Diaphragmatic hernia following pneumonectomy; report of a case

We report a case of diaphragmatic hernia following left pleuropneumonectomy. A 70-year-old man was referred to our hospital after tube drainage for 3 months due to left pyothorax. He had a past history of left lung tuberculosis. Pleuropneumonectomy with partial resection of the muscle layer of the diaphragm was performed because adhesion of pleurae was severe. On the 19th postoperative day, he started to develop a slight fever. Chest X-ray and computed tomography (CT) demonstrated diaphragmatic hernia. On the 22nd postoperative day, we performed surgery because panperitonitis developed. At laparotomy, the transverse colon was pierced by the cut end of the rib. We successfully repaired the diaphragm and established transverse colostomy. The patient has been in good health for more than 10 years after the surgery.     

Acute abdomen due to a right-sided strangulated traumatic diaphragmatic hernia. Case report

Traumatic rupture of diaphragm is sometimes diagnosed many years after the traumatic event. Due to the silent nature of diaphragmatic injuries, the diagnosis is easily missed or difficult. We describe a rare case of right diaphragmatic hernia, in which the diagnosis was made many years after the trauma. The incidence of right diaphragmatic hernia is about 11-14% of all diaphragmatic hernias. The patient showed acute hernia of the small intestine and was treated with resection of the intestinal loop and repair of breakthrough by suture. The diagnosis was made with a standard X-ray of thorax and abdomen. CT scan and NMR give more accurate information in these cases. The surgical repair is the treatment of choice in all traumatic diaphragmatic hernias.     

Differentiating Chilaiditi’s Syndrome with hollow viscus perforation: A case report

IntroductionChilaiditi‘s syndrome is a rare condition accounting for only 0.25%–0.28% of all abdominal imaging worldwide. To rule out Chilaiditi‘s syndrome from other acute abdominal emergencies is very important to avoid unnecessary treatment or surgical procedure.Presentation of caseA 25-year-old female presented in the emergency room with 1 week history of abdominal discomfort. At time of examination, she had a mild shortness of breath that was not related with rigorous activities. A plain abdominal x-ray was suggested the presence of an air-filled bowel tract within the right subphrenic space (Fig. 1). Abdominal computed tomography suggested colonic loop present between the right hemi-diaphragm and liver. The absence of abdominal free air confirmed an isolated pseudo-pneumoperitoneum due to colonic interposition between the liver and diaphragm.DiscussionChilaiditi sign is radiolucency in the subdiaphragmatic space as a result of bowel interposition between a diaphragm and the liver. If gastrointestinal symptoms present, the condition is known as Chilaiditi's syndrome. The abdominal symptoms including severe pain, anorexia, diarrhea, nausea, vomiting, bloating and constipation might mislead physicians or surgeons with diaphragmatic hernia, subdiaphragmatic abscess, bowel perforation, infected hydatid cyst and liver tumor. Thorough physical examination, imaging, and timely follow up is very important to avoid unnecessary exploratory laparotomies.ConclusionChilaiditi’s Syndrome is often misdiagnosed with bowel perforation because the presence of pseudopneumoperitoneum in the plain X-Rays. It is important to understand the unique characteristics of the sign, symptoms and findings of Chilaiditi’s Syndrome to prevent unnecessary surgical procedures.     

Delayed traumatic diaphragmatic hernia diagnosed by magnetic resonance imaging and direct coronal computed tomography: report of a case

A 59-year-old woman was admitted to our hospital with abdominal symptoms. A diagnosis of delayed traumatic diaphragmatic hernia was made from the findings of a plain X-ray film, magnetic resonance imaging (MRI) and computed tomography (CT). We successfully performed repair of the diaphragm via abdominal approach. Thus, MRI and direct coronal CT can be very useful for establishing a diagnosis of traumatic diaphragmatic hernia.     

Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.     

Laparoscopic repair of congenital diaphragmatic hernia with prosthesis: a case report

We report here our experience in the treatment of a large congenital diaphragmatic hernia, an uncommon pathology, approachable by laparoscopy. The patient was a 33-year-old woman with trisomy 21 syndrome, who only complained of colicky abdominal pain and a cough for 7 months before the hospitalization. Thoracic and abdominal CT scans showed a large anteromedial diaphragmatic hernia with slippage of the colon into the mediastinum and posterior displacement of the cardiovascular structures. The patient underwent laparoscopic repair of the hernia. The colon was put back in the abdomen; the defect (8×4 cm) was repaired by a Composix mesh (PTFE-polypropylene), fixed to the diaphragm by nonabsorbable stitches and staples. The patient was discharged on the third postoperative day. The postoperative course was uneventful. Follow-up at 18 months didn't show any complications or recurrence. We believe laparoscopic repair of diaphragmatic hernia to be the elective surgical choice, because of its technical feasibility and certain intra- and postoperative advantages. Electronic Publication     

Right delayed traumatic diaphragmatic hernia; report of a case

An 80-year-old woman was admitted to our hospital with abnormal shadow on chest X-ray 8 years after a chest trauma during which multiple ribs on the right side were fractured causing hemothorax. A diagnosis of right delayed traumatic diaphragmatic hernia was based on the findings on plain X-ray and multislice computed tomography. We performed surgery via thoracic approach with thoracoscopic assist. The transverse colon, liver, and omentum were dislocated into the right thoracic cavity and hardly adhered to the lung. We successfully repaired the ruptured diaphragm. The postoperative course was uneventful and the patient was discharged on the 33rd postoperative day.     

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.     

Diaphragmatic endometriosis-associated pneumothorax triggered by abortion; report of a case

The patient was a 36-year-old woman. She had previously undergone surgery for hysteromyoma and endometriosis. At 8 week of pregnancy, the fetus's heart stopped beating, and the woman underwent abortion. On the same day, she began experiencing difficulty in breathing in the evening. After 4 days, she was referred to our hospital with dyspnea. Chest X-ray finding showed a right pneumothorax. Tube toracotomy was performed, and the right lung re-expanded immediately. Two months later, pneumothorax recurred without any association with the menstruation cycle. Thoracoscopic surgery was performed. No lesion was detected in the lung or visceral pleura, but a small hole and some thinned areas were noted in the diaphragm. Partial resection of the diaphragm was performed. Microscopic examination revealed endometriosis and localized lymphocyte infiltration in the resected diaphragm. It was suggested that the recurrence of pneumothorax without menstruation was caused by the thinning of the diaphragm due to endometriosis.     

Laparoscopic repair of traumatic rupture of the left diaphragm cupola with prosthetic mesh

We present the case of a 23-year-old patient who had a car accident with a steering wheel trauma 6 months previously. The patient complained of abdominal pain, getting easily tired, and breathing difficulties. A diagnosis of traumatic diaphragmatic hernia was established by a contrast radiographic examination. Laparoscopy confirmed a rupture of the left diaphragmatic cupola and prolapse of the stomach, small intestine, and colon in the left thoracic cavity. Laparoscopic repair of the diaphragm with polypropylene mesh was performed. The patient recovered rapidly and was discharged 72 h after the operation. The control radiographs and computed tomography (CT) contrast investigations showed no recurrence. The patient's preoperative complaints had resolved completely. The case is interesting because traumatic diaphragmatic hernia is sometimes difficult to diagnose. Its laparoscopic treatment is still a challenge for modern surgery, and there are not enough publications on the problem.     

Complicated right-sided Bochdalek hernia in an adult

Bochdalek hernias on the right side of the diaphragm are very rarely diagnosed in adults. We report a case of a 52-year-old female patient, who presented to the emergency department with acute intestinal obstruction. Plain and cross-sectional imaging identified a large right-sided Bochdalek hernia containing small bowel loops and the right colon. A laparoscopic approach was performed. The herniated intestinal loops and the right colon were reduced into the abdominal cavity. The diaphragmatic defect was closed using clips with reinforcement by a prosthetic polypropylene mesh. A mini median laparotomy was performed to ensure the viability of the bowel and a few stitches were inserted on superficial lesions of the serosa. The recovery was uneventful and the patient was discharged from the hospital 6 days after admission. Nine months later the patient is doing well.     

Dislocation of three segments of the liver due to hernia of the right diaphragm

Right diaphragmatic hernia is a rare injury (0.25–1%) following blunt abdominal trauma. The diagnosis may be delayed and achieved years after the trauma during laparotomies for other reasons. A 75-year-old male fell 6 years before, and was symptom-free since then. He was admitted to the hospital for abdominal pain, and chest X-rays revealed intestinal gas in the lower right thoracal region. Abdominal ultrasonography showed agenesis of the gallbladder, and computed tomography demonstrated that the right upper abdominal viscera were located in the vicinity of the heart. The patient underwent a laparotomy for right diaphragmatic hernia, and the right hepatic lobe and the medial segment of the left lobe, the gall bladder, the proximal part of the transverse colon, the omentum and some segments of the intestine were dislocated into the thoracal cavity by a tear in the right diaphragm. The organs were returned to the abdominal cavity uneventfully and the defect in the diaphragm, measuring 10 × 5 cm, was repaired by unabsorbable sutures. The diagnosis, surgical treatment and postoperative course of the right diaphragmatic hernia is discussed with a review of the literature.     

Catamenial pneumothorax due to diaphragmatic endometriosis confirmed by histological examination; report of a case

We reported a case of catamenial pneumothorax caused by diaphragmatic endometriosis that was histologically confirmed. A 49-year-old female who had recurrent chest pain and cough appearing on the day preceding each menstruation from 5 years ago. These episode suggested catamenial pneumothorax. Thoracotomy revealed the characteristic appearances of catamenial pneumothorax such as blueberry spots and multiple small holes on the central tendon of the right diaphragm. But there were no lesions on the visceral pleura of the lung. Partial resection of the diaphragm including these lesions were performed. Histological examination showing positive for estrogen receptor and progesterone receptor confirmed the presence of endometrial tissue on the diaphragm. The patient has been well controlled by therapy with gonadotropin releasing hormone, without recurrence of catamenial pneumothorax.     

Complicated Right-sided Bochdalek Hernia in an Adult

Bochdalek hernias on the right side of the diaphragm are very rarely diagnosed in adults. We report a case of a 52-year-old female patient, who presented to the emergency department with acute intestinal obstruction. Plain and cross-sectional imaging identified a large right-sided Bochdalek hernia containing small bowel loops and the right colon.

A laparoscopic approach was performed. The herniated intestinal loops and the right colon were reduced into the abdominal cavity. The diaphragmatic defect was closed using clips with reinforcement by a prosthetic polypropylene mesh. A mini median laparotomy was performed to ensure the viability of the bowel and a few stitches were inserted on superficial lesions of the serosa.

The recovery was uneventful and the patient was discharged from the hospital 6 days after admission. Nine months later the patient is doing well.     

Intrathoracic gastric perforation: a late complication of an unknown postpartum recurrent hiatal hernia

Diaphragmatic hernias occurring during pregnancy are an uncommon event. In very rare occasions, the clinical situation can suddenly worsen due to obstruction, torsion or infarction of the herniated viscera. Here, we describe a challenging case of a post-partum diaphragmatic hiatus hernia complicated by intrathoracic gastric perforation. A 23-year old woman was admitted at our hospital with a syndrome characterized by epigastralgy, dyspnoea and fever. She had previously undergone a laparoscopic antireflux surgery for hiatus hernia (6 years before) and a recent (4 months) unremarkable vaginal delivery. Due to the persistence of a pelvic pain after the delivery, she had been taking pain-killers as a self-administered medication. A CT scan showed a massive left pleural effusion and a complete herniation of the stomach into the left hemithorax. After placing a chest drainage and removing up to 3000?ml of brownish purulent fluid, a repeat CT scan (with water soluble contrast swallow) showed a leak at the level of the stomach. At surgery, we observed a complete intrathoracic herniation through a large diaphragmatic hiatal defect and a small well-defined gastric ulcer. A primary repair of both the stomach and the diaphragm was performed. We take the opportunity presented by this report to briefly discuss the patho-physiological mechanisms underlying this unusual complication.     

Right diaphragmatic iatrogenic hernia after laparoscopic fenestration of a liver cyst: report of a case and review of the literature

Iatrogenic right diaphragmatic hernia is very rare. We report the first case of a patient who had a diaphragmatic hernia after laparoscopic fenestration of liver cyst. A herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Diaphragmatic hernias are not as common as the traumatic type. Surgeons can easily miss diaphragmatic injuries during the operation especially after laparoscopy. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. Ct scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients. The incidence of iatrogenic diaphragmatic hernia after surgery may be reduced if the surgeon checks for the integrity of the diaphragm before the end of the operation. A review of the literature is also performed regarding this rare complication.     

Recurrent paraesophageal hernia due to diaphragm rupture: a case report

A 58-year-old male patient was operated for complaints of dysphagia, anemia and retrosternal discomfort due to a type II hiatal hernia. A complete hernia sac excision and posterior crural repair was performed laparoscopically with support of the da Vinci™ robotic system. An antireflux procedure was not performed because of the absence of gastroesophageal reflux disease. Nine months after surgery the patient presented with recurrent complaints of dysphagia and retrosternal pain. Barium esophagram series revealed a recurrent paraesophageal hernia which was confirmed on esophagogastroscopy. A robot-assisted re-laparoscopy was performed. Left to the still intact hiatoplasty of the original operation a tear in the diaphragm, through which part of the stomach covered with peritoneum had herniated, was encountered. The hernia sac was excised, the diaphragmatic defect closed and reinforced with an expanded polytetrafluoroethylene strip of 5×8 cm. After surgery the patient recovered quickly, oral intake was resumed on the first postoperative day and the hospital stay was 3 days. The use of prosthetic mesh to reinforce the hiatoplasty and the addition of an antireflux procedure after hiatal hernia repair are ongoing controversial aspects of hiatal hernia repair. Reports on laparoscopic redo surgery for recurrent diaphragmatic hernia are limited and will be addressed in this case report, in perspective of the aforementioned controversial components.     

Pneumothorax at menses caused by concomitant diaphragmatic endometriosis and a leaking bulla: a case report

Menses-associated pneumothorax has largely been attributed to thoracic endometriosis. We report a case of a 37-year-old woman who presented with a right pneumothorax during menses and was found, on thoracoscopy, to have diaphragmatic endometriosis causing fenestrations in the tendinous diaphragm and a pulmonary bulla. A water-seal test demonstrated an air leak from the bulla. The patient then underwent a video-assisted thoracoscopic resection of the bulla and the involved portion of the diaphragm. Pathologic examination of diaphragmatic lesions demonstrated endometrial glands. The patient was treated with chemical pleurodesis and hormonal suppression of her endometriosis. She is currently symptom-free at 12?months of follow-up.     

Chilaiditi-Syndrom mit subdiaphragmal perforierter Appendizitis

We report on a case of an 80-year-old female patient who presented to the emergency room of with right upper quadrant abdominal pain since the day before. During the initial diagnostic an abdominal x-ray study revealed an air-filled colonic section of the bowel under the right hemidiaphragm corresponding to Chilaiditi??s sign. The clinical symptoms and laboratory results were mild at this time. After 12?h the patient developed right upper quadrant peritonitis due to a perforated, subdiaphragmatic appendicitis based on Chilaiditi??s syndrome. During surgical treatment the cecum and parts of the ascending colon were found to be interposed between the liver and right hemidiaphragm. A right hemicolectomy was performed which led to complete recovery of the patient. In addition to presenting this interesting case this article highlights the regime of the diagnostics and therapy of a complication of the very rare condition of Chilaiditi??s syndrome.     

Adult Bochdalek hernia with volvulus of the stomach

We report a rare case of Bochdalek hernia, congenital posterolateral diaphragmatic hernia with volvulus of the stomach, in an adult A 74-year-old man was admitted to our hospital complaining of sudden abdominal pain and vomiting. Roentgenologic examination of the chest showed air above the left diaphragm, and the mediastinum was displaced to the right. Upper gastrointestinal series revealed volvulus of the stomach in which the pylorus was displaced to the left. The surgical repair was done through left thoracotomy with combining laparoscopy and thoracoscopy without surgical complications, 1 year later the patient is asymptomatic.