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

Rare Right-Sided Posterolateral Diaphragmatic Hernia in an Adult Presenting as an Incarcerated Large Bowel Obstruction: A Case Report

Introduction

A diaphragmatic hernia (DH) is a defect within a part of the diaphragm that allows intra-abdominal contents to enter the thoracic cavity. Diaphragmatic hernias can be congenital or acquired later in life. The most common congenital DH is the Bochdalek hernia (posterolateral hernia), but the most commonly acquired DH is due to traumatic injury. These hernias are rare in adults and are typically diagnosed incidentally. Surgical repair is the standard of care; however, data regarding the surgical approach is scarce. We report a case of a rare right posterolateral DH in an adult female patient who presented with acute abdominal pain.

Case Presentation

A 69-year-old female presented with recurrent epigastric pain that had acutely worsened, nausea, vomiting, and food intolerance. A computed tomography (CT) scan demonstrated a right posterolateral DH containing the hepatic flexure of the colon. The patient was taken urgently to surgery due to concern for strangulation. Reduction of the hernia was attempted laparoscopically but was converted to an open procedure with a subcostal incision due to poor visualization. This approach revealed adequate exposure of the defect and subsequent reduction of the herniated abdominal contents. The defect was easily closed without tension or the use of mesh. The patient was discharged on postoperative day 3.

Conclusion

Chronic DH can have severe life-threatening sequelae when left untreated. This case demonstrates the importance of thorough history-taking and raises awareness of missed diaphragmatic injuries in trauma situations. Since patients who present with a symptomatic DH often need urgent repair, it is important for surgeons working in the acute care setting to understand the surgical options available and when mesh placement may benefit the situation. Our case outlines a successful primary defect repair, without mesh, of a right-sided DH in which a minimally invasive technique was attempted but converted to laparotomy for patient safety.

Congenital Hernias in Adults: Bochdalek Hernias

Bochdalek hernias are a rare occurrence in adults and usually asymptomatic, resulting in incidental discovery. However, surgical intervention is recommended for both symptomatic and asymptomatic Bochdalek hernias due to the risk of acute morbidity and mortality. There are various possible surgical approaches that may be appropriate depending on the circumstance, with robotic repair becoming increasingly popular. To date, the rarity of the condition has limited the available data on postoperative outcomes.

Asymptomatic Bochdalek's Hernia in an Adult: A Case Report

Bochdalek's hernia is the most common congenital malformation of the diaphragm with a defect in its posterolateral part. Its clinical manifestation in adulthood is rare. It is often an incidental finding, and its diagnosis may be challenging. A high index of suspicion is necessary, especially in cases presenting with cardiopulmonary or abdominal symptoms and an ambiguous finding on the initial chest X-ray. We present a case of an asymptomatic 50-year-old male patient with a bulky left-sided Bochdalek's hernia. Surgical treatment was indicated, and a direct suture of the defect after reduction of the herniated greater omentum, transverse colon, and tail of the pancreas was performed from the upper midline laparotomy. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. The management of adult patients with these kinds of hernias in both acute and chronic settings is discussed, and some recommendations are mentioned to minimize unnecessary pitfalls.

Up to the chest in bowels: case of strangulated right diaphragmatic hernia with paraesophageal hernia in a non-trauma patient

A Bochdalek hernia is a rare congenital diaphragmatic hernia often diagnosed in infancy and classically occurring on the left side. We report a case of a 78-year-old female who presented with a right-sided posterolateral diaphragmatic hernia containing multiple loops of bowel with evidence of ischemia as well as a type 4 paraesophageal hernia. The stomach was rotated on the organoaxial plane, and the duodenum was within the mediastinum. The patient was taken emergently for an exploratory laparotomy. A posterolateral hernia defect containing 50 cm of strangulated small bowel was identified and resected, a primary stapled enteroenterostomy was performed and the hernia defect was repaired primarily. The stomach was reduced, a primary crura repair was performed, and gastropexy was performed with a gastrojejunostomy tube. The patient was transferred to the intensive care unit, and subsequently extubated, enteral feeds were initiated, and had anticipated discharge to a skilled nursing facility. This case highlights an uncommon atraumatic presentation of an adult with a congenital diaphragmatic hernia. Its rarity is further denoted due to its right-sided laterality and strangulated small bowel as the usual herniated abdominal organs are the liver or colon.

Strangulated Bochdalek Hernia in Adults: Timely Recognition and Surgical Intervention Can Prevent a Lethal Outcome

Bochdalek hernias are rare diaphragmatic hernias most commonly seen in pediatric populations. Adults with this condition may be asymptomatic or present with gastrointestinal symptoms such as abdominal pain, pressure, choking, or dysphagia. Computed tomography imaging is a gold standard in diagnosing the condition. The definitive treatment is surgery, recommended and encouraged for asymptomatic patients as well to reduce the risk of future complications. Whilst the approach to surgical management differs on a case-by-case basis, the main goal is to reduce the herniating organ and repair the defect. It is important to note that in severe cases, intestinal obstruction and strangulation may occur. We present a unique case of this very phenomenon in a patient diagnosed and treated as a case of strangulated Bochdalek hernia. We aim to highlight the importance of diagnosing this condition as clinical symptoms may be non-specific, and rapid surgical intervention is necessary.

Incidental finding of Bochdalek hernia in an adult: a case report

A Bochdalek hernia, also known as a congenital diaphragmatic hernia (CDH), is a type of hernia that occurs in infants. The diaphragm, the muscle that separates the chest cavity from the abdominal cavity, is characterized by a hole or gap during birth. This opening allows the abdominal organs, such as the stomach, intestines, or liver, to pass through the thoracic cavity. Here, we report a 56-year-old male patient who came to our hospital because of rectal bleeding, symptoms unrelated to the hernia. We performed a Computed Tomography (CT) scan with contrast enhancement to find the cause of the bleeding and as an incidental finding we diagnosed the hernia: it is very rare to find a silent Bochdalek hernia for more than 50 years.

Late presentation of a congenital problem; complicated left-sided Bochdalek's hernia in an adult: A case report

Background

A diaphragmatic hernia is a defect or hole in the diaphragm through which abdominal contents can enter the chest cavity. Diaphragmatic hernias may be congenital (Morgagni hernia, Bochdalek hernia), a hiatal hernia, or acquired (iatrogenic and traumatic). Bochdalek's hernia typically occurs on the left side and rarely occurs in adults. Less than 100 cases of left Bochdalek's hernia in adults have been described in the literature. Most of them are asymptomatic.

Case report

We report a complicated left Bochdalek hernia in a 43-year-old adult male who is a smoker. He came to the pulmonary clinic with symptoms and signs of pneumonia of the left lower lobe with persistent dyspeptic symptoms. Chest radiography revealed evidence of a left diaphragmatic hernia, which was confirmed by computed tomography of the chest and abdomen, and subsequently treated by left diaphragmatic repair via limited left thoracotomy.

Conclusion

We report a rare case of a left Bochdalek hernia in an adult who underwent an appropriate left thoracotomy. Bochdalek hernias in adults are rare and usually asymptomatic, but when they become symptomatic, surgical intervention is required to avoid complications. BH should be considered in the differential diagnosis when radiographs suggest pneumothorax and should be treated early to avoid complications.

Incarcerated Diaphragmatic Hernias After Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common operations performed for morbid obesity. Some of the known surgical complications include anastomotic leaks and small bowel obstructions due to internal hernias. Diaphragmatic hernias are common in the general population, and repair of symptomatic hernias is generally recommended. Diaphragmatic hernia after a prior LRYGB is markedly less common. Diaphragmatic hernias can occur via a hiatal defect or rarely a parahiatal defect that is found lateral to the hiatus. We present two cases of incarcerated diaphragmatic hernias after a LRYGB with vastly different presentations. The first patient presented with a giant defect containing incarcerated jejunum after a prior LRYGB. The second patient presented with a parahiatal defect with an incarcerated remnant stomach. The first patient was successfully managed laparoscopically by reinforcing the defect with a mesh after defect closure. The second patient required an open operation due to the inability to reduce the tightly incarcerated stomach and defect approximated with sutures without the need for mesh reinforcement. Both patients did well postoperatively and remain symptom-free.

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.

Morgagni hernia presented as sudden dyspnea in 70 years old man: a case report

Diaphragmatic hernia is a structural defect caused by inadequate fusion of the pleuroperitoneal membrane of the diaphragm, allowing peritoneal viscera to protrude into the pleural cavity. The occurrence of Morgagni hernia in the adult is infrequent and almost asymptomatic. Symptomatic cases are even rarer, with a wide range of respiratory and gastrointestinal manifestations that make it difficult to diagnose. We present the case of a 70-year-old man with unexpected onset abdominal pain and respiratory distress. The chest computed tomography scan showed the right-side diaphragmatic Morgagni hernia. The defect was corrected through open surgical repair without complications. Within five months of the procedure, a follow-up radiograph revealed full recovery. This case should alert physicians to consider this diagnosis when faced with an unexpected manifestation of Morgagni hernia.

Bochdalek Hernia and Partial Diaphragmatic Agenesis: Pedicled Intercostal Muscle Flap and Mesh Repair in a Young Adult with Sickle Cell Disease

Congenital Bochdalek hernia (BH) in an adult is rare and has an unusual presentation. They are confined to the pediatric age group with an incidence of 1:3,000 live births. It rarely persists asymptomatic until adulthood. Surgical repair by thoracic, abdominal, or thoraco-abdominal approach is the treatment of choice with diaphragmatic reconstruction in associated diaphragmatic agenesis. With only 10 cases of BH with partial diaphragmatic agenesis reported to date, we discuss the rarity, unusual presentation, and management of BH in a young adult with sickle cell disease that has not been reported in the literature.

Bochdalek Hernia in an Adult Causing Intraoperative Complication

Bochdalek hernias are rarely diagnosed in adults and account for 0.17-6% of all diaphragmatic hernias. It is a congenital diaphragmatic hernia caused by a defect in the posterior attachment of the diaphragm due to a failure of the pleuroperitoneal membrane closure in utero. This may rarely cause chest pain, respiratory symptoms, or gastrointestinal symptoms. In this study, we present a case of a laparoscopic paraesophageal repair via Nissen fundoplication. The incidental finding and subsequent repair of a Bochdalek hernia during this case may have resulted in complications of the surgery including pneumothorax due to the defect in the pleuroperitoneal membrane. 

Giant Bochdalek Hernia: A Minimally Invasive Transabdominal Approach

A Bochdalek hernia is the most common congenital diaphragmatic hernia (CDH). It can rarely evade prenatal detection and persist into adulthood with minimal symptoms. Large CDH repair has often required an open approach in the past. In this article, we present a case of a patient with large CDH who was asymptomatic until later in her adult life who subsequently developed symptoms and sought a surgical evaluation. A minimally invasive transabdominal approach was used to effectively reduce and repair this rare giant hernia. The patient has remained free of recurrence and has had resolution of her symptoms after 18 months of follow-up. This case illustrates that even the largest of these can be handled in a minimally invasive fashion and achieve durable results.