Right strangulated bochdalek hernia in a 65-year-old and repair with laparotomy approach

Melissa M Gabriel; Nicholas S V. Philippson; Charlotte N Horrigan; Jakub Kadlec; Irshad A Shaikh

doi:10.4103/JME.JME_182_20

CASE REPORT

Year : 2021 | Volume : 2 | Issue : 3 | Page : 236-239

Right strangulated bochdalek hernia in a 65-year-old and repair with laparotomy approach

Melissa M Gabriel¹, Nicholas S V. Philippson¹, Charlotte N Horrigan¹, Jakub Kadlec², Irshad A Shaikh¹
¹ Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, England
² Department of Thoracic Surgery, Norfolk and Norwich University Hospital, Norwich, England

Date of Submission	06-Nov-2020
Date of Decision	15-Jan-2021
Date of Acceptance	06-Feb-2021
Date of Web Publication	28-Dec-2021

Correspondence Address:
Dr. Melissa M Gabriel
Department of General Surgery, Norfolk and Norwich University Hospital, Norwich
England

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_182_20

How to cite this article:
Gabriel MM, V. Philippson NS, Horrigan CN, Kadlec J, Shaikh IA. Right strangulated bochdalek hernia in a 65-year-old and repair with laparotomy approach. J Med Evid 2021;2:236-9

How to cite this URL:
Gabriel MM, V. Philippson NS, Horrigan CN, Kadlec J, Shaikh IA. Right strangulated bochdalek hernia in a 65-year-old and repair with laparotomy approach. J Med Evid [serial online] 2021 [cited 2023 Jun 3];2:236-9. Available from: http://www.journaljme.org/text.asp?2021/2/3/236/333954

Introduction

Diaphragmatic hernias are morphologically classified according to location of the diaphragmatic defect. The most common type is Bochdalek hernia, usually seen on the posterolateral aspect of the left hemidiaphragm.^[1] This type of hernia commonly presents antenatally or soon after birth with respiratory distress.^[1] The literature describes the majority of adult Bochdalek hernias being asymptomatic and incidental diagnoses for posterolateral defects in the diaphragm.^[2] Typically, 80%–90% occur through the left hemidiaphragm.^[2] We report a rare case of a patient presenting with an acute abdomen and herniation through the right hemidiaphragm defect, resulting in strangulation and small bowel necrosis.

Case Report

A 65-year-old female, with no significant medical history, presented to the emergency department with a 1-day history of severe sudden-onset right upper quadrant abdominal pain. The pain radiated to the back and right shoulder tip and was associated with 2 days of loose stools and vomiting. On examination, there was tenderness in the right upper quadrant and epigastrium, and the abdomen was soft with no palpable masses.

Initial blood tests revealed a mildly elevated C-reactive protein, normal white cell count and lactate. A chest X-ray (CXR) showed a loop of bowel in the right hemidiaphragm [Figure 1] and subsequent computed tomography (CT) scan of the abdomen and pelvis confirmed a small right posterior lateral diaphragmatic hernia with small bowel closed loop herniation and signs of ischaemia [Figure 2].

Figure 1: Chest X-ray showing right posterior lateral diaphragmatic hernia with small bowel closed loop herniation

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Figure 2: CTAP showing right posterior lateral diaphragmatic hernia with small bowel closed loop herniation

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Immediate management included fluid resuscitation with Hartmann's solution, analgesia and insertion of a wide-bore Ryles tube. Joint surgery was planned with the thoracic consultant and general surgery on-call teams using a two-stage approach. The first stage involved performing an upper midline laparotomy to confirm herniation of small bowel and identify the defect, and the second stage included completing a diaphragmatic repair. After laparotomy, dissection was made towards the right lobe of the liver where strangulated small bowel was found in the posterior diaphragmatic opening (2 cm × 2 cm) [Figure 3]. The diaphragmatic opening was increased in size with a small cut to allow reposition of herniated loops. Approximately 15 cm of necrotic small bowel was resected, and a side-to-side stapled anastomosis was performed, oversewn with 2-0 prolene. The pleural cavity was washed with 1 litre of warm normal saline. Diaphragmatic repair was undertaken by the thoracic consultant and the defect was oversewn in two layers with continuous 2-0 prolene [Figure 4]. Right lung ventilation was checked, with no obvious air leak identified, and a right 28F chest drain was inserted and connected to a Thopaz system on − 1.5 kPa of suction.

Figure 3: Image showing necrotic small bowel after release from the right posterior diaphragmatic defect

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Figure 4: Image showing right diaphragmatic repair with 2-0 prolene

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Immediate postoperative course was uneventful and the Ryles tube was removed after 24 hours. The chest drain was removed on day 3, and she received daily chest physiotherapy.Total length of stay was 4 days, and she was discharged once tolerating a normal diet. Postoperatively, she had a superficial infection of the laparotomy wound and was treated with empirical antibiotics. Swab cultures showed no bacterial growth. She was reviewed 6 weeks after surgery, with full recovery and no signs of recurrence on CXR [Figure 5].

Figure 5: Chest X-ray at 6-week follow-up showing no recurrence of Bochdalek hernia

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Discussion

Bochdalek hernia was first described by Bochdalek in 1848 as the failure of the posterolateral foramina to completely join between the 8^th and 10^th weeks of gestation.^[3],[4] It is now proposed that the diaphragm is formed from four components during gestation: the septum transversum, pleuroperitoneal membranes, dorsal mesentery of the oesophagus and muscular ingrowth from the lateral body walls^.[5] Bochdalek hernias occur from altered union of the pleuroperitoneal membrane with the other three above-listed components^.[5] It accounts for 70%–85% of congenital diaphragmatic hernias and is usually diagnosed before 8 weeks of age, presenting in neonates with respiratory and circulatory distress^.[6] It is rare in adults, accounting for 0.17%–6% of adult diaphragmatic hernias^,[4] with only 27% occurring on the right side.^[7] This highlights the rarity of the right-sided presentation in our case report. The preponderance for left-sided Bochdalek hernia may be due to the earlier closure of the pleuroperitoneal cavity canal on the right side compared to the left.

When presenting in adults, most cases are asymptomatic and found incidentally. A PubMed search found 31 documented cases of adult symptomatic right-sided Bochdalek hernia in the literature. When symptomatic, Bochdalek hernia can present acutely or chronically and symptoms can be atypical and non-specific, including abdominal pain, nausea, cough and chest pain.^[7],[8],[9] Presentation in adults is predominantly with gastrointestinal symptoms, while in neonates, it is mainly with pulmonary symptoms.^[10] This includes respiratory distress, tachycardia and cyanosis. There is a wide range of presentations in adults which means diagnosis is not always easy, with misdiagnosis being as high as 38%.^[11] An increased complication rate occurs from delayed diagnosis, with mortality from elective surgery being 3%, while emergency surgery is 32%.^[7],[12]

In this report, we present a patient who acutely developed small bowel strangulation due to a small right-sided Bochdalek hernia. This is unusual because the liver supports the right diaphragm, reducing the likelihood of abdominal organ herniation. Indeed, only eight previous cases of right-sided Bochdalek hernia with small bowel incarceration have been reported in the literature.^{[13],[14],[15],[16],[17],[18],[19],[20]} For adults presenting with abdominal symptoms, an increased awareness for Bochdalek hernia as a differential diagnosis is needed, to diagnose and manage the condition in a timely manner to prevent complications such as small bowel necrosis and perforation. A CXR can show gas-filled bowel loops above the diaphragm, but sensitivity is low. An abdominal ultrasound can also be used; this is a good imaging modality for patients presenting with right upper quadrant pain and is very useful in diagnosing conditions such as gallstones. However, diagnosis can be operator dependent and if no abnormality is found, a CT scan is often warranted. A CT scan of the abdomen and pelvis is considered the first-line investigation for acute abdominal pain in older patients due to its high sensitivity, and it can aid in ruling out Bochdalek hernia as a possible diagnosis.^[21] In this case, where the diagnosis is not clear and there was high clinical suspicion of bowel ischaemia, a CT scan is the most appropriate modality.

Surgery is the only management option for Bochdalek hernia, with the type of procedure depending on the presentation. For right-sided Bochdalek hernia, a combined approach of laparotomy and thoracotomy is normally the preferred method.^[3] Our case, however, shows that abdominal access via upper midline laparotomy incision can be used for successful management and was used to resect 15 cm of necrotic small bowel and repair the defect. The teamwork and combined expertise between our thoracic and colorectal teams were key to the success of this patient's outcome.

Conclusion

We have highlighted a rare case of an acutely presenting right-sided Bochdalek hernia in a 65-year-old female, which needed emergency bowel resection and repair, managed with a laparotomy approach. This case report adds to the increasing literature documenting symptomatic right-sided Bochdalek hernia in adults. It should therefore be on the list of differentials in adults presenting with acute or chronic abdominal symptoms to prevent a delayed diagnosis and further complications. Right-sided Bochdalek hernia can be ruled out with a CT scan of the abdomen and pelvis and managed surgically using abdominal access for repair.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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