==== Front Int J Surg Case RepInt J Surg Case RepInternational Journal of Surgery Case Reports2210-2612Elsevier S2210-2612(18)30154-810.1016/j.ijscr.2018.04.028ArticleLaparoscopic surgery for a Bochdalek hernia triggered by pregnancy in an adult woman: A case report Matsudera Shotaro matsu-s@dokkyomed.ac.jp⁎Nakajima Masanobu Takahashi Masakazu Muroi Hiroto Kikuchi Maiko Shida Yosuke Ihara Keisuke Yamaguchi Satoru Sasaki Kinro Tsuchioka Takashi Kato Hiroyuki First Department of Surgery, Dokkyo Medical University, Tochigi, Japan⁎ Corresponding author at: Department of Surgery, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Shimotsuga, Tochigi 321-0293, Japan. matsu-s@dokkyomed.ac.jp01 5 2018 2018 01 5 2018 48 10 15 5 3 2018 20 4 2018 26 4 2018 © 2018 The Author(s)2018This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).Highlights • We report a case of Bochdalek hernia (BH) triggered by pregnancy in a pregnant adult. • Laparoscopic surgery can be safely performed for BH without complications. • We reviewed 30 cases of laparoscopic and/or thoracoscopic repair of adult BH. Introduction A Bochdalek hernia (BH) is a type of congenital diaphragmatic hernia. We herein describe an adult woman with a BH triggered by pregnancy and treated by laparoscopic surgery. Presentation of case A 26-year-old woman was referred to our hospital because of abdominal pain and dyspnea resulting from a left diaphragmatic hernia. She was diagnosed with a BH and underwent laparoscopic surgery. Her postoperative progress was satisfactory, and no recurrence was found at follow-up approximately 1 year later. Discussion A recently published study reviewing detailed cases of laparoscopic and/or thoracoscopic repair of adult BH from 1999 to 2016 identified 30 cases. A laparoscopic approach for treatment of BH has recently attracted increasing interest. Conclusion Laparoscopic surgery can be safely performed on adults with BH without complications. Abbreviations BH, Bochdalek herniaKeywords Adult Bochdalek herniaLaparoscopic surgeryMesh repairCase report ==== Body 1 Introduction A Bochdalek hernia (BH), a form of congenital diaphragmatic hernia, occurs when muscular portions of the diaphragm fail to develop normally, resulting in displacement of abdominal organs into the thoracic cavity. BH occurs mainly during the 8th to 10th week of foetal life [1]. Most BHs cause severe cardiorespiratory distress immediately after birth and should therefore be surgically treated during the neonatal period [1]. BH is relatively rare in adults. We performed laparoscopic surgery for a BH in an adult woman after she had given birth. This case report has been reported in line with the SCARE criteria [2]. 2 Presentation of case A 26-year-old woman was referred to our hospital because of abdominal pain and dyspnoea resulting from a left diaphragmatic hernia. She had no history of previous abdominal or thoracic trauma. Left abdominal tenderness was found on physical examination. Laboratory analyses were within normal limits. Chest X-ray films showed an air bubble with an air–fluid interface in the left thoracic cavity (Fig. 1). Contrast-enhanced chest and abdominal computed tomography showed prolapse of the spleen, stomach, and colon into the left thoracic cavity (Fig. 2). The patient was therefore diagnosed with a BH.Fig. 1 Chest radiograph shows gastric bubbles occupying the left thoracic cavity. Fig. 1Fig. 2 Computed tomography shows that the stomach, spleen, and colon were prolapsing into the left thoracic cavity. Fig. 2 We attempted endoscopic reduction, but it was difficult. So, a decision was made to perform laparoscopic hernia repair. The patient was placed in the supine position with her legs apart. Three trocars were used, one each in the umbilical (12 mm), right hypochondriac (5 mm), and left hypochondriac (12 mm) regions (Fig. 3). A 7- × 5-cm hernial defect without a hernial sac was found (Fig. 4). The stomach, spleen, small intestine, and left side of the colon were protruding into the hernia orifice. A suspended thread covered by an 8-F Nelaton catheter was used to elevate the left lobe of the liver to minimise liver injury and facilitate laparoscopic repair of the BH. The visceral organs were placed back into the abdominal cavity. Because the spleen had adhered to the thoracic cavity, the adhesions were exfoliated using Harmonic ACE shears (Ethicon, Somerville, NJ, USA). Thereafter, the spleen was carefully placed back into the abdominal cavity using an Endo Retract Maxi (Covidien, Dublin, Ireland) covered by gauze (TroX; Osaki, Nagoya, Japan). The defect was repaired with absorbable suture (3-0 Vicryl; Ethicon) and reinforced with Parietex Optimized Composite mesh (Covidien). The mesh was fixed to the diaphragm with an Endo Universal stapler (Covidien) (Fig. 5).Fig. 3 Three trocars were placed in the umbilical (12 mm), right hypochondriac (5 mm), and left hypochondriac (12 mm) regions. Fig. 3Fig. 4 A 7- × 5-cm hernial defect was found without a hernial sac. Fig. 4Fig. 5 The defect was repaired with absorbable suture (3-0 VICRYL; Ethicon) and reinforced with Parietex Optimized Composite mesh (Covidien). The mesh was fixed to the diaphragm with an Endo Universal stapler (Covidien). Fig. 5 The postoperative course was uneventful, and the patient was discharged 4 days after surgery. At the 1-year follow-up, physical and radiological examinations showed no signs of recurrence (Fig. 6).Fig. 6 The postoperative chest radiograph at the 1-year follow-up showed no sign of recurrence. Fig. 6 3 Discussion A BH, which is caused by posterolateral defects of the diaphragm, was first described by Bochdalek in 1848 [1]. Its incidence is reportedly 1 in 2200–12,500 live births [3]. Most BHs are detected after birth on the left side [3]. BHs are relatively rare in adults, most of whom present with chronic atypical symptoms such as chronic dyspnoea, chest pain, recurrent chest infection, pleural effusion, recurrent abdominal pain, and vomiting. The cause remains unknown [3]. Wiseman et al. reported that increased intra-abdominal pressure, such as that occurring in pregnancy, during exercise, and in patients with obesity, is an important influential factor [4]. In the present case, we surmised that the BH had developed during late pregnancy, when the patient first became aware of abdominal pain on her left side. After giving birth, her intra-abdominal pressure increased rapidly during exercise, exacerbating her symptoms. When symptoms such as abdominal pain and/or dyspnoea develop during pregnancy, clinicians should consider the possibility of a BH. Radiological investigations can be helpful in the diagnosis of BH. Chest radiographs may show abnormal contents above the diaphragm, and chest and abdominal computed tomography usually confirms the diagnosis. It is generally recommended that all adult patients with BH undergo surgical repair to prevent the life-threatening complications that can result from incarceration. The surgical approach depends on the patient’s clinical condition. Surgery generally comprises laparotomy, thoracotomy, or a combination of both. An advantage of the thoracoscopic approach is that peeling back the intrathoracic cavity and repair of the hernial defect are simple. Moreover, an advantage of the laparoscopic approach is that placement of the hernia contents into the abdominal cavity is easy when no adhesions are present in the thoracic cavity. Repair of diaphragmatic hernias by laparoscopy or thoracoscopy, with or without mesh reinforcement, has recently become possible. Advantages of these approaches include the fact that they are minimally invasive techniques and have favourable cosmetic effects and shorter lengths of hospitalisation. A recently published study reviewing detailed cases of laparoscopic and/or thoracoscopic repair of adult BHs from 1999 to 2016 identified 30 cases (Table 1); 10 men and 20 women with a mean age 48.6 years [1], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Of these 30 hernias, 23 occurred on the left side and 7 on the right. The main complications were incarceration, gastric volvulus, and intestinal perforation. The hernia contents were the colon (n = 12), stomach (n = 15), small intestine (n = 7), omentum (n = 7), spleen (n = 3), kidney (n = 1), liver (n = 3), and retroperitoneal tissue (n = 2). The hernia orifice was repaired by simple sutures (n = 10), sutures and mesh (n = 4), mesh only (n = 13), and unknown means (n = 2) (no repair: n = 1). Simple closure was selected for small hernia orifices and mesh repair for large orifices. The surgical methods comprised laparoscopy (n = 23), endoscopic reduction and laparoscopy (n = 1), conversion to laparotomy (n = 2), thoracotomy-assisted laparoscopy (n = 1), laparoscopy and thoracoscopy (n = 2), and left thoracotomy with combined laparoscopy and thoracoscopy (n = 1). Most of the reported patients had satisfactory clinical courses.Table 1 Review of adult patients with Bochdalek hernias repaired by laparoscopic/thoracoscopic approaches from January 1999 to December 2016 [1], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Table 1 All cases(n = 30) Age (yr) 48.6 Sex (Male: Female) 10:20 Side (Right or Left) 7:23 Complications Gastric volvulus:5 Perforation:3 Hernia contents Colon:12 Stomach:15 Small intestine:7 Omentum:7 Spleen:3 Kidney:1 Liver:3 Retroperitoneal tissue:2 Repair methods Simple suture:10 Suture and mesh:4 Only mesh:13 No repair:1 Unknown:2 Surgical methods Laparoscopy:23 Endoscopic reduction and laparoscopy:1 Laparotomy convert:2 Thoracotomy assisted laparoscopy:1, Laparoscopy&thoracoscopy:2 Left thoracotomy with combining laparoscopy and thoracoscopy:1 4 Conclusions A laparoscopic approach for the treatment of BH has recently attracted increasing interest. Laparoscopic surgery can be safely performed in patients with a BH without complications. In the present case, laparoscopic surgery was successful and associated with a short inpatient stay. Conflicts of interest The authors declare that they have no competing interests. Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical approval Institutional review board approval was exempt from our institution because all data were collected from clinical records and imaging systems for routine preoperative planning and follow up. Consent Informed consent was obtained from the patient and her family for this publication. Author contribution SM performed the operation and acquisition and analysis of data and wrote the manuscript. MN performed the operation and organized the writing of the manuscript. MT, HM, MK, YS, KI, SY, KS, and TT contributed in the critical revision of the manuscript. HK made the final approval of the manuscript. All authors have read and approved the final manuscript. Registration of research studies This paper reports just the record of patient treatment. This is not a paper about research work involving human participants. Guarantor Masanobu Nakajima. Acknowledgements We thank Hugh McGonigle, Trish Reynolds, and Angela Morben, from Edanz Group (www.edanzediting.com/ac), for editing drafts of this manuscript. ==== Refs References 1 Tokumoto N. Tanabe K. Yamamoto H. Suzuki T. Miyata Y. Ohdan H. Thoracoscopic-assisted repair of a Bochdalek hernia in an adult: a case report J. Med. Case Rep. 4 2010 366 21083878 2 Agha R.A. Fowler A.J. Saeta A. Barai I. Rajmohan S. Orgill DP; SCARE Group: The SCARE Statement: Consensus-based surgical case report guidelines Int. J. Surg. 34 2016 180 186 27613565 3 Sutedja B. Muliani Y. Laparoscopic repair of a Bochdalek hernia in an adult woman Asian J. Endosc. Surg. 8 2015 354 356 26303737 4 Harada M. Tsujimoto H. Nagata K. Ito N. Yamazaki K. Kanematsu K. Successful laparoscopic repair of an incarcerated Bochdalek hernia associated with increased intra-abdominal pressure during use of blow gun: a case report Int. J. Surg. Case Rep. 23 2016 131 133 27111876 5 Laaksonen E. Silvasti S. Hakala T. Right-sided Bochdalek hernia in an adult: a case report J. Med. Case Rep. 3 2009 9291 20062780 6 Oguma J. Ozawa S. Kazuno A. Nitta M. Ninomiya Y. Laparoscopic mesh repair of adult diaphragmatic hernia: a report of two cases Asian J. Endosc. Surg. 10 2016 179 182 27860376 7 Nishihara Y. Kawaguchi Y. Urakami H. Seki S. Ohishi T. Isobe Y. Gastric volvulus with a large Bochdalek hernia in an adult successfully treated with emergency endoscopic reduction followed by elective laparoscopic mesh repair: a case study Asian J. Endosc. Surg. 9 2016 318 321 27456780 8 Kikuchi S. Nishizaki M. Kuroda S. Kagawa S. Fujiwara T. A case of right-sided Bochdalek hernia incidentally diagnosed in a gastric cancer patient BMC Surg. 16 2016 34 27245581 9 Koca Y.S. Barut I. Yildiz I. Yazkan R. The cause of unexpected acute abdomen and intra-abdominal hemorrhage in 24-week pregnant woman: Bochdalek hernia Case Rep. Surg. 2016 2016 6591714 28018700 10 Yagmur Y. Yiğit E. Babur M. Gumus S. Bochdalek hernia: a rare case report of adult age Ann. Med. Surg. 5 2015 72 75 11 Atef M. Emna T. Bochdalek hernia with gastric volvulus in an adult: common symptoms for an original diagnosis Medicine (Baltimore) 94 2015 e2197 26705205 12 Ikarashi M. Matsuda M. Murayama I. Fujii M. Takayama T. Laparoscopic repair of Morgagni hernia with composite mesh in an elderly woman: report of a case Asian J. Endosc. Surg. 8 2015 216 218 25913591 13 Vega M.T. Maldonado R.H. Vega G.T. Vega A.T. Lievano E.A. Velazquez Late-onset congenital diaphragmatic hernia: a case report Int. J. Surg. Case Rep. 4 2013 952 954 24055915 14 Husain M. Hajini F.F. Ganguly P. Bukhari S. Laparoscopic repair of adult Bochdalek’s hernia BMJ Case Rep. 2013 2013 (bcr2013009131) 15 Debergh I. Fierens K. Laparoscopic repair of a Bochdalek hernia with incarcerated bowel during pregnancy: report of a case Surg. Today 44 2014 753 756 23291903 16 Toydemir T. Akinci H. Tekinel M. Tekinei M. Suleyman E. Acunas B. Laparoscopic repair of an incarcerated Bochdalek hernia in an elderly man CLINICS 67 2012 199 201 22358250