Laparoscopic repair of a strangulated Bochdalek hernia

Laparoscopic repair of a strangulated Bochdalek hernia CO McDonnell, P Naughton, A Aziz, TN Walsh Department of Surgery, Royal College of Surgeons in Ireland, James Connolly Memorial Hospital, Dublin, Ireland

Abstract Background Bochdalek herniae are rare. They are usually repaired by open abdominal surgery or by a thoracic video-assisted approach. When strangulated and in a compromised patient the options are fewer. Aim To describe a case treated by a laparoscopic approach. Results The procedure was technically difficult, but the patient recovered without recurrence. Conclusion Laparoscopic repair is possible even with strangulation.

Introduction Bochdalek hernia is rare and when it presents with complications in a compromised patient the therapeutic options are limited. A laparoscopic approach is possible even when strangulation has occurred.

Case report A 74-year-old male was admitted under the care of the medical team for management of an exacerbation of chronic obstructive pulmonary disease (COPD). His background history was remarkable for COPD, type I respiratory failure, ischaemic heart disease, atrial fibrillation, congestive cardiac failure and peptic ulcer disease. Four days after admission he deteriorated acutely, and on the basis of chest x-ray was diagnosed as having a rightsided pneumothorax. An intercostal drain was placed in the right hemithorax and this drained faeculent fluid. A surgical opinion was sought and his chest x-ray was interpreted as showing a right-sided diaphragmatic hernia and that the chest drain had perforated the bowel. The patient had no history to suggest a traumatic diaphragmatic hernia. In view of the severity of his comorbid medical conditions, he was initially treated conservatively. When his condition deteriorated, a decision was taken to intervene surgically. In view of his precarious respiratory status, a laparoscopic approach was employed to minimise postoperative respiratory complications associated with laparotomy. At operation, four ports were inserted, at the umbilicus, the epigastrium, the right subcostal region and the right iliac fossa. The caecum and ascending colon were lying lateral to the liver with part of the caecum and a loop of ascending colon herniating through a 2cm defect in the right hemidiaphragm, consistent with a Bochdalek hernia. The hernia was reduced with difficulty using a combination of traction and water dissection from the jet of the laparoscopic irrigation system. The caecum was gangrenous. The right iliac fossa portsite was enlarged and the necrotic bowel delivered and debrided. A loop caecostomy was performed using 3/0 Maxon sutures. The patient returned to the intensive care unit and made a slow but uneventful postoperative recovery. He remained in hospital due to further exacerbations of his respiratory disease, from which he died some months later.

Discussion A Bochdalek hernia is a congenital posterior diaphragmatic defect resulting from failure of the re t roperitoneal canal membrane to fuse with the dorsal oesophageal mesentery and Irish Journal of Medical Science • Volume 172 • Number 3

the body wall.1 Adult hernias account for just 5% of cases2 with fewer than 100 cases reported in the literature.3 Herniation of the colon is even rarer, with less than a dozen reported cases.4 Less than 10 cases of right-sided Bochdalek hernias have been reported in the world literature.5 Approximately 90% of reported cases occur through the left hemidiaphragm. This is thought to be due to the earlier closure of the septum transversum on the right and the protective presence of the liver on the right hemidiaphragm. A right-sided hernia often masquerades as a pleural effusion, an asymptomatic intrathoracic mass or intestinal obstruction.6 Thomas7 reports that an incorrect initial diagnosis is made in 38% of cases due to a lack of awareness of the condition. The chest x-ray may suggest the diagnosis. However, a previously normal film does not preclude the diagnosis, as the defect may be plugged by a confining sac.7 Findings on CT are usually characteristic enough to allow a definitive diagnosis to be made.8 Diaphragm

Colon

Hernial Orifice

Lateral Border of Right Hepatic Lobe

Figure 1. Laparoscopic view of Bochdalek hernia. The surgical options are limited. Campbell and Lilly advocated a transabdominal approach.6 Silen and colleagues report the use of video-assisted thoracic surgery (VATS) in the treatment of an adolescent who subsequently was discharged 145

CO McDonnell et al

home within 24 hours of surgery.9 The extra-pleural position of the Bochdalek hernia would suggest that an abdominal approach would be more direct anatomically. Comorbid illnesses outruled both of these options in our patient and the laparoscopic approach was selected. While the laparoscopic approach to these hernias is well described in the elective setting,2 its use in an emergency situation, while described,10 is far less well reported. This case illustrates the versatility of laparoscopic surg e r y and its importance in the medically-compromised patient.

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Paediatr Surg 1995; 5 (2): 113-5. Kanazawa A, Yoshioka Y, Inoi O, Murase J, Kinoshita H. Acute respiratory failure caused by an incarcerated right sided adult Bochdalek hernia: report of a case. Surg Today 2002; 32 (9): 8125. 6. Campbell DN, Lilly JR. The clinical spectrum of right Bochdalek’s hernia. Arch Surg 1982; 117 (3): 341-4. 7. Thomas S, Kapur B. Adult Bochdalek hernia – clinical features, management and results of treatment. Jpn J Surg 1991; 21 (1): 114-19. 8. Shin MS, Mulligan SA, Baxley WA, Ho KJ. Bochdalek hernia of diaphragm in the adult. Diagnosis by computed tomography. Chest 1987; 92 (6): 1098-101. 9. Silen ML, Canvasser DA, Kurkchubasche AG, Andrus CH. Videoassisted thoracic surgical repair of a foramen of Bochdalek hernia. Ann Thorac Surg 1995; 60 (2): 448-50. 10. Harinath G, Senapati PS, Pollitt MJ, Ammori BJ. Laparoscopic reduction of an acute gastric volvulus and repair of a hernia of Bochdalek. Surg Laparosc Endosc Percutan Tech 2002 (In Press). 5.

Correspondence to: Mr TN Walsh, Department of Surgery, Academic Centre, James Connolly Memorial Hospital, Blanchardstown, Dublin 15. Email: [email protected]

Irish Journal of Medical Science • Volume 172 • Number 3