Hernia (2011) 15:23–30 DOI 10.1007/s10029-010-0699-3 ORIGINAL ARTICLE Bochdalek hernia in the adult: demographics, presentation, and surgical management S. R. Brown • J. D. Horton • E. Trivette • L. J. Hofmann • J. M. Johnson Received: 21 December 2009 / Accepted: 12 June 2010 / Published online: 8 July 2010 Ó U.S. Government 2010 Abstract Conclusions Using modern surgical techniques to include Background Bochdalek hernias are a very rare form of laparoscopy, repair can be performed safely, with a short diaphragmatic hernias. There are no robust studies that hospital stay, and with minimal morbidity or mortality. reveal the true natural history of this disease process. The aim of this study was to summarize clinically relevant data Keywords Diaphragmatic hernias Á Bochdalek hernias Á for the purpose of assisting surgeons with the work-up, Laparoscopic repair Á Congenital diaphragmatic hernia Á diagnosis, and treatment of adult patients with Bochdalek Posterolateral hernia hernia. Methods A literature search was performed using Pub- Med, Google scholar, EMBASE and the following key- Introduction words: Bochdalek hernia, congenital diaphragmatic hernia, and posterolateral hernia. All case reports and series after Bochdalek hernia (BH) is usually thought of as a perinatal 1955 that pertained to adults were included in the review. pathology associated with significant morbidity and mor- The following data points were queried: age, sex, presen- tality [1]. However, the surgical literature is stippled with tation, studies utilized during work-up, laterality, surgical case reports and small series of BH presenting in adults. In approach, hernia sac management, specific minimally the adult patient, there have been no large retrospective or invasive surgical techniques, and follow-up. prospective studies on BH. Due in part to the exotic nature Results A total of 124 articles comprising 173 patients of this hernia in the adult patient population, there are no met the inclusion criteria. Based on the data provided, well established indications for elective surgical repair. In several conclusions regarding this disease process can be addition, the clinical presentation may be confusing. made. Most patients present with symptoms related to their With the evolution of modern surgical technology, new hernia (86%). Pain is the most common complaint (69%). techniques for repairing these defects have been developed. While laparotomy is the most widely used surgical This review attempts to provide the clinician with an outline approach (38%), minimally invasive surgical techniques for the presentation, work-up, and surgical management of have gained popularity since their first report in 1995. BH. This analysis represents the most comprehensive Laparoscopic repair can be performed with a low compli- review to date on the topic of BH in adults. cation rate (7%) and short hospital stay (4 days). Materials and methods We conducted an English language literature search using S. R. Brown (&) Á J. D. Horton Á E. Trivette Á PubMed, EMBASE, and Google Scholar for every case L. J. Hofmann Á J. M. Johnson report, series, and literature review relating to BH in adults. Department of Surgery, William Beaumont Army Medical Center, 5005 North Piedras St, El Paso, TX 79920, USA Keywords included ‘‘Bochdalek hernia’’, ‘‘congenital dia- e-mail: [email protected] phragmatic hernia’’, and ‘‘posterolateral hernia’’. For the 123 24 Hernia (2011) 15:23–30 purposes of this review, all individuals 15 years of age and included: obesity, exertion, trauma, pregnancy, laughter, older were considered adults. All articles from November amusement park ride, recent weight gain, large meal, scuba 1955 until April 2010 were included in this study. Articles diving, diving from diving board, gymnastics, sexual inter- pertaining to the evaluation of BH in pediatric and or course, large meal, prior surgical repair (congenital), neonatal patients were excluded, as well as those studies retching, coughing, constipation secondary to medication that included the incidental discovery of BH on autopsy. effect, and COPD. More than one precipitating factor or Two authors extracted data from each article in a stan- inciting event was present in five cases. The most common dardized manner. Included in the analysis was the patient’s precipitating factor was pregnancy and the most common age, sex, laterality, presence of congenital abnormalities, inciting event was exertion, found in 13 and 7% patients, presenting symptoms, preoperative diagnostic studies, respectively. presence of precipitating factors, surgical approach, time of Only 14% of patients were asymptomatic at the time of diagnosis, additional surgical procedures, placement of presentation. Our analysis categorized the symptomatic chest tube, requirement for emergency surgery, defect size, patients according to the following manifestations: stran- presence of hernia sac, resection of the hernia sac, method gulation, obstruction, pulmonary symptoms, and pain, of hernia repair, recurrence, hernia sac contents, compli- bleeding, dysphagia, or GERD/dyspepsia; the percent of cations, postoperative stay, 30-day mortality, and follow patients presenting with each symptom is listed in Table 2. up. Due to the large numbers of small reports, only Pulmonary symptoms were defined as dyspnea, cough, and descriptive statistics were performed. shortness of breath. The pain/pressure category included patients with chest or abdominal discomfort that was not related to a bowel obstruction. Results Several diagnostic modalities were used to evaluate patients with a BH. Many patients had multiple studies. Our search of the literature yielded 141 articles containing The most common study was chest X-ray (88%); followed 173 cases from 31 countries. Despite an English-language- by CT scan (39%), UGI/barium (33%), contrast enema only search strategy, we included authors from around the (10%), EGD (6%) and MRI (4%). world, including six Middle Eastern and six Asian coun- Authors reported surgical repair via five approaches: tries. The disciplines of general surgery, minimally inva- laparotomy, thoracotomy, laparoscopy, thoracoscopy, or sive surgery, thoracic surgery, internal medicine, and combined approach (Table 3). The review identified 17 radiology contributed articles for analysis. Of the 173 cases of laparoscopy in the literature. In nine of these cases, cases, 55% of patients were male and 45% were female the presence or absence of a hernia sac was not recorded. (Table 1). The mean age of men and women was 39 years Three laparoscopic cases identified the presence of a hernia and 41 years, respectively, with a range of 15–88 years. sac [2–4], while the remaining six cases stated there was no The hernia defect was located on the left side in 78% of hernia sac. The hernia sac was not resected in these cases. patients, on the right side in 20%, with bilateral hernias found in 2% of the patients. The size of the defect was not Table 2 Presenting symptoms and the percentage of patients with related to laterality. those symptoms Factors precipitating symptoms or an inciting event were Presenting symptoms defined as any factor or event that the article’s author felt contributed to the patient’s presentation. A precipitating Asymptomatic 14% factor or an inciting event was present in 25% of cases and Pain/pressurea 69% Obstruction 39% Pulmonary symptoms 37% Table 1 Demographic information for the patients included in this Strangulated 28% review Dysphagia 3% Demographics and laterality (N = 173) Results Bleeding 4% Average age (years) 40 GERD 4% Female 45% Other (HTN, fatigue, indigestion) 9% Precipitating factor/inciting event 25% Symptoms for less than 1 month 47% Congenital anomalies 12% The majority of patients were symptomatic at presentation and the Right sided 20% symptom of pain was specific for pain not related to obstruction or Left sided 78% strangulation a Bilateral 2% Located in chest or abdomen, not related to obstruction/ strangulation 123 Hernia (2011) 15:23–30 25 Table 3 Comparison of surgical approaches Laparotomy Thoracotomy Laparoscopy Thoracoscopy Combined Choice of surgical approach 38% (53/141) 32% (45/141) 12% (17/141) 3% (4/141) 16% (22/141) Diagnosis prior to surgery 65% (30/46) 51% (23/45) 65% (11/17) 100% (4/4) 67% (10/15) Emergency surgery 42% (19/45) 13% (6/45) 19% (3/16) 0% (0/4) 56% (10/18) Size of defect (cm2)42(n = 20) 38 (n = 15) 45 (n = 11) NS 36 (n = 9) Resection of hernia sac 20% (1/5) 50% (4/8) 0% (0/3) 0% (0/2) NS Primary repair 95% (40/42) 82% (31/38) 53% (8/15) 100% (4/4) 67% (12/18) Interposition mesh graft 7% (3/42)a 21% (8/38)a 60% (9/15)b 25% (1/4)a 39% (7/18) Complications 18% (9/51) 16% (6/36) 6% (1/16) 0% (0/3) 38% (6/16) 30 Day mortality 2% (1/50) 5% (2/43) 0% (0/15) 0% (0/4) 0% (0/20) Hospital stay, days (mean) 10 (n = 24) 20 (n = 16) 4 (n = 11) 5 (n = 4) 13 (n = 11) Recurrence 0% (0/48) 0% (0/42) 0% (0/16) 0% (0/4) 0% (0/22) Follow-up, months (mean) 22 (n = 21) 38 (n = 14) 26 (n = 11) 8 (n = 1) 8 (n = 11) a One was combined primary repair reinforced with mesh b Two with combined primary repair reinforced with mesh Primary closure was performed in 53% of laparoscopic diaphragm, where a BH develops. Complete closure occurs cases, with 60% of cases incorporating mesh into the on the right side before it is complete on the left side—a repair. One case resulted in a stated complication, which fact that may contribute to the left sided BH being more was a pneumothorax immediately postoperatively requiring common than right sided hernias. a chest tube [5]. Only four cases using the thoracoscopic approach have been reported in the English literature [6–9]. Incidence and presentation The incidence of asymptomatic BH in the adult population Discussion has been well characterized. The best data regarding the incidence of BH comes from Mullins and colleagues, who History reviewed 13,138 CT scans.