Introduction

Bochdalek hernia is one of the most common types of congenital diaphragmatic hernia caused by the failure of the postlateral diaphragmatic foramina to fuse properly at around 8^th - 10^th weeks of gestation, it was described by the Czechoslovakian anatomist Vicent Alexander Bochdalek in 1848, but the first description appeared in 1575. Successful surgical treatment of congenital diaphragmatic hernia in an infant was first performed in 1902, whereas the first neonate operated within 24 hours of life was reported in 1946. [1] Congenital diaphragmatic hernia occurs in 1 in 2000 to 3000 newborns, normally it is diagnosed in neonatal and postnatal patients - the clinical manifestation of symptoms and diagnosis in adults is extremely rare. [2] Most of the hernias (80 to 90%) are found on the left side. Right-sided hernias are rarer because the right pleuroperitoneal canal closes earlier and the liver buttresses the right diaphragm [3, 4]. Rarely, hernias present bilaterally, a peritoneal hernia sac is not present in over 85% and also appears dependent on the timing of pleuroperitoneal fold fusion [5]. Normally Bochdalek hernia is diagnosed in childhood for acute respiratory symptoms; adult presentation while is rarely reported but the diagnosis of Bochdalek hernia have increased with introduction of chest CT scan for sourveillance of cancer or assessment of vague symptoms.

Presentation of Case

We present the case of a 30-year-old male patient with giant left-sided congenital posterolateral diaphragmatic hernia (Bochdalek hernia) with progressive dyspnea and abdominal symptoms due to incarceration of the stomach, spleen, pancreas, small bowel and transverse colon, but without a history of trauma. There was no relevant past medical history. He had complaints such as epigastric pain, nausea, vomiting, shortness of breath, severe left sided chest pain radiadeted to the ipsilateral dorsal region. His vital signs were blood pressure 110/65, heart rate 110 beats per minute, respiratory rate 22 per minute and temperature 37°C. The bowel sounds were audible on the left side of the chest.

Chest X-ray and CT-scan (Figures 1-3) was used as diagnostic methods. In the left hemithorax was seen spleen, pancreas tail, a prominent gastric bubble, transverse colon and small bowel. Dislocation of mediastinum and stretching of hepatic pedicle was demonstred.

Figures 1-3: Coronal, sagital and axial CT-scan showing a large posterior defect at the left hernia diaphragm, a mediastinal shift to the right and the presence of herniated viscera in the left thoracic cavity. (stomach, omental fat, small intestine, colon, spleen and pancreas tail).

A laparotomy was performed. There was a 6 cm defect in the postlateral left hemi-diaphfragm (Figure 4). The stomach, tranverse colon, small bowel, spleen and pancreas tail were carefully reduced in to the abdominal cavity through the hernia defect. There were any anatomopathological lesion of viscera. Suture of diaphragm decfet was performed and dual mesh was fixed to the defect area to close definitlty the diaphragm defect (Figure 5). No complication was observed during the surgical procedure and in postoperative hospital stay.

Figure 4: Intraoperative vision of the wall defect.

Figure 5: Diaphragm suture and placement of the dual mesh prosthesis.

The patient was taken into the intensive unite care for one day. The oral intake started in second postoperative day and patient discharged in sixth postoperative day.

The best surgical approach in in an elective setting is laparoscopy or thoracoscopy, but in emergency most surgeons prefer laparotomy for visceral complication; in our case we preferred laparotomy approach for the presence of the spleen and the promiment gastric bubble in the thoracic cavity.

Discussion

Bochdaleck hernia is congenital defect resulting from a developmental failure of the diaphragm located in the posterior insertion described by Vincent Alexander Bochdaleck in 1848. The disease is due to the failure of closure of the canal between the septum trasversum and the esophagus during the 8^th week of gestation. The most frequent are the left posterolateral hernias (85%) whereas the right side or bilateral are 13% and 2% respectively Normally BH are diagnosed in children and neonates that present clinical symptoms caused by associated pulmonary insufficiency. In adults BH diagnosis is difficult for its rarity and the symptoms are nonspecific and may be confused with other diseases (dyspnea, breathlessness, cough, chest pain, generic chronic gastrointestinal symptoms).

The correct diagnosis is normally performed with X-ray chest, CT-scan or RMI that offer a better visualization of the defect.

These hernias may contain intraperitoneal or retroperitoneal structures; in the right-sided hernias the contents are the liver, the kidney, and fat while left-sided BH may contain the transverse colon, loops of the small bowel, the liver, the speen, the pancreas.

The management of BH includes reduction of hernia contents to the peritoneal cavity and repair of the diaphragmatic defect. The defect is sutured for the restoration of the anatomy between the thoracic and the abdominal cavities; many surgeons prefer a prosthetic dual mesh graft because the continuing stress on the diaphragm that results from respiratory and cardiac motions.

Laparotomy is the widely used surgical approach, while mininvasive approach, laparoscopy or thoracoscopy, are used in elective setting; however all these techniques are used in relation to the surgeon skills and the presence of visceral complications.

Conclusion

Adult BH is very rare condition. Correct diagnosis and early treatment is very important to avoid the occurrence of morbidity and a higher complication rate.

Surgical management is recommended in order to prevent complications like intestinal obstruction or viscera stangulation, hemorrhage and visceral perforation in the chest cavity .

References

1. Puri P, Wester T (1997) Historical aspects of congenital diaphramatic PediatrSurg Int; 12: 95-100.
2. Keijzer R, Puri P (2010) Congenital diaphragmatic hernia. Semin Pediatr Surg; 19: 180-5.
3. Kanazawa A, Yoshioka Y, Inoi O, Murase J, Kinoshita H (2002) Acute respiratory failure caused by an incarcerated right-sided adult Bochdalek hernia: report of a case. Surg Today, 32: 812-815.
4. Laaksonen E, Silvasti S, Hakala T (2009) Right-sided Bochdalek hernia in an adult: a case report. Journal of Medical Case Reports, 3: 9291.
5. Perch P, Houck W, de Anda A (2002) Symptomatic Bochdalek hernia in an octogenarian. Ann Thorac Surg; 73: 1288-9.