What is the management plan for a patient with a large left Bochdalek (Congenital Diaphragmatic) hernia containing fat, presenting with periumbilical abdominal pain?

Management of Left Bochdalek Hernia with Fat Presenting with Periumbilical Abdominal Pain

Surgical repair is strongly recommended for this patient with a symptomatic left Bochdalek hernia containing fat and presenting with periumbilical abdominal pain. 1

Diagnostic Confirmation

Before proceeding with treatment, confirm the diagnosis with:

• CT scan with contrast of the chest and abdomen (gold standard for diagnosing diaphragmatic abnormalities) 1
• Assess for potential complications such as incarceration, strangulation, or compression of thoracic organs

Treatment Algorithm

1. Initial Assessment:

   • Evaluate hemodynamic stability
   • Assess for signs of strangulation (severe pain, fever, leukocytosis)
   • Review comorbidities that might affect surgical approach

2. Surgical Management:

   • For stable patients: Minimally invasive approach (laparoscopic repair) is preferred 1
   • For unstable patients or signs of strangulation: Open surgical approach via laparotomy 1

3. Surgical Technique:

   • Reduction of herniated fat back into the abdominal cavity
   • Primary repair of the diaphragmatic defect with non-absorbable sutures if defect is small (<8 cm) 1
   • For larger defects (>8 cm), mesh reinforcement is recommended 1
   • Biological or biosynthetic mesh is preferred in cases of potential contamination 1

Specific Considerations for Bochdalek Hernia

• Left-sided Bochdalek hernias (85% of cases) are more common than right-sided (15%) 1
• Even asymptomatic Bochdalek hernias in adults should be repaired to prevent future complications 2
• The mesh should overlap the defect edge by 1.5-2.5 cm 1

Potential Complications to Monitor

• Respiratory compromise due to reduced lung volume
• Compartment syndrome if abdominal cavity has insufficient space for reduced contents
• Recurrence of hernia (more common with primary repair of large defects)
• Post-surgical pain

Post-Surgical Care

• Monitor for signs of respiratory distress
• Gradual return to normal activities
• Follow-up imaging (chest X-ray) at 3-6 months to assess for recurrence

Pitfalls to Avoid

1. Delayed diagnosis: Bochdalek hernias in adults can present with vague symptoms and be easily missed
2. Inadequate repair: Using primary closure for defects >8 cm increases recurrence risk
3. Tension repair: Creating excessive tension during repair can lead to respiratory compromise
4. Overlooking associated conditions: Patients with Bochdalek hernias may have other congenital abnormalities

Special Considerations

For patients with large hernias where reduction may cause abdominal compartment syndrome, consider staged repair or extended resection of involved organs if necessary 2.

Laparoscopic repair has been shown to be successful even in difficult cases and fragile patients, with significant clinical improvement and reduced postoperative complications 2, 1.