Vol.3, No.10, 609-61
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
2 (2011) Health
Bochdalek hernia (Acute gastric obstruction and
laparoscopic approach)
Rafael Diaz-Nieto1*, Alvaro Naranjo-Torres2
1Department of General and Digestive Surgery, “Virgen de la Victoria” University Hospital, Málaga, Spain; *Corresponding Author:
2Department of General and Digestive Surgery, “Infanta Margarita” Hospital, Cabra-Córdoba, Spain.
Received 3 August 2010; revised 20 September 2010; accepted 28 October 2010.
Bochdalek hernia is a rare clinical entity which
consist of a lack of development of the diaph-
ragm. Its diagnosis is more common in children
and in relation to respiratory symptons. But it is
also possible to appear in adulthood and usua-
lly related with acute digestive problems. Due to
acute present ation often require emergency sur-
gery. After reviewing the current literature, lapa-
roscopic appro ach see ms to be the techn ique of
choice, with or without mesh placement. We re-
port a new case of a young man w ith acute obs-
truction syndrome and laparoscopic treatment.
Keywords: Cbochdal ek He rn ia; Ga stri c
Obstructi o n ; L a p aroscopic Approach
Bochdalek hernia is a congenital pathology which
consists of an uncomplete development of the diaphragm,
which entails the persistence of a hole or weakness in the
posterolateral side of the diaphragm. This lack of deve-
lopment can take place at different times of embryoge-
nesis between the sixth and tenth week. If the disorder
take place in the sixth-seventh week of gestation, pleuro-
peritoneales membranes have not been formed yet so
there will be a complete absence of hernia sack. But if it
happens around the eighth week, these membranes can
have been already formed, and what we will found is a
diaphragmatic eventration. Bochdalek hernia itself is the
first case.
Congenital diaphragmatic hernias are rare (excepting
hiatal hernia), and they can be approximately founded
one in every 3200 children born alives [1]. Bochdalek
hernia is much more frequent compared to Morgany-
Larry hernia, and also more usual in the left side against
the right one. Bilateral cases rise up to 3% of children
[2,3]. This can be explained anatomically, as the last side
in developing is the right one and also, liver in the left
side project the development of hernia across little sacks.
From a clinical point of view, 90% are diagnosed in
childhood and usually asociated with pulmonary hypop-
lasia due to the compression of the lung. This situation
carry on acute hemodinamic and respiratory failure that
require treatment. Those in the left side develope chronic
symptoms depending on the size [4].
Diagnosis of Bochdalek hernia in adulthood is extre-
mely rare and most cases founded in the literature were
diagnosed as acute gastrointestinal problems compared
to cardiorrespiratory symptoms, unlike what happens in
childhood [5]. Commonly, we found patients who are
free of symptoms for years, and suddenly or related to
minimal effort or trauma they start with an acute clinical
problem. Severe trauma or recent surgery should su-
ggest the presence of a traumatic diaphragmatic rupture.
Many diagnostic steps may be useful, as a single x-ray
or a gastrointestinal study [5]. But up to date helicoidal
tommogrphy seems to be the technique of choice; and
magnetic resonance has not already shown benefits ex-
cept in cases of doubt [6]. Due to in adulthood we are
used to find an emergency problem and the differential
diagnosis with traumatic rupture of the diaphragm is not
always possible, this clinical entity is usually indication
of emergency surgery because of the potential complica-
tions arising from it [7].
We present the case of a 28 years-old man without
medical or surgical pathology; who is examinated in the
emergency room due to a lumbar and epigastric pain sin-
ce two days. In the last 24 hours the patient had deve-
loped also oral intolerancy with vomiting. The man did
not remember any prior injury or trauma.
The examination showed difficulty breathing, need of
air and a mild pain in the abdominal exploration.
Analytically leukocytosis was founded with no other
alteration. In the early explorations a chest radiograph
R. Diaz-Nieto et al. / Health 3 (2011) 609-612
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was included where we observed the stomach above the
diaphragma. (Figure 1)
Endoscopy was performed and a gastrointestinal tran-
sit reported intrathoracic stomach with possible gastric
volvulus due to hiatal hernia as most probable diagnosis.
(Figure 2)
Endoscopic decompression and nasograstric aspiration
were tried but the evolution was not satisfactory and
finally emergency surgery was decided.
Laparoscopic approach was performed. A Bochdalek
diaphragmatic hernia was found with gastric, colon and
spleen inside thorax (Figures 3 and 4) and without the
presence of hernia sack. Laparoscpically we reduced the
organs to abdominal cavity (Figure 5), we putted a chest
drainage and proceeded to a primary free-tension her-
niorraphy (Figure 6).
Postoperative course was good and free of respiratory
or digestive symptoms. In subsequent clinical and radio-
logical controls, the patient keeps asymptomatic.
Bochdalek hernia was described in 1848 [8]. In adul-
thood is a very rare clinical entity with very few cases
Figure 1. X-Ray at diagnosis moment.
Figure 2. Gastrointestinal study.
Figure 3. Laparoscopic findings. White arrow: large bowel and
double black arrow: diafragm.
Figure 4. Laparoscopic findings. Stomach after reduction of
large bowel into cavity and partial reduction of it (white arrow).
Diafragm (black arrow).
Figure 5. Reduction into cavity of the spleen.
R. Diaz-Nieto et al. / Health 3 (2011) 609-612
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Figure 6. Primary stuture of diafragm.
included in the literature. It can leads us not to pay atten-
tion enough to this patology in the emergency room, and
a recent review shows that also 38% of cases were initi-
ally wrong diagnosed [5].
Unlike what happens in childhood, clinical manifesta-
tions are mainly gastrointestinal and in all cases review-
ed in the literature they course as an acute problem or
are diagnosed incidentally.
Surgery is the initial treatment due to potencial comp-
liactions, and unless certain exceptions or diagnosis dur-
ing elective surgery, it is an indication of emergency sur-
gery because his course is indistinguishable from a trau-
matic rupture of the diafragm [7].
Regarding the type of treatment is where there are some
disputes, and generally in relation to the approach. You
can try both thoracic and abdominal approaches, with no
scientific evidence to support one or the other. Several
articles bring cases operated by chest (thoracoscopy or
thoracotomy) [9,10] and according to a recent review,
this is the most common approach for Morgany-Larry
hernia [11] and seems to be a good alternative in case of
recurrence after a abdominal approach. But the trend
seems to support an abdominal approach due to the po-
tential gastrointestinal complications that may have been
caused by the hernia, and that would be better repaired
by abdominal approach [12].
Technique itself has also alternatives. The disjunction
between laparotomy or laparoscopy appears to be reso-
lved in favor of laparoscopic surgery. Well demonstrated
advantages of laparoscopy, are also applicable to this
disease, so there are authors who suggest it as the gold
standard of this surgery [13] also in cases of acute and
chronic presentation if the patient is stable and if done
by expert laparoscopic surgeons [14]. Another technical
issue is whether or not to place a mesh for the correction
of the hernia defect. There is no evidence to support ei-
ther method. Several authors describe successful without
the use of mesh [10,13,15], however the current trend is
proceeding to an herniophlastia thanks to the develop-
ment of meshes that allow them use intraabdominally
[16,17]. But there is no studies that demonstrate the ad-
vantages of either technical or compare the rate of recur-
rence or long-term results.
The presentation of a Bochdalek hernia in adulthood
is rare but is necessary to know it well because, at pre-
sent, a large number of diagnoses are wrong initially. It
usually appears in acute way and usually related to gas-
trointestinal problems, unlike what happens in childhood,
where clinic is mainly respiratory.
Treatment is surgery and the approach we recommend
is laparoscopic approach against the thoracic one. Surg-
eons must be experts in laparoscopy and this type of surg-
The use of mesh is controversial because of the absen-
ce of long-term results but it seems more suitable at pre-
sent. In the absence of tension or very small defects we
can choose a primary suture.
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