Diagnosis of ABH is not easy. A misdiagnosis rate has been reported as 38% by Thomas and Kapur [7]. ABH onset is considered to be due to trauma or carbon dioxide during laparoscopic surgery which raises abdominal pressure, usually without a history in the neonatal period [8]. Further, ABH is said to have a deep relationship with body mass index [9]. In this case, the patient did not have a history of trauma or abdominal surgery. Obesity was considered to be one of the causes of hernia. Unlike infants who lapse into severe dyspnea soon after birth, the most frequent symptoms in ABH patients are mild discomfort such as chest tightness, abdominal discomfort, and dyspnea on effort [10]. Twenty-five percent of ABH patients do not complain about any symptoms [10]. Sagittal and coronal scan of enhanced CT with contrast media is useful for diagnosis. This provides detailed information about herniated viscera and diaphragm defects. In addition, the chest CT reveals the filled intestinal segments or the presence of soft tissues on the diaphragm and helps in making a definitive diagnosis of ABH. MRI was also reported as useful for depicting hernia and diaphragm defects [11].
For surgical treatment of Bochdalek hernias, both transabdominal and transthoracic approaches have been reported [2, 4, 12, 13]. If the patient had signs of intestinal obstruction or strangulation, an abdominal approach might be preferable to reintroduce the intestinal tract, resect ischemic organs, and reconstruct [2]. Meanwhile, if the protruded organs are suspected fatty tumors, a transthoracic approach might be an easier procedure for separating adhesions, resecting tumor, and repairing the diaphragm, especially if it is right-sided. Minimal invasive approaches by complete thoracoscopic surgery were also reported [14]. Proper surgical procedures should be selected due to the result of preoperative image examination.
In many cases, the hernia sac is returned to the abdomen to avoid pleural injury by incising the hernia sac [15]. Although the risk of seroma was reported in the remnant sac, it had been reported that the remnant sac disappeared after surgery [16]. Moreover, several reports said that surgeons tried to reduce the remnant sacs [15, 16]. In our case, there was no hernia sac because it was just a sliding hernia of the retroperitoneal fat pad through the Bochdalek foramen into the thoracic cavity. Many surgeons prefer to construct a repair that is reinforced with a prosthetic graft because of the continuing stress on the diaphragm that results from respiratory movements [17]. However, if the diaphragm defect is not so large, it may be better to construct the diaphragm by direct suturing to avoid infection and postoperative adhesions.