Video-assisted thoracoscopic surgery for adult Bochdalek hernia: a case report
Shen et al. Journal of Cardiothoracic Surgery
Video-assisted thoracoscopic surgery for adult Bochdalek hernia: a case report
Yu-Guang Shen 0 3
Na-Na Jiao 2
Wei Xiong 1
Quan Tang 1
Qing-Yong Cai 1
Gang Xu 1
Gui-You Liang 1
0 Department of Thoracic and Cardiovascular Surgery, The First People's Hospital of Zunyi , Fenghuang Road, Zunyi, Guizhou Province 563000 , People's Republic of China
1 Department of Thoracic and Cardiovascular Surgery, Affiliated Hospital of Zunyi Medical College , Dalian Road, Zunyi, Guizhou Province 563003 , People's Republic of China
2 Department of Nursing , Dalian Road , Affiliated Hospital of Zunyi Medical College , Zunyi, Guizhou Province 563003 , People's Republic of China
3 Department of Thoracic and Cardiovascular Surgery, The First People's Hospital of Zunyi , Fenghuang Road, Zunyi, Guizhou Province 563000 , People's Republic of China
Background: Bochdalek hernia is a type of congenital diaphragmatic hernia that typically presents in childhood, while this diseases is extremely rare in adults. Case presentation: We review a case of a 63-year-old man with a left-sided Bochdalek hernia who was experiencing occasional pain at the left side of his chest for 8 months. The diagnosis of Bochdalek hernia was made by chest computed tomography. A part of the retroperitoneal adipose tissue was herniated into the left thoracic cavity through the diaphragmatic defect. The hernia was treated via video-assisted thoracoscopic surgery and he made an uneventful recovery. Conclusions: We report a rare case of a left-sided Bochdalek hernia for which our patient was treated successfully via video-assisted thoracoscopic surgery. Even though rare, this disorder should be recognised, examined and treated appropriately to avoid complications.
Congenital diaphragmatic hernia; Bochdalek hernia; Video-assisted thoracoscopic surgery; Case report
Bochdalek hernias (BH) are a congenital posterolateral
diaphragmatic defect, which were first described by
Bochdalek in 1848 . Once diagnosed, Bochdalek
hernias should be surgically treated during the neonatal
period. Therefore, adult cases are rare, with a reported
frequency of 0.17 to 6% among all diaphragmatic hernias
. Herein we present a case of a 63-year-old man
whose Bochdalek hernia was successfully treated by
video-assisted thoracoscopic surgery (VATS).
A 63-year-old man was referred to our hospital because
of chest pain. He had experienced occasional pain at the
left side of his chest for 8 months. During the past
month the pain had become increasingly severe with no
hard signs (negative physical examination). The computed
tomography (CT) showed a mass in the left thoracic cavity
and a left diaphragmatic defect (Fig. 1). According to
computed tomography scan and such a location, the
diagnosis of a Bochdalek hernia was thus suggested.
The Video-assisted thoracoscopic surgery (VATS) was
performed under general anesthesia with single lung
ventilation on June 30, 2015. The patient was placed in
the right decubitus position, a 15 mm port was made
through the 7th intercostal space on the midaxillary line,
and then a 30-degree thoracoscope was inserted. Another
two ports were next placed at the 5th intercostal space on
the anterior axirally line and 7th intercostal space on the
Exploratory thoracoscopy showed that a part of the
retroperitoneal adipose tissue was herniated into the left
thoracic cavity through the defect (Fig. 2a), 4 cm in
length approximately, in the posterior region of the left
diaphragm, but no hernia sac was identified. After
cutting the parietal pleura enveloping the mass, clear
margins of the defect of the diaphragm were revealed
(Fig. 2b). The herniated tissue was moved back to the
abdominal cavity, and the defect of the diaphragm was
then closed with 3-0 polypropylene sutures. The
postoperative course was uneventful and the patient was
discharged 8 days after the operation without any symptoms.
At follow-up, he remains well without any signs of
recurrence 6 months after surgery.
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Fig. 1 Preoperative chest and abdominal computed tomography (CT) scans. The chest CT shows a posterolateral left-sided mass with fat tissue
density (a), and the white arrow indicates the diaphragmatic defect (b)
BH is a common congenital anomaly in neonatal and
postnatal patients and occurs in about one in 2,200 to
12,500 live births, but it is rare in adults . A defective
closure of the lumbar and costal muscle groups in the
posterolateral diaphragm during the embryonic stage is
considered to be the cause of BH. This congenital
diaphragmatic hernia is considered to be extremely rare in
adults and have a left-sided predominance. Our patient
also had left-sided hernia. Complete closure occurs on
the right side before it is complete on the left side-a fact
that may contribute to the left sided BH being more
common than right sided hernias . Most BH are
found and repaired in childhood, as many as 5% are first
detected in adulthood . BH usually present with
severe respiratory distress immediately after birth, which
is life-threatening, while most adults present with more
chronic symptoms, such as chronic dyspnoea, chest pain
and pleural effusion. Recurrent abdominal pain,
postprandial fullness and vomiting are the most common
abdominal symptoms in adults . Our patient was
experiencing the symptoms of recurrent chest pain,
while some patients have no symptoms and the disorder
is unexpectedly detected on chest X-ray .
Diagnosis is usually made on radiological findings. The
best radiological investigation in adults is CT scan which
has a sensitivity of 78% for left-sided hernia and 50% for
the right-sided hernia . Usually, the CT scan show a
mass of fat or soft tissue contour of the upper surface of
the diaphragm, and a discontinuity of the diaphragm
adjacent to the mass. In our case, the diaphragmatic defect
could be identified clearly in the computed tomography
(CT), and the diagnosis was confirmed. In contrast to
Morgagni hernias, BH rarely contains a hernia sac. Only
10.4% patients (18/173) had a hernia sac . Most
asymptomatic Bochdalek hernias contain only
retroperitoneal adipose tissue, but almost any organ of the
peritoneal cavity can herniated through the foramen of
The first successful repair of a BH was performed in
1901 by Aue . The most frequent approach for the
Bochdalek hernia is a thoracotomy or transabdominal,
and the surgical method is to return the herniated organs
to the abdominal cavity and close the diaphragmatic
defect . Transthoracic approach is thought to be effective
as it allows for direct observation of the herniated viscera
or hilium of the hernia or sac, and it is easier to remove
the herniated viscera if there is some adherence . With
Fig. 2 Thoracoscopic view of the Bochdalek hernia. The retroperitoneal adipose tissue was herniated into the thoracic cavity through the diaphragmatic
defect (a), and the black arrow indicates the diaphragmatic defect margins (b)
the advancement of modern surgical techniques, less
invasive means of repair are available. The VATS is generally
considered to be advantageous over standard thoracotomy
because it is less invasive, reduced postoperative pain, and
allows the surgeon to make more precise incisions. The
diaphragmatic defects sometimes do not have sufficient
margin for reapproximation directly. Several surgeons
reported using artificial material for closing large defect
[13, 14]. In our case, the diaphragmatic defect was small
(3 cm × 4 cm in size), so we perform primary closure of
the diaphragmatic defect by thoracoscopic surgery alone,
and we didn’t apply a mesh to reinforce the diaphragm.
We report a rare case of a left-sided Bochdalek hernia in an
adult who was treated via VATS. People with a Bochdalek
hernia may not have any symptoms and the disorder may
be detected unexpectedly, or the symptoms and expressions
may vary from mild to serious complications. Even though
rare, this disorder should be recognised, examined and
treated appropriately to avoid complications.
Consent for publication
Written informed consent was obtained from the patient for publication of
this case report and any accompanying images. A copy of the written consent
is available for review by the Editor-in-Chief of this journal.
1. Novakov IP , Paskalev G . Adult Bochdalek hernia simulating left pleural effusion: a review and a case report . Folia Med (Plovdiv) . 2010 ; 52 ( 4 ): 62 - 6 .
2. Tokumoto N , Tanabe K , Yamamoto H , et al. Thoracoscopic-assisted repair of a bochdalek hernia in an adult: a case report . J Med Case Rep . 2010 ; 4 : 366 .
3. Laaksonen E , Silvasti S , Hakala T. Right-sided Bochdalek hernia in an adult: a case report . J Med Case Rep . 2009 ; 3 : 9291 .
4. Brown SR , Horton JD , Trivette E , et al. Bochdalek hernia in the adult: demographics, presentation, and surgical management . Hernia . 2011 ; 15 ( 1 ): 23 - 30 .
5. Langham Jr MR , Kays DW , Ledbetter DJ , et al. Congenital diaphragmatic hernia. Epidemiology and outcome. Clin Perinatol . 1996 ; 23 ( 4 ): 671 - 88 .
6. Kanazawa A , Yoshioka Y , Inoi O , et al. Acute respiratory failure caused by an incarcerated right-sided adult bochdalek hernia: report of a case . Surg Today . 2002 ; 32 ( 9 ): 812 - 5 .
7. Niwa T , Nakamura A , Kato T , et al. An adult case of Bochdalek hernia complicated with hemothorax . Respiration . 2003 ; 70 ( 6 ): 644 - 6 .
8. Husain M , Hajini FF , Ganguly P , et al. Laparoscopic repair of adult Bochdalek's hernia . BMJ Case Rep . 2013 ; 2013 . doi:10.1136/bcr- 2013 - 009131 .
9. Wilbur AC , Gorodetsky A , Hibbeln JF . Imaging findings of adult Bochdalek hernias . Clin Imaging . 1994 ; 18 ( 3 ): 224 - 9 .
10. Abdullah M. Congenital diaphragmatic hernia in a post-partum woman . Med J Malaysia . 2003 ; 58 ( 1 ): 99 - 101 .
11. Mousa A , Sanusi M , Lowery RC , et al. Hand-assisted thoracoscopic repair of a Bochdalek hernia in an adult . J Laparoendosc Adv Surg Tech A . 2006 ; 16 ( 1 ): 54 - 8 .
12. Brusciano L , Izzo G , Maffettone V , et al. Laparoscopic treatment of Bochdalek hernia without the use of a mesh . Surg Endosc . 2003 ; 17 ( 9 ): 1497 - 8 .
13. Nguyen TL , Le AD . Thoracoscopic repair for congenital diaphragmatic hernia: lessons from 45 cases . J Pediatr Surg . 2006 ; 41 ( 10 ): 1713 - 5 .
14. Ambrogi V , Forcella D , Gatti A , et al. Transthoracic repair of Morgagni's hernia: a 20-year experience from open to video-assisted approach . Surg Endosc . 2007 ; 21 ( 4 ): 587 - 91 .