Thoracoscopic Repair of Left Bochdalek Hernia

This video will demonstrate thoracoscopic repair of a bocdele or posterolateral diaphragmatic hernia. The patient is a 14-month-old boy who presented with 3 days of fever and cough. A chest X-ray showed no evidence of pneumonia, but revealed a large diaphragmatic hernia with bowel loops seen both anteriorly and posteriorly on the lateral film. A CT scan was performed to elucidate whether the hernia was an anterior or morgangny type versus posterior or boctallic type. The scan clearly showed a posterolateral defect with herniation of most of the bowel loops. A thochoscopic approach was used for repair 2 weeks after resolution of the acute illness. The positioning and port sites for the procedure are shown here. An insufflation pressure of 6 millimeters of mercury and a flow rate of 2 L per minute are used. Herniation of the small and large bowel can be seen. A 5 millimeter strep throat car is inserted anteriorly. And a similar trocar is inserted posteriorly. The colon is reduced first. Followed by bimanual reduction of the small bowel using two atraumatic graspers. Full reduction has been achieved. One can see that the anterior rim of the defect is free, while the posterior rim is adherent to a partial hernia sac. These adhesions are therefore divided with a hook cautery to free up the posterior rim and achieve full reduction. This is most important at the posterolateral margin, where most recurrences occur. The lateralmost stitch is placed first. The needle is introduced through the chest wall, takes a bite of the anterior rim, then a good bite of the posterior rim, exiting the chest wall on the inferior side of the same rib. The suture is tied extracorporeally after passing the needle back to the entry site. This anchors the lateral repair around the rib. One can see that completion of this stitch nicely outlines the remainder of the defect. Additional interrupted tuoethebo sutures are then placed to approximate the defect and tied extra corporeally. The most medial suture is placed. A final suture is placed in a small gap in the medial aspect. The patient was discharged the following day. His chest x-rays immediately after the operation and at his four-year follow-up are shown here. An intact repair is seen with no signs of recurrence.