Minimally Invasive Transabdominal Repair of a Massive Incarcerated Adult Bochdalek Hernia

Document Type

Conference Proceeding

Publication Date

5-19-2025

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction: Bochdalek hernias are the most common form of congenital diaphragmatic hernia (CDH). While the majority of posterolateral diaphragmatic defects are identified in pediatric patients with respiratory distress, adult patients may remain asymptomatic until later in life. Symptomatic cases in adults are rare and may present with vague respiratory and/or gastrointestinal symptoms. These large hernias may contain multiple intra-abdominal organs at risk for volvulus and strangulation, necessitating timely surgical repair. We present the case of a 73 year-old who underwent successful laparoscopic transabdominal repair of a massive, incarcerated Bochdalek hernia with patch placement. Case Presentation: The patient, a 73 year old male with an active lifestyle as a weightlifter and golfer, initially presented to his primary care physician with a 50-pound unintentional weight loss, poor appetite, dyspnea and fatigue. Computed tomography scan demonstrated a large left sided posterolateral diaphragmatic hernia containing the spleen, pancreatic tail, splenic flexure of the colon, small intestine and a large portion of stomach with mesoaxial volvulus (Fig 1A). After nasogastric decompression of the stomach, he was taken for urgent laparoscopic diaphragmatic hernia repair. Intraoperatively the transverse colon was adherent to the pleura, necessitating division of the gastrohepatic ligament and division of colonic attachments up to the splenic flexure. Once mobilized, the hernia contents were successfully reduced without injury to the spleen. The diaphragmatic defect measured 10 x 15 centimeters and was repaired using Gore Dual Mesh, which was secured to the diaphragm (Fig 1B). On postoperative day one, he tolerated clear liquids after a normal esophagram without leak or obstruction. He then tolerated full liquids on postoperative day two and was discharged to home. Conclusions: Traditionally, open repair of CDH was preferable in younger patients given lower recurrence rates when compared to minimally invasive (MIS) approaches. These repairs can be approached either through a transabdominal or transthoracic approach. MIS transabdominal repair with or without patch placement has more recently gained favor over open repair with comparable recurrence rates. Previous data may have been biased by patient complexity, surgeon preference and technical limitations. Overall, reduction and repair of massive diaphragmatic hernia defects can be achieved via a transabdominal MIS approach with durable results in select patients. Fig 1A. CT depicting large left sided diaphragmatic hernia containing stomach, small intestine, transverse colon, spleen and distal pancreas. 1B. Intraoperative photo of hernia defect with entire spleen in thoracic cavity. 1C. Dual Gore Mesh repair of hernia defect.

Volume

211

First Page

1

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