Case Report
Laparoscopic Repair of the Bochdalek Hernia in an Adult
Chatenay M., Meier M., St Germaine R., Paton-Gay J.D.
ABSTRACT
Prior to 1999 Bochdalek hernias in adult patients were repaired by thoracotomy,
thoracoscopic or laparotomy approaches. Since 1999, the laparoscopic approach has
been reported by several groups. Here we use the case of a 52 year old male who
presented with a 3 month history of worsening left sided chest pain and symptoms of
reflux to describe such a repair.
INTRODUCTION
The Bochdalek hernia, first described in 1848 by Czech Professor of Anatomy
Bochdalek(bochdalek)10, is one of two classes of true congenital diaphragmatic hernias,
the other being the Morgagni-Larrey hernia. The Bochdalek hernia is due to a defect in
the posterolateral diaphragm whereas the Morgagni-Larrey hernia is a consequence of
malformation in the ventral portion of the diaphragm. During the first weeks of fetal
development, no separation exists between the future pleural and peritoneal cavities.
However, by the seventh week of gestation, the body cavity is divided transversely by the
growth of 3 structures. From both the left and right sides of the body cavity’s dorsal wall
the pleuroperitoneal folds grow medially and ventrally. At the same time, the septum
transversum extends posteriorily from the anterior body wall. Complete separation of the
pleural and peritoneal cavities relies upon adequate growth and fusion of these structures
with the esophageal mesentery, the body wall musculature and with each other. Failure
of growth of a pleuroperitoneal fold results in the posterolateral malformation that gives
rise to the Bochdalek hernia. Failure of fusion of the septum transversum with the
posterior aspect of the sternum and seventh costal cartiledge results in a retrosternal
defect through which the Morgagni and Larrey hernias occur. By definition, Morgagni
hernias occur to the right of the xiphoid process and Larrey hernias occur to its
left(Thoman, Sadler)1,2. Hernia of Bochdalek occurs most commonly on the left,
however, its definition includes right sided lesions(Mar Fan)8.
The reported prevalence of congenital diaphragmatic hernia (CDH) varies between
1/2000 and 1/5000 births with posterolateral (Bochdalek) defects accounting for the vast
majority of cases(Thoman, Sadler, Schumpelick)1-3. Diagnosis is most commonly made
antenatally by ultrasound or immediately postnatally, either incidentally on respiratory
exam or by chest xray in the workup of neonatal respiratory distress. CDH in the adult
population is exceedingly rare, accounting for only 5% of cases, and presentation in the
adult varies widely from an incidental radiographic finding to acute gastric
volvulus(Harinath)9. Patients may present with vague upper abdominal or chest pain of
varying duration, frequency and intensity or symptoms of gastroesophageal reflux 1,38
(Thoman, Schumpelick, Richardson, Frantzides, Al-emadi, Rice, Mar Fan) Despite the
varying severity of symptomatology, surgical repair is indicated in all symptomatic adult
cases11(Taskin).
Laparoscopic repair of a Morgagni hernia was first reported in 1992 by Kuster et al. The
laparoscopic approach to the repair of Morgagni hernias was quickly adopted because of
the shortened recovery period it afforded and numerous case reports describe the
procedure1,4,12(Thoman, Richardson, Rau). However, it was not until 1999 that the first
laparoscopic Bochdalek hernia repair was reported(Al-E madi). Still, very few case
reports exist describing laparoscopic repair of the Bochdalek hernia.
Herein, we describe the laparoscopic Bochdalek hernia repair in a patient presenting with
symptoms of gastroesophageal reflux disease.
CASE REPORT
A 52 year old male was referred for surgical treatment of GERD. He described a 3.5
month history of retrosternal and left sided chest pain that radiated to his left shoulder
and neck. The pain worsened with lying supine and occasionally woke the patient at
night. In the mornings, he had noticed some odynophagia with both solids and liquids.
He denied both exacerbation of the pain and increased shortness of breath with exertion.
Over the same time period he had noticed increasing regurgitation of gastric contents
without emesis. He had been treated with omeprazole 20 mg qd but noted little relief.
Past medical history was significant for hypertension and the patient had no past surgical
history. Physical exam was entirely unremarkable.
In May of 2003, gastroscopy and esophageal manometry were undertaken and revealed
only weak lower esophageal sphincter tone and reproduction of the patient’s symptoms
with acid infusion. Chest x-ray demonstrated a left sided Bochdalek hernia. Augmented
computed tomography further characterized the lesion as a hernia sac with transverse
dimensions of 7.5 X 9.5 cm that extended to the level of the left inferior pulmonary vein.
The gastric fundus was entirely contained within the hernia sac. The aperture in the
posterior portion of the left hemidiaphragm measured between 2 and 3 cm in diameter.
Laparoscopy was performed on July 7, 2003. The patient was placed in the lithotomy
position and the procedure was done from between the patient’s legs.
Pneumoperitoneum was established via a Hasson port just superior to the umbilicus. A
10 mm port was placed left of the xiphisternum beneath the costal margin and two 5 mm
ports were placed in each mid clavicular line. A 10 mm port was placed in the left
anterior axillary line beneath the costal margin and a 5 mm port was placed just left of the
umbilicus. With the liver retracted, the stomach was grasped and reduced through the
defect along with some attached greater omentum. The lesser omentum was then incised
using electrocautery and the incision was carried superiorly to reveal the hernia sac. The
diaphragmatic defect was identified lateral to the left crus and the hernia sac was
circumsized from the rim of the aperture. The left inferior phrenic artery was very
closely approximated to the left border of the defect and was transacted during excision
of the hernia sac. Bleeding was controlled with 5 mm vascular clips and 2-0 Ethibond
suture intracorporeally. Upon reduction of the hernia sac, the left inferior phrenic vessels
were again encountered. They were clipped again with 10 mm vascular clips and
divided. With adequate hemostasis ensured, the approximately 3 cm circular
diaphragmatic defect was closed using 2-0 Ethibond suture and the ports were removed.
The patient was discharged from hospital on the first post operative day and returned to
normal activity ……………………………………………………………………………
…………………………………
DISCUSSION
References
1. Thoman DS, Hui T, Phillips EH. Laparoscopic diaphragmatic hernia repair. Surg
Endosc 2002;16:1345-1349.
2. Sadler TW. Langman’s Medical Embryology, Eighth Edition. Baltimore:
Lipincott Williams and Wilkins, 2000, pp 201-7.
3. Schumpelick V, Steinau G, Schluper I, Prescher A. Surgical embryology and
anatomy of the diaphragm with surgical applications. Surg Clin North Am
2000;80:213-240.
4. Richardson WS, Bolton JS. Case report: Laparoscopic repair of congenital
diaphragmatic hernias. J Laparoendosc Adv Surg Tech 2002;12:277-280.
5. Frantzides CT, Carlson MA, Pappas C, Gatsoulis N. Case report: Laparoscopic
repair of a congenital diaphragmatic hernia in an adult. J Laparoendosc Adv Surg
Tech 2000;10:287-290.
6. Al-Emadi M, Helmy I, Nada MA, Al-Jaber H. Laparoscopic repair of Bochdalek
hernia in an adult. Surg Laparosc Endosc 1999;9: 243-245.
7. Rice GD, O’Boyle CJ, Watson DI, Devitt PG. Laparoscopic repair of Bochdalek
hernia in an adult. ANZ J Surg 2001;71:443-445.
8. Mar Fan MJ, Coulson ML, Siu SK. Adult incarcerated right-sided Bochdalek
hernia. ANZ J Surg 1999;69:239-241.
9. Harinath G, Senapati PS, Pollitt MJK, Ammori BJ. Laparoscopic Reduction of an
acute gastric volvulus and repair of a hernia of Bochdalek. Surg Laparosc Endosc
Perc Tech 2002;12:180-183.
10. Bochdalek VA. Einige Betrachtungen uber die Entstehung des angeborenen
Zwerchfellbruches: Als Beitrag Zur pathologischen Anatomie der Hernien.
Vierteljahrsschrift fur die praktische Heilkunde 1848;19:89.
11. Taskin M, Zengin K, Unal E, Eren D, Korman U. Laparoscopic repair of
congenital diaphragmatic hernias. Surg Endosc 2002;16(5):869.
12. Rau HG, Schardey HM, Lange V. Laparoscopic repair of a Morgagni hernia. Surg
Endosc 1994;8:1439-1442.
13. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of
Morgagni: laparoscopic repair case report. J Laparoendosc Surg 1992;2:93-100