Thoracoscopic Repair of Left Bochdalek Hernia

The patient is a 14-month-old boy who presented with 3 days of fever and cough

Chest X-ray showed no evidence of pneumonia but revealed a large diaphragmatic hernia with bowel loops seen both anteriorly and posteriorly on lateral film

CT scan clearly showed a posterolateral defect with herniation of most of the bowel loops

A thoracoscopic approach was used for repair 2 weeks after resolution of the acute illness

An insufflation pressure of 6 millimeters of mercury and a flow rate of 2 L per minute are used for thoracoscopic Bochdalek hernia repair

The colon is reduced first, followed by bimanual reduction of the small bowel using two atraumatic graspers

The anterior rim of the defect is free, while the posterior rim is adherent to a partial hernia sac

Adhesions are divided with hook cautery to free up the posterior rim and achieve full reduction, most important at the posterolateral margin where most recurrences occur

The lateralmost stitch is placed first, with the needle introduced through the chest wall taking a bite of the anterior rim then 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, anchoring the lateral repair around the rib

Additional interrupted sutures are placed to approximate the defect and tied extracorporeally

The patient was discharged the following day after thoracoscopic Bochdalek hernia repair

Chest X-rays immediately after operation and at four-year follow-up showed intact repair with no signs of recurrence