Laparoscopic repair of an incarcerated Bochdalek hernia in an elderly man

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The Bochdalek hernia (BH) is a posterior congenital closing defect of the diaphragm, usually seen in infants.1 BH occurs rarely in adulthood and frequently is incidentally discovered in patients admitted for gastrointestinal or respiratory symptoms.2 Either in infants or in adults, such hernias can represent a life‐threatening condition.4 The incidence of congenital diaphragmatic hernias varies from 1:2000 to 1:5000 live births and BHs account for 75 to 85% of these.1 The literature concerning the incarcerated BH in adults is rather limited. Herein, we report a well‐documented case, successfully treated by a laparoscopic approach.
An 81‐year‐old man was admitted to the emergency room for an abdominal pain presented 24 h before with associated vomiting, chest tightness, dyspnoea and heart palpitations without fever. He also complained of dull epigastric pain with heartburn unsuccessfully treated with proton pump inhibitors in the last 8 months. Physical examination showed a swollen abdomen, painful in the left upper quadrant, without rebound tenderness or signs of peritoneal irritation; besides, he had a harmless umbilical hernia and an empty rectal vault. His past medical history was clear and no previous trauma was reported.
X‐ray showed a heterogeneous opacity in the left side of the thorax (Fig. 1) and a bowel distention; moreover, a double, that is intravenous and oral, contrast‐enhanced computed tomography was carried out to confirm the presence of a large left‐side BH (Fig. 2), evidencing multiple dilated and fluid‐filled small bowel loops as well. Laboratory routine tests were within the normal range, except for a slight neutrophilic leukocytosis (12 × 109/L, 79%) and an increased C‐reactive protein level (17.9 mg/dL, normal ≤0.5). The arterial blood gas values indicated the presence of a hypoxaemic respiratory failure. The nasogastric tube drained more than 500 mL, but pain was not relieved at all. A three‐trocar laparoscopy approach, maintaining pneumoperitoneum pressure at 10 mmHg, was performed. A large defect was identified in the posterolateral left hemidiaphragm (Fig. 3) entrapping the omentum, a segment of transverse colon comprising the splenic flexure and multiple small bowel loops. The restoration of all the content back into the abdominal cavity was extremely laborious and accomplished with gentle retraction using atraumatic bowel graspers without enlargement of the hernia.
The defect was closed and reinforced by means of an on‐laying mesh and the vitality of all enteric segments extracted was carefully checked before closing the trocar sites. Operative time was approximately 150 min and blood loss was minimal. The patient had an uneventful in‐hospital stay and was discharged in the sixth post‐operative day. He showed a significant clinical improvement and still continues to do well 12 months post‐operatively.
The diagnosis of BH in adulthood is usually made if complications occur.1 The high frequency of organ incarceration and strangulation points out the need for an early diagnosis and an effective operative management, which contribute to obtain satisfactory results. Owing to its rarity and varied presentation, it can represent a diagnostic challenge. Diaphragmatic hernias must be considered as possible aetiology in the differential diagnosis of patients presenting bowel obstruction symptoms, as early surgery may significantly affect and reduce both morbidity and mortality. Laparoscopic approach appears to be safe and feasible in the hands of experienced laparoscopic surgeons.

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