In an asymptomatic young, otherwise healthy patient with an incidentally discovered Bochdalek diaphragmatic hernia, should elective repair be performed to prevent future complications?

Management of Asymptomatic Bochdalek Hernia in Young Adults

Elective surgical repair should be performed in young, otherwise healthy patients with incidentally discovered Bochdalek hernias, even when asymptomatic, to prevent future life-threatening complications including gastric volvulus, bowel obstruction, strangulation, and visceral ischemia. 1

Rationale for Prophylactic Repair

The natural history of Bochdalek hernias strongly favors early intervention in young patients:

• Bochdalek hernias can remain asymptomatic for decades before becoming symptomatic in later stages, either because the hernia enlarges or develops secondary visceral complications such as gastric obstruction, strangulation, volvulus, incarceration, or bleeding 1

• The risk of complications increases with time, as delayed presentation commonly leads to emergency situations with significantly higher morbidity and mortality 1

• Young, healthy patients tolerate elective surgery far better than elderly patients who present emergently with complications 1, 2

Surgical Approach Recommendations

For stable, asymptomatic young patients, a minimally invasive laparoscopic approach is the preferred method 1:

• Laparoscopic repair has excellent safety profile with reported in-hospital mortality of only 0.14% 1
• Shorter hospital stay and reduced morbidity compared to open surgery 1
• Similar perioperative outcomes to laparotomy in stable patients 1

Technical Considerations

• Primary repair with non-absorbable sutures (2-0 or 1-0 monofilament) in two layers should be attempted first 1
• For defects larger than 8 cm or >20 cm² area, mesh reinforcement is indicated to prevent tension and recurrence 1
• Biosynthetic or biologic meshes are preferred with minimum 1.5-2.5 cm overlap beyond defect edges 1

Key Clinical Pitfalls to Avoid

Do not adopt a "watchful waiting" approach in young, healthy patients:

• The unpredictable nature of symptom onset means patients may present emergently years later when surgical risk is substantially higher 1, 3
• Emergency repair carries 25-50% decrease in pulmonary function and significantly higher mortality 1
• Complications like gastric volvulus or bowel strangulation can develop suddenly, requiring urgent intervention with worse outcomes 1

Do not delay repair based on current lack of symptoms:

• Multiple case reports demonstrate that even large, asymptomatic hernias in adults eventually become symptomatic and require emergency surgery 4, 2, 3, 5
• The physical characteristics of the hernia (size, contents) do not reliably predict when complications will occur 1

Comparison to Pediatric Hernia Management

The approach mirrors pediatric inguinal hernia guidelines, where all hernias are repaired to avoid incarceration risk, regardless of symptoms 1, 6:

• Pediatric guidelines recommend repair within 1-2 weeks of diagnosis to prevent life-threatening complications 6
• The same principle applies to congenital Bochdalek hernias discovered in young adults 1

When Conservative Management May Be Considered

The only scenario where observation might be acceptable is in elderly patients with significant comorbidities who are poor surgical candidates and have small, fat-containing hernias without visceral contents 7. However, this does not apply to your young, healthy patient population.