Is elective repair appropriate for a 40‑year‑old woman with a Bochdalek diaphragmatic hernia involving the basal portions of both lungs?

Management of Bilateral Bochdalek Hernias in a 40-Year-Old Woman

Elective surgical repair is strongly recommended for this 40-year-old woman with bilateral Bochdalek hernias involving the lung bases, as surgery is the definitive treatment for congenital diaphragmatic hernias in adults to prevent life-threatening complications including strangulation, perforation, and progressive respiratory compromise. 1

Rationale for Surgical Intervention

Surgery is mandatory for Bochdalek hernias in adults, even when asymptomatic, because these congenital defects carry significant risk of acute complications. 1, 2 The patient's age of 40 years falls precisely within the typical presentation age for adult Bochdalek hernias (average 40 years), and bilateral involvement makes this case particularly high-risk. 1

Key Clinical Considerations

• Bochdalek hernias in adults are rare (0.17% incidence) but require surgical intervention regardless of symptom severity to prevent catastrophic complications such as visceral strangulation, ischemia, or perforation. 1, 2

• The bilateral nature of this patient's hernias is exceptionally rare and increases surgical complexity, as most adult Bochdalek hernias occur unilaterally on the left side (85%). 1

• Even asymptomatic adult Bochdalek hernias warrant repair because symptoms can develop acutely and unpredictably, leading to emergency surgery with higher morbidity and mortality. 2

Recommended Surgical Approach

A minimally invasive approach (laparoscopic or thoracoscopic) is the preferred method for stable patients with congenital diaphragmatic hernias. 1

Approach Selection Algorithm

• For bilateral hernias, staged procedures may be necessary, addressing the more symptomatic or larger defect first, followed by the contralateral side after recovery. 1

• Laparoscopic approach is recommended if the patient has predominantly abdominal symptoms (dyspepsia, abdominal pain, bowel obstruction symptoms), offering excellent visualization of both hemidiaphragms and the ability to assess bilateral defects. 1, 3, 4

• Thoracoscopic approach is preferred if severe adhesions are suspected or if the patient has primarily respiratory symptoms (dyspnea, chest pain), as chronic herniation creates viscero-pleural adhesions that are better managed thoracoscopically. 1, 5, 6

• Minimally invasive surgery has demonstrated superior outcomes with in-hospital mortality of only 0.14%, shorter hospital stays, and reduced morbidity compared to open approaches. 1

Surgical Technique Specifications

Primary Repair Strategy

• Primary closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers should be attempted first for defects that can be approximated without excessive tension. 1

• Mesh reinforcement is mandatory for defects larger than 3 cm or when primary closure would create tension, as primary repair alone carries a 42% recurrence rate. 1

Mesh Selection and Placement

• Biological or biosynthetic meshes are strongly preferred due to lower recurrence rates, higher infection resistance, and reduced displacement risk compared to synthetic meshes. 1

• Mesh must overlap the defect edges by 1.5-2.5 cm and can be fixed using transfascial sutures or tackers (avoiding proximity to pericardium). 1

• For defects larger than 8 cm or areas exceeding 20 cm², mesh interposition is required rather than attempting tension-laden primary closure. 1

Management of Hernial Sac

• Excision of the hernial sac remains controversial but may reduce recurrence risk, particularly when stomach or colon is contained within the sac, as manipulation of only the sac (rather than contents) reduces transmural visceral injury risk. 1

• Sac retention is acceptable if excision risks damage to pericardium or mediastinal structures, as most studies show no obvious complications from retained sacs. 1

Additional Procedures to Consider

Gastropexy and Anti-Reflux Procedures

• Gastropexy should be performed after reduction of herniated stomach to prevent recurrent herniation and provide anterior stomach fixation to the abdominal wall. 1

• Fundoplication is strongly recommended for congenital diaphragmatic hernias due to the high incidence of gastroesophageal reflux (up to 62%) following repair. 1

• Nissen fundoplication is the preferred technique for durable GERD symptom control in patients with normal esophageal motility. 1

Critical Pitfalls to Avoid

• Do not attempt primary closure if the distance between the diaphragm edge and chest wall exceeds 3-4 cm, as this creates excessive tension and guarantees recurrence. 1

• Avoid tackers near the pericardium due to risk of cardiac complications; use transfascial sutures in this region instead. 1

• Do not delay surgery waiting for symptoms to worsen, as acute presentations require emergency surgery with significantly higher morbidity. 2

• Bilateral repairs should not be attempted simultaneously unless both defects are small and easily accessible; staged procedures reduce operative time and physiologic stress. 1

Expected Outcomes

• Minimally invasive repair offers excellent safety profile with minimal blood loss (mean 1.0 mL in thoracoscopic series), no visceral injury when proper technique is used, and zero recurrence rates in recent series. 6

• Operative duration for minimally invasive approach averages 212 minutes but provides superior cosmetic results and faster recovery compared to open surgery. 6

• Long-term functional benefit approaches 100% with significant improvement in dyspnea and quality of life following successful repair. 7