Vincent Alexander Bochdalek first described a congenital hernia resulting from the developmental failure of the diaphragmatic posterolateral foramina to fuse properly [6,7,8]. Bochdalek hernia is one of the most common abnormalities in infants with a reported incidence of approximately 1 in 3000 live births and represents approximately 80% of congenital diaphragmatic hernias [9]. This condition is usually diagnosed during infancy, which may present with signs and symptoms of cardiopulmonary insufficiency secondary to herniation of abdominal contents through the diaphragmatic defect.
In adults, Bochdalek hernia is considered extremely rare [1,2,3] and usually presents with vague and non-specific symptoms. The common presenting symptoms include chest pain, dyspnea, gastrointestinal bleeding, and abdominal pain [3]. In our case, he presented with none of these symptoms.
The diagnosis of diaphragmatic hernia in adults is usually established through radiologic investigations [10] such as chest radiography or barium studies. CT is the most accurate imaging modality for the diagnosis and evaluation of hernia [11, 12]. In about 80% of cases, Bochdalek hernia predominantly occurs on the left hemithorax because the right pleuroperitoneal canal closes earlier than the left [6]. In our case, the patient was initially suspected to have pleurisy based on the chest radiograph. However, due to the presence of the diaphragmatic defect on the left posterolateral area as seen in CT, a diagnosis of Bochdalek diaphragmatic hernia was made.
The conventional treatment of diaphragmatic hernia involves placing the herniated organs back to the abdominal cavity and closing the diaphragmatic defect using sutures [13, 14]. Although surgical procedures for these hernias may be performed with laparotomy, thoracotomy, or a combination of both, minimally invasive approaches (e.g., laparoscopy or thoracoscopy) have recently been approved [4, 5]. Laparoscopic surgery may allow an easier and safer return of the herniated organs back to the abdominal cavity and may provide a better examination of the whole abdominal cavity than thoracoscopic surgery [15]. In contrast, thoracoscopic surgery permits easier dissection of adhesion in the thoracic cavity than laparoscopic surgery [16]. In our case, because of the large volume of herniated omentum and the possibility of adhesion to the thoracic wall, combined laparoscopic and thoracoscopic surgery was planned to reverse the herniation and repair the orifice. Although reports of combined laparoscopic and thoracoscopic surgery exist, these were emergency operations or involved the intraoperative addition of either approach [17]. A strength of our case was that we planned combined surgery from the beginning and performed the surgery safely.
Hernial sacs have been reported to occur in 10–38% of cases [18]. In our case, no hernial sac was seen.
The hernial orifice can be closed using different methods. For cases where the defect is small, the orifice can be sutured and closed. On the other hand, for cases with large orifices (> 10 cm in diameter), mesh reinforcement may be warranted [15, 19]. As our patient’s hernial orifice was less than 10 cm in diameter, simple closure was performed with sutures. Nonetheless, there was no recurrence in the year following surgery.
