Bochdalek's hernia in an elderly male - A case report.

Diaphragmatic hernia is protrusion of the abdominal contents into the thoracic cavity. It is a congenital defect of the diaphragm. It is most commonly encountered in infancy but rarely in adults. Here, we would like to present a rare case of 75-year-old male with Bochdalek's hernia. The patient had presented for the first time in his life for his symptoms. This case report emphasises the rare presentation of Bochdalek's hernia in an elderly male. The patient was treated using minimal access surgery i.e., laparoscopic approach and hence had a better post-operative outcome.

INTRODUCTION

The incidence of diaphragmatic hernia is 1:2000–1:4000 live births. Its presentation is rare in the adults. The presentation in infancy is due to signs and symptoms of respiratory distress. However, in adults, the presentation is mostly asymptomatic or might present with respiratory and abdominal symptoms. Here, the authors would like to report an unusual case of Bochdalek's hernia in a 75-year-old male who presented with pain abdomen and slight dyspnoea. This patient was treated with minimally invasive technique i.e., laparoscopic repair of the posterolateral defect in the diaphragm.

CASE REPORT

A 75-year-old man came to our outpatient department with a history of pain abdomen, vomiting and slight dyspnoea with the onset of all these symptoms since 4 days from his presentation. His medical and family history was unremarkable. The physical examination was noncontributory. Ultrasound revealed prostatomegaly. His chest X-ray revealed well-defined radiopacity in the left lower zone completely obscuring left heart border and left hemidiaphragm s/o left moderate pleural effusion. Multiple curvilinear gaseous shadows were noted in the left lower lung field [Figure 1].

Figure 1

Pre-operative chest X-ray and compute tomography

To confirm the diagnosis, a contrast-enhanced computed tomography (CECT) abdomen pelvis with high-resolution computed tomography (HRCT) of lower lung fields was done which revealed, Eventration/left diaphragmatic hernia with intrathoracic extension of bowel loops causing mediastinal shift toward the right side. Dilated fluid filled proximal small bowel loops with collapsed distal small and large bowel loops, suggesting small bowel obstruction [Figure 1]. It was diagnosed to be a Bochdalek's hernia, and it was planned to be operated laparoscopically. The patient underwent laparoscopic repair and had positive outcomes with better and early recovery.

We decided to operate the patient for laparoscopic repair of diaphragmatic hernia. The patient was operated under general anaesthesia with single lung ventilation. The contents of hernia were stomach, colon and small bowel. They were reduced into the abdomen, and lower peritoneal adhesiolysis was done. The defect was closed primarily, and then a composite mesh was placed to strengthen the defect [Figure 2]. The patient had an intercostal drainage tube placed on the operated site which was removed on post-operative day 3. He had an uneventful recovery with spirometry exercises and chest physiotherapy. His 3-month follow-up was asymptomatic with no complications.

Figure 2

Intraoperative findings (a) Herniation of bowel into the diaphragm (b) Defect in the posterolateral aspect of the left side of diaphragm (c) Defect closure by endo suturing (d) Placement of composite mesh to strengthen the defect site

DISCUSSION

Bochdalek's hernia was first described in 1848 by the Czechoslovakian anatomist, Vincent Alexander Bochdalek.[1] A Bochdalek hernia is a congenital defect of the diaphragm located in the posterior insertion. This is caused by a lack of closure of the pleuroperitoneal cavity by incomplete diaphragmatic development before the intestine returns to the abdomen from the yolk sac between 8-10 weeks of gestation. In adults, this defect is uncommon, the lung in most cases develop normally, and therefore, symptoms are rare.[2] In this age group, there are two typical clinical presentations: (a) an incidental finding in chest X-ray performed for symptoms not related to the hernia[34] or (b) when symptoms develop as a result of incarceration, strangulation and visceral perforation inside the chest cavity. Symptoms vary according to the affected organ: digestive symptoms include intermittent abdominal pain, vomiting and dysphagia while respiratory symptoms include chest pain and dyspnoea.[35] The most commonly displaced organ is the stomach followed by the colon, spleen, small intestine and ureter.[267] Chest X-ray, CECT abdomen pelvis and HRCT of chest will be helpful in diagnosing the condition and help in planning the mode of treatment. However, an emergency situation might not provide the time for a detailed imaging. The surgical approach for this pathology depends on the presence of visceral complications. In an elective setting, most surgeons recommend the laparoscopic approach; however, when there are septic complications, the abdominal approach is preferred. The current trend is to use minimal invasive surgical techniques such as laparoscopy and thoracoscopy, which has been satisfactorily performed in adults.[8]

CONCLUSION

The incidence of Bochdalek's hernia is rare in adults and might present both symptomatically as well as asymptomatically. These patients mostly present in infancy. In adults, they present with symptoms due to complications of hernia. The knowledge of its incidence in adults is vital for its diagnosis and treatment, as it is treated surgically to avoid complications or to treat them if the patient presents with them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.