Frank P Bendewald, MD
BACKGROUND: Congenital Diaphragmatic Hernia is estimated to occur in up to 1 in 2000 births. Adult presentation of Bochdalek Hernia is uncommon. A recent literature review found 173 cases reported between 1955 and 2010. Of these, 141 underwent surgical repair. Laparoscopy was used in 17 cases. The goals of this paper are: 1) to add to the reported surgical experience with adult Bochdalek Hernia repair, and 2) to provide a detailed description of laparoscopic repair with mesh in 2 cases.
METHODS: Two adult male patients in their fifth decade presented with chronic, worsening chest discomfort and exertional dyspnea. Evaluation in both cases included computed tomography scans of the chest, revealing large left-sided diaphragmatic hernia defects containing abdominal viscera. Surgical repair of the diaphragm was undertaken laparoscopically in both cases, and in both cases the hernia defect measured 91 cm2 (7 cm x 13 cm). Because of the large size of the defects, interposition mesh repairs with expanded polytetrafluoroethylene (ePTFE) were performed. A detailed description of the procedure, including diagrams of patient positioning and intra-operative photographs, is provided. Pre- and post-operative radiographs are also shown.
RESULTS: Both operations were completed laparoscopically. The operating time was 145 and 191 minutes in the first and second cases, respectively. There were no intraoperative complications. In follow-up both patients reported resolution of their chest discomfort and exertional dyspnea. The first patient was discharged from the hospital after two days. He complained of left shoulder pain, requiring oral narcotic analgesics for 3 weeks, but his recovery was otherwise uneventful. The second patient, who had recently recovered from aspiration pneumonia, required supplemental oxygen and had post-operative atelectasis on chest x-ray, but he was discharged form the hospital on room air after 5 days. He later complained of new-onset gastroesophageal reflux symptoms which responded to proton pump inhibitor therapy.
CONCLUSION: Laparoscopic adult Bochdalek Hernia repair with interposition mesh is an uncommon operation. It can be performed safely; however, no individual surgeon is likely to acquire a volume of cases necessary to generate and overcome a learning curve. Therefore, careful pre-operative planning could facilitate the operation, decrease operative time and optimize patient outcomes.
Session: Poster Presentation
Program Number: P271