Laparoscopic surgery for a Bochdalek hernia triggered by pregnancy in an adult woman: A case report.

INTRODUCTION: A Bochdalek hernia (BH) is a type of congenital diaphragmatic hernia. We herein describe an adult woman with a BH triggered by pregnancy and treated by laparoscopic surgery. PRESENTATION OF CASE: A 26-year-old woman was referred to our hospital because of abdominal pain and dyspnea resulting from a left diaphragmatic hernia. She was diagnosed with a BH and underwent laparoscopic surgery. Her postoperative progress was satisfactory, and no recurrence was found at follow-up approximately 1 year later. DISCUSSION: A recently published study reviewing detailed cases of laparoscopic and/or thoracoscopic repair of adult BH from 1999 to 2016 identified 30 cases. A laparoscopic approach for treatment of BH has recently attracted increasing interest.
CONCLUSION: Laparoscopic surgery can be safely performed on adults with BH without complications.

Introduction

A Bochdalek hernia (BH), a form of congenital diaphragmatic hernia, occurs when muscular portions of the diaphragm fail to develop normally, resulting in displacement of abdominal organs into the thoracic cavity. BH occurs mainly during the 8th to 10th week of foetal life [1]. Most BHs cause severe cardiorespiratory distress immediately after birth and should therefore be surgically treated during the neonatal period [1]. BH is relatively rare in adults.

We performed laparoscopic surgery for a BH in an adult woman after she had given birth.

This case report has been reported in line with the SCARE criteria [2].

Presentation of case

A 26-year-old woman was referred to our hospital because of abdominal pain and dyspnoea resulting from a left diaphragmatic hernia. She had no history of previous abdominal or thoracic trauma. Left abdominal tenderness was found on physical examination. Laboratory analyses were within normal limits. Chest X-ray films showed an air bubble with an air–fluid interface in the left thoracic cavity (Fig. 1). Contrast-enhanced chest and abdominal computed tomography showed prolapse of the spleen, stomach, and colon into the left thoracic cavity (Fig. 2). The patient was therefore diagnosed with a BH.

Fig. 1

Chest radiograph shows gastric bubbles occupying the left thoracic cavity.

Fig. 2

Computed tomography shows that the stomach, spleen, and colon were prolapsing into the left thoracic cavity.

We attempted endoscopic reduction, but it was difficult. So, a decision was made to perform laparoscopic hernia repair. The patient was placed in the supine position with her legs apart. Three trocars were used, one each in the umbilical (12 mm), right hypochondriac (5 mm), and left hypochondriac (12 mm) regions (Fig. 3). A 7- × 5-cm hernial defect without a hernial sac was found (Fig. 4). The stomach, spleen, small intestine, and left side of the colon were protruding into the hernia orifice. A suspended thread covered by an 8-F Nelaton catheter was used to elevate the left lobe of the liver to minimise liver injury and facilitate laparoscopic repair of the BH. The visceral organs were placed back into the abdominal cavity. Because the spleen had adhered to the thoracic cavity, the adhesions were exfoliated using Harmonic ACE shears (Ethicon, Somerville, NJ, USA). Thereafter, the spleen was carefully placed back into the abdominal cavity using an Endo Retract Maxi (Covidien, Dublin, Ireland) covered by gauze (TroX; Osaki, Nagoya, Japan). The defect was repaired with absorbable suture (3-0 Vicryl; Ethicon) and reinforced with Parietex Optimized Composite mesh (Covidien). The mesh was fixed to the diaphragm with an Endo Universal stapler (Covidien) (Fig. 5).

Fig. 3

Three trocars were placed in the umbilical (12 mm), right hypochondriac (5 mm), and left hypochondriac (12 mm) regions.

Fig. 4

A 7- × 5-cm hernial defect was found without a hernial sac.

Fig. 5

The defect was repaired with absorbable suture (3-0 VICRYL; Ethicon) and reinforced with Parietex Optimized Composite mesh (Covidien). The mesh was fixed to the diaphragm with an Endo Universal stapler (Covidien).

The postoperative course was uneventful, and the patient was discharged 4 days after surgery. At the 1-year follow-up, physical and radiological examinations showed no signs of recurrence (Fig. 6).

Fig. 6

The postoperative chest radiograph at the 1-year follow-up showed no sign of recurrence.

Discussion

A BH, which is caused by posterolateral defects of the diaphragm, was first described by Bochdalek in 1848 [1]. Its incidence is reportedly 1 in 2200–12,500 live births [3]. Most BHs are detected after birth on the left side [3]. BHs are relatively rare in adults, most of whom present with chronic atypical symptoms such as chronic dyspnoea, chest pain, recurrent chest infection, pleural effusion, recurrent abdominal pain, and vomiting. The cause remains unknown [3]. Wiseman et al. reported that increased intra-abdominal pressure, such as that occurring in pregnancy, during exercise, and in patients with obesity, is an important influential factor [4]. In the present case, we surmised that the BH had developed during late pregnancy, when the patient first became aware of abdominal pain on her left side. After giving birth, her intra-abdominal pressure increased rapidly during exercise, exacerbating her symptoms. When symptoms such as abdominal pain and/or dyspnoea develop during pregnancy, clinicians should consider the possibility of a BH.

Radiological investigations can be helpful in the diagnosis of BH. Chest radiographs may show abnormal contents above the diaphragm, and chest and abdominal computed tomography usually confirms the diagnosis. It is generally recommended that all adult patients with BH undergo surgical repair to prevent the life-threatening complications that can result from incarceration.

The surgical approach depends on the patient’s clinical condition. Surgery generally comprises laparotomy, thoracotomy, or a combination of both. An advantage of the thoracoscopic approach is that peeling back the intrathoracic cavity and repair of the hernial defect are simple. Moreover, an advantage of the laparoscopic approach is that placement of the hernia contents into the abdominal cavity is easy when no adhesions are present in the thoracic cavity. Repair of diaphragmatic hernias by laparoscopy or thoracoscopy, with or without mesh reinforcement, has recently become possible. Advantages of these approaches include the fact that they are minimally invasive techniques and have favourable cosmetic effects and shorter lengths of hospitalisation.

A recently published study reviewing detailed cases of laparoscopic and/or thoracoscopic repair of adult BHs from 1999 to 2016 identified 30 cases (Table 1); 10 men and 20 women with a mean age 48.6 years [1], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Of these 30 hernias, 23 occurred on the left side and 7 on the right. The main complications were incarceration, gastric volvulus, and intestinal perforation. The hernia contents were the colon (n = 12), stomach (n = 15), small intestine (n = 7), omentum (n = 7), spleen (n = 3), kidney (n = 1), liver (n = 3), and retroperitoneal tissue (n = 2). The hernia orifice was repaired by simple sutures (n = 10), sutures and mesh (n = 4), mesh only (n = 13), and unknown means (n = 2) (no repair: n = 1). Simple closure was selected for small hernia orifices and mesh repair for large orifices. The surgical methods comprised laparoscopy (n = 23), endoscopic reduction and laparoscopy (n = 1), conversion to laparotomy (n = 2), thoracotomy-assisted laparoscopy (n = 1), laparoscopy and thoracoscopy (n = 2), and left thoracotomy with combined laparoscopy and thoracoscopy (n = 1). Most of the reported patients had satisfactory clinical courses.

Table 1

Review of adult patients with Bochdalek hernias repaired by laparoscopic/thoracoscopic approaches from January 1999 to December 2016 [1], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16].

	All cases(n = 30)
Age (yr)	48.6
Sex (Male: Female)	10:20
Side (Right or Left)	7:23
Complications	Gastric volvulus:5
	Perforation:3
Hernia contents	Colon:12
	Stomach:15
	Small intestine:7
	Omentum:7
	Spleen:3
	Kidney:1
	Liver:3
	Retroperitoneal tissue:2
Repair methods	Simple suture:10
	Suture and mesh:4
	Only mesh:13
	No repair:1
	Unknown:2
Surgical methods	Laparoscopy:23
	Endoscopic reduction and laparoscopy:1
	Laparotomy convert:2
	Thoracotomy assisted laparoscopy:1, Laparoscopy&thoracoscopy:2
	Left thoracotomy with combining laparoscopy and thoracoscopy:1

Conclusions

A laparoscopic approach for the treatment of BH has recently attracted increasing interest. Laparoscopic surgery can be safely performed in patients with a BH without complications. In the present case, laparoscopic surgery was successful and associated with a short inpatient stay.

Conflicts of interest

The authors declare that they have no competing interests.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

Institutional review board approval was exempt from our institution because all data were collected from clinical records and imaging systems for routine preoperative planning and follow up.

Consent

Informed consent was obtained from the patient and her family for this publication.

Author contribution

SM performed the operation and acquisition and analysis of data and wrote the manuscript. MN performed the operation and organized the writing of the manuscript. MT, HM, MK, YS, KI, SY, KS, and TT contributed in the critical revision of the manuscript. HK made the final approval of the manuscript. All authors have read and approved the final manuscript.

Registration of research studies

This paper reports just the record of patient treatment. This is not a paper about research work involving human participants.

Guarantor

Masanobu Nakajima.