What is the appropriate referral for a patient with Chronic Obstructive Pulmonary Disease (COPD) presenting with bilateral Bochdalek hernias containing fat, measuring 6.5 and 6.8 cm?

From the Guidelines

For a patient with COPD who has bilateral Bochdalek hernias containing fat and measuring 6.5 and 6.8 cm, referral to a thoracic surgeon is recommended. While both thoracic and general surgeons may have experience with diaphragmatic hernias, thoracic surgeons typically have more specialized training for managing hernias that extend into the chest cavity, particularly in patients with underlying lung disease like COPD 1. The patient's COPD adds complexity to surgical management, as respiratory function must be carefully monitored perioperatively. These hernias, while containing only fat currently, should be evaluated for potential surgical repair to prevent future complications such as incarceration or strangulation of abdominal contents.

The patient's overall health status and symptom burden should be considered when determining if surgical intervention is warranted, taking into account the presence of comorbidities commonly associated with COPD, such as cardiovascular disease, metabolic disturbances, and skeletal muscle dysfunction 1. The surgeon will need to consider the patient's pulmonary function tests and optimize COPD management before any surgical intervention is considered. Conservative management might be appropriate if the hernias are asymptomatic and the surgical risk is high due to severe COPD.

Key considerations for the surgeon include:

• Evaluating the patient's pulmonary function tests and overall health status
• Optimizing COPD management before surgical intervention
• Considering the risk of complications such as incarceration or strangulation of abdominal contents
• Assessing the patient's symptom burden and quality of life
• Taking into account the presence of comorbidities commonly associated with COPD.

From the Research

Surgical Approach for Bilateral Bochdalek Hernias

The patient's condition, presenting with bilateral Bochdalek hernias and a history of COPD, requires careful consideration of the surgical approach.

• The hernias are asymptomatic, but surgical intervention is recommended due to the risk of acute morbidity and mortality 2.
• The choice of surgeon, either a cardiothoracic surgeon or a general surgeon, depends on the specific circumstances of the case and the surgeon's expertise in handling such rare conditions.

Considerations for Surgical Repair

• Various surgical approaches are possible, including robotic repair, which is becoming increasingly popular 2.
• The patient's COPD may increase the risk of perioperative cardiopulmonary complications, such as empyema or cardiac arrest caused by the tamponade effect of the herniated viscera 3.
• Anesthetic management is crucial to prevent exacerbation of pneumothorax, which is a common complication in laparoscopic repair of Bochdalek hernias 4.

Preferred Treatment Approach

• A systematic review of the literature suggests that surgical approach is the preferred method for managing Bochdalek hernias in adults, with open procedures being preferable in emergency cases 5.
• Minimal invasive approach may be considered, but it necessitates experienced centers 5.
• The current management pathway for adult right-sided Bochdalek hernias emphasizes the importance of rapid and accurate diagnosis, surgical repair, and regular follow-up 6.