Asian Cardiovasc Thorac Ann 2008;16:e42-e44
© 2008 Asia Publishing EXchange Ltd
A Rare Cause of Dyspnea in Adult: a Right Bochdalek’s Hernia-containing Colon
Alberto Terzi, MD,
Umberto Tedeschi, MD1,
Alessandro Lonardoni, MD,
Simone Furia, MD2,
Cristiano Benato, MD2,
Francesco Calabrò, MD
Thoracic Surgery Unit
1 First General Surgery Unit, Azienda Ospedaliera-Universitaria di Verona
2 Thoracic Surgery Speciality School University of Verona, Verona, Italy
For reprint information contact: Alberto Terzi, MD, Tel: 39 01 712 728, Fax: 39 01 7164 2491, Email: alterzi{at}libero.it, Thoracic Surgery Unit, Azienda Ospedaliera Santa Croce e Carle, Cuneo Via Coppino 26 12100, Cuneo, Italy.
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ABSTRACT
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Symptomatic cases of Bochdalek’s hernia (BH) are uncommon in adults; symptoms arise only due to complications. Most of symptomatic cases are related to a left-sided hernia. Right colon herniation in adults has never been reported. We present a case of a 70-year-old woman with right BH-containing colon. The patient was successfully treated by combined laparoscopic and thoracoscopic approach.
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INTRODUCTION
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Bochdalek’s foramen is the result of inadequate fusion of the pleuroperitoneal membrane with the other components of diaphragm in the posterolateral part. BH is usually diagnosed in children who present with clinical symptoms caused by associated pulmonary insufficiency and cardiovascular collapse. In adults a BH is diagnosed on a routine imaging of the chest or abdomen for unrelated reasons1 or following symptoms related to the intra-thoracic migration of abdominal viscera. We describe an exceedingly rare case of right BH with intra-thoracic herniation of transverse colon, diagnosed in an adult.
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CASE REPORT
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A 70-year-old woman was referred to us after a chest X-Ray taken for a mild dyspnea revealed a possible posterior hepato-diaphragmatic interposition of the colon and a computed tomographic (CT) scan of the chest showed the possible presence of colon in the chest cavity (Figure 1A–B
). There was no history of trauma. Magnetic resonance imaging of the chest (Figure 1C–D) demonstrated a right posterolateral defect in the diaphragm with intrathoracic herniation of the colon and the omentum. A decision to operate the patient was taken due to the high risk of complications related to the presence of colon in the chest. A minimally invasive approach was chosen. After oro-tracheal intubation with a double lumen endotracheal tube the patient was placed in the left lateral position and a video-thoracoscope was introduced in the right pleural space. The hernial sac containing the large bowel and adhesions between the sac and the lower lobe were seen. Using the other two port accesses it was realised that it was not possible to reduce the colon and omentum in the abdomen through this access only. Accordingly the right lung was ventilated and a pneumo-peritoneum was induced. Four laparoscopic accesses were placed and the right coronal ligament was sectioned. The right lobe of the liver was mobilized to visualize the inferior vena cava and the postero-lateral foramen was identified. Adhesions between the colon and the rim of the foramen were lysed and the large bowel and the omentum were pulled into the abdominal cavity (Figure 2). The right lung ventilation was thereafter discontinued. Adhesions between the hernia sac and right lower lobe were lysed and the sac resected. The foramen (about 4 cm) was closed and a polypropylene mesh was sutured to the diaphragm. A drain was left in the pleural space and the abdomen. Postoperative course was uneventful and the patient was discharged on the 4th postoperative day.
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Figure 1. (A) Chest X-Ray showing hepato-diaphragmatic interposition of colon; (B) Chest CT showing large bowel in the chest; (C–D) MR imaging sagittal and coronal views showing the passage of colon and omentum through a postero-lateral defect of the diaphragm
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DISCUSSION
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Bochdalek’s hernia occurs approximately in 1:2000 to 1:5000 live births,2 twice as often in males as in females, the left side more commonly involved than the right. In adults, most BH are asymptomatic. With the widespread use of CT and other imaging studies asymptomatic BH are increasingly discovered as incidental findings. The true prevalence of BH however remains unknown, with estimates ranging from a low of 1 in 2000–7000 based on autopsy studies3 to as high as 6% based on the findings of early-era CT examinations.4–5 Recently in a retrospective study on 13,138 abdominal CT examinations performed at a single institution, incidental BH was diagnosed in 22 patients (0.17%). Contrary to what is usually reported, BH was more frequent in women than in men (17/5, 77%) and in the right side (15/22, 68%) while (3/22, 14%) were bilateral. 73% of hernias contained only fat or omentum and 27% solid organs, in no case the colon was detected. These data, however, refer to asymptomatic patients while the symptomatic ones usually present with a left-sided BH. The contents of right-sided BH are predominantly the liver, the kidney, fat and rarely the small intestine.6 Colon-containing hernias are very rare and usually occur through left-sided defects and to our knowledge no case of adult right BH-containing colon has so far been reported.
Once diagnosed, the reduction of abdominal viscera in the abdominal cavity is mandatory due to the risk of life threatening complications.7 Laparotomy or thoracotomy alone or in conjunction are the standard approaches for the treatment of BH, however, cases of laparoscopic or thoracoscopic treatment have also been reported.8 We used a combined mini-invasive procedure that allowed the reduction of abdominal viscera into the peritoneal cavity, the management of intra-thoracic adhesions, the resection of the hernial sac and placement of prosthetic mesh with a minimal discomfort to the patient.
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REFERENCES
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ABSTRACT
INTRODUCTION
