What is a Bochdalek hernia?

From the Guidelines

Bochdalek hernia is a congenital diaphragmatic hernia that occurs when abdominal organs protrude into the chest cavity through a defect in the posterior part of the diaphragm, most commonly on the left side, and requires surgical repair to prevent complications and improve quality of life. This condition develops during fetal development when the diaphragm fails to close properly 1. Bochdalek hernias are typically diagnosed in newborns who present with respiratory distress shortly after birth, as the herniated abdominal contents compress the developing lungs. However, some smaller Bochdalek hernias may go undetected until adulthood, when they might be discovered incidentally or present with vague gastrointestinal or respiratory symptoms 1.

Clinical Presentation and Diagnosis

The diagnosis of Bochdalek hernia is difficult due to its rarity and wide range of presenting symptoms 1. In adults, the incidence of Bochdalek hernia is 0.17%, presenting at an average age of 40 years 1. The condition is named after Victor Alexander Bochdalek, the Czech anatomist who first described this particular type of diaphragmatic hernia in the 19th century.

Treatment and Management

Treatment requires surgical repair to move the abdominal organs back to their proper position and close the diaphragmatic defect 1. The prognosis depends on the size of the defect, the degree of lung development (pulmonary hypoplasia), and whether other congenital abnormalities are present. Laparoscopic repair has a lower morbidity (6%) compared with the open approach (18%) 1. The survival rate in adults presenting with delayed complicated CDH varies between 97 and 100% 1.

Complications and Outcomes

Postoperative pulmonary complications, including atelectasis, are common following surgery for TDH 1. Other complications include surgical infection, bleeding, respiratory failure, ileus, gastroesophageal reflux, chronic pain, hernia recurrence, and cardiac injury. The recurrence of a diaphragmatic hernia may be due to the use of absorbable sutures for the primary repair, suture tension, improper fixation of the prosthetic material to the defect edges with a minimal overlap, increased intra-abdominal pressure due to a prolonged ileus, poor chest toileting, and an intra-abdominal sepsis causing tension, disruption of tissue and sutures, leading to mesh displacement or re-opening of the defect 1.

Key Points

• Bochdalek hernia is a congenital diaphragmatic hernia that requires surgical repair 1.
• Laparoscopic repair has a lower morbidity compared with the open approach 1.
• The prognosis depends on the size of the defect, the degree of lung development, and whether other congenital abnormalities are present 1.
• Postoperative pulmonary complications are common following surgery for TDH 1.

From the Research

Definition and Presentation of Bochdalek Hernia

• Bochdalek hernia (BH) is a congenital diaphragmatic hernia that typically presents after birth with respiratory symptoms and requires surgical treatment in the neonatal period 2.
• However, some cases of BH may remain asymptomatic until adulthood, with a reported incidence as low as 0.17% 3.
• Adult presentation of BH often requires surgery to avoid complications, and the diagnosis can be made based on chest X-ray, CT scan, and MRI 2, 4.

Surgical Treatment of Bochdalek Hernia

• Surgical repair of BH can be performed through various approaches, including laparoscopy, thoracoscopy, and open surgery 2, 4, 3.
• Laparoscopic repair of BH has been successfully performed in several cases, with significant clinical improvement and no recurrence 2, 4, 3, 5.
• The use of mesh reinforcement and biosynthetic web scaffolds has been reported in some cases to repair the diaphragmatic defect 2, 4.
• Robotic repair is also becoming increasingly popular for the treatment of BH in adults 6.

Diagnosis and Preoperative Evaluation

• CT scan of the abdomen and chest with oral and IV contrast is considered the gold standard for diagnosis of BH 3.
• Preoperative work-up may include chest X-ray, CT scan, and MRI to evaluate the extent of the hernia and the presence of any complications 2, 4.
• The absence of a hernia sac has been described as a distinct characteristic that confirms the diagnosis of BH 3.