopic surgery was successfully performed for right-sided BH with massive liver prolapse and abnormal liver morphology.

Significant Liver Atrophy Due to Vascular Compromise Associated With Adult Congenital Diaphragmatic Hernia

Diaphragmatic hernia in adults is mostly post-traumatic in origin, and rarely congenital. In both situations, the right side is less commonly involved due to the protection offered by the liver and earlier closure of the right pleuroperitoneal canal. A congenital diaphragmatic hernia may present in adulthood with multi-visceral contents, of which the liver is an extremely rare content, mentioned only in a few previous reports. A herniated liver may mimic a pulmonary tumor and may be completely atrophic due to sustained compression of the venous outflow. Careful operative planning is essential to identify and reduce the liver, along with other contents. We are reporting two adults with a congenital diaphragmatic hernia, with multi-visceral contents and an atrophied liver. The first patient was a 28-year-old man with a remote history of trauma found to have a large right diaphragmatic hernia on imaging. The right liver was completely atrophied due to right hepatic venous compression, while the left liver underwent massive hypertrophy and rotation of the left portal axis. Exploratory laparotomy and reduction of contents, along with mesh repair, were accomplished with satisfactory results. The second patient was a 26-year-old man with Down’s syndrome detected to have multiple bowel loops in the right thorax on imaging. At laparoscopy, a Larrey’s type of Morgagni hernia with a right paramedian defect was found. The left liver was atrophied into a leaf-like appendage due to possible portal obliteration and was dissected away from the diaphragm edge. Appropriate mesh repair was completed by a minimally invasive technique.

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.