Laparoscopic repair of a spontaneous diaphragmatic hernia

Spontaneous diaphragmatic hernia without a previously documented history of trauma is uncommon. Most of the cases described involve either subcostal (foramen of Morgagni), or posterior (foramen of Bochdalek defects). Clinical presentation varies in each patient and repair with either transthoracic or transabdominal (open or laparoscopic) approach has been described (1,2).

In this video (Figure 1) we present a challenging and rare case of gastric perforation within a large spontaneous diaphragmatic hernia in the central part of the left hemithorax managed laparoscopically using biological mesh.

Figure 1 Laparoscopic repair of a spontaneous diaphragmatic hernia (3). Available online: http://www.asvide.com/articles/945

The video demonstrates the difficulty in diagnosing the diaphragmatic hernia from a paraoesophageal hernia as this was not clear on the preoperative imaging. This was confirmed following identification of the right crus and dissection of the hiatus. Following reduction of the stomach from the hernial sac, the perforated fundus was excised down to healthy tissue. Suture repair of the gastric defect was performed as stapling was not safe due to the thickness and quality of tissue. Due to the large defect size and the induration of the surrounding tissue, a mesh repair was done rather than primary repair. A biological mesh was used in this case as the abdomen was contaminated.

The patient had an uneventful recovery and remains asymptomatic with no clinical or radiological evidence of recurrence at 18 months follow-up.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

References

1. Sofi FA, Ahmed SH, Dar MA, et al. Nontraumatic massive right-sided Bochdalek hernia in an adult: an unusual presentation. Am J Emerg Med 2011;29:356.e5-7.
2. Gupta S, Bali RK, Das K, et al. Rare presentation of spontaneous acquired diaphragmatic hernia. Indian J Chest Dis Allied Sci 2011;53:117-9. [PubMed]
3. Markakis C, Mok KW, Vasilikostas G, et al. Laparoscopic repair of a spontaneous diaphragmatic hernia. Asvide 2016;3:189. Available online: http://www.asvide.com/articles/945