R. Diaz-Nieto et al. / Health 3 (2011) 609-612
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
611611
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.
4. CONCLUSION
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-
ery.
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.
REFERENCES
[1] Kaiser, J.R. and Rosenfeld, C.R. (1999) A population-
based study of congenital diaphragmatic hernia: Impact
of associatedanomalies and preoperative blood gases on
survival. Journal of Pediatric Surgery, 34, 1196-1202.
doi:10.1016/S0022-3468(99)90151-3
[2] Miller, S. (1994) Diaphragmatic hernia: Resuscitation.
Anesthesia and Uncommon Pediatric Diseases. Anesthe-
siology Review, 366.
[3] Kirks, D.R. (1991) Practical pediatric imaging. 2nd Edi-
tion, Little, Brown and Company, Boston.
[4] Bagłaj, M. (2004) Late-presenting congenital diaphragm-
matic hernia in children: a clinical spectrum. Pediatric
Surgery International, 20, 658-669.
doi:10.1007/s00383-004-1269-5
[5] Thomas, S. and Kapur, B. (1991) Adult Bochdalek hernia
clinical features, management and results of treatment.
Japanese Journal of Surgery, 21, 114-119.
doi:10.1007/BF02470876
[6] Barbiera, F., Nicastro, N., Finazzo, M., Lo Casto, A.,
Runza, G., Bartolotta, T.V. and Midiri, M. (2003) The
role of MRI in traumatic rupture of the diaphragm. Our
experience in three cases and review of the literature. La
Radiologia Medica, 105, 188-194.
[7] Crandall, M., Popowich, D., Shapiro, M. and West, M.
(2007) Posttraumatic hernias: Historical overview and
review of the literature. The American Journal of Surgery,
73, 845-850.
[8] Puri, P. and Wester, T. (1997) Historical aspects of con-
genital diaphragmatic hernia. Pediatric Surgery Interna-
tional, 12, 95-100. doi:10.1007/BF01349971