Although the initial records of diaphragmatic hernia date back as far as the 1690s [
6], the improper fusion of the postero-lateral foramina of the diaphragm was first described by Bochdalek in 1848 [
7,
8]. The true incidence of asymptomatic Bochdalek hernia remains unknown and ranges from 1/7,000 to 6% [
7,
9]. There is also reported predominance on the right side in asymptomatic cases [
2]. Undiagnosed patients may never be identified as having Bochdalek hernia [
2]. The left-sided presentation in our patient is in accord with the majority of cases reported in the literature. During the formation of the diaphragm, the pleural and coelomic cavities remain in continuity by means of the pleuroperitoneal canal. The posterolateral communication is the last to be closed by the developing diaphragm. Failure of the diaphragmatic development leaves a posterolateral defect symptomatic mostly on the left side. The defective closure of the pleuroperitoneal canal leads to three types of congenital hernias: the posterolateral (Bochdalek hernia), anterolateral and pars sternalis. The posterolateral subgroup accounts for 81% of these congenital diaphragmatic hernias [
10]. Most of the Bochdalek hernias are diagnosed in children who present with pulmonary symptoms [
6,
7,
11]. Since Bochdalek hernia in an adult is an asymptomatic condition, it is usually an incidental finding which makes its incidence difficult to be estimated. These can sometimes present with vague chest and gastrointestinal symptoms [
6,
11]. The predominance of the left side in symptomatic cases both in neonates and adults may be due to narrowing of the right pleuroperitoneal canal by the caudate lobe of the liver [
12]. Another reason may be that the right pleuroperitoneal canal closes earlier. According to a recent report in 2002, there are only seven symptomatic cases involving the right hemidiaphragm in the literature [
13]. The hernial size varies and the content of the hernial sac may differ from each other in every age group. Hernias on the left side may contain intestinal loops, spleen, liver, pancreas, kidney or fat. Colon in a Bochdalek hernia is a rare condition and usually found in the left-sided hernias as was also the case in our patient [
7,
14]. A medline search for cases of colon in a BH revealed about 32 cases (Table
1) [
15‐
39]. A coexisting hernial sac has also been reported in 10–38% of the cases according to large series [
7]. Some authors believe that long-term survival may be due to the persistence of a pleuroperitoneal sac (hernial sac) and that the rupture of the sac in adult life may trigger the characteristic symptoms [
40]. There was no hernial sac in our patient. Drugs such as thalidomide or antiepileptics administered during pregnancy i.e. before the closure of the pleuroperitoneal canal before 9th to 10th weeks' gestation along with the genetic predisposition have been incriminated as the etiological factors. A congenital diaphragmatic hernia can be accompanied by other congenital anomalies in 25–57% and by chromosomal disorders in 10–20% of cases [
10]. Our patient did not have any obvious congenital anomaly. Bochdalek hernias may show up on chest X-rays as air and fluid-filled viscera in the hemithorax, as in our case. Associated mechanical obstruction may be obvious on plain X-ray imaging. Contrast-enhanced computed tomography (CT) has been an increasingly important investigation method in assessment of acute presentation which was not used in our case. The rare finding of a dilated bowel above the hemidiaphragm makes the diagnosis obvious. Other investigations including upper gastrointestinal contrast studies can exclude malrotation [
41]. Gastrointestinal contrast studies could not be done since our case was an emergency situation. A delayed or missed diagnosis of diaphragmatic hernia can lead to significant morbidity and mortality [
42]. The diagnosis of Bochdalek hernia in adults is not easy, and on a couple of occasions has been misdiagnosed as pneumothorax and managed initially by a chest tube drainage resulting in feculent discharge from the chest and delayed discovery of hernia [
5,
43]. Management of a Bochdalek hernia includes reducing the abdominal contents and repairing the defect through a laparotomy or thoracotomy. The best approach for management of hernias occurring on the left side is controversial. Those who advocate a thoracotomy claim about the improved ability to separate adhesions between thoracic viscera and the hernial sac [
42]. Those in favour of a laparotomy believe that the abdominal approach is superior to thoracotomy for the recognition and management of a possible concomitant malrotation and for dealing with visceral complications such as obstruction or strangulation [
44]. Oliveira et al. favour a combined approach (laparotomy plus thoracotomy) for the right-sided cases to facilitate the replacement of the herniated viscera and to close the diaphragmatic defect to overcome the mass effect of the liver [
45]. Our patient underwent an emergency laparotomy because of the presence of hollow viscus perforation with peritonitis. In the postoperative period, complications like abdominal compartment syndrome have been reported in literature following repair of an adult Bochdalek hernia [
46,
47]. The overall mortality in BH is around 12%. It is higher following emergency laparotomies (32%) than after elective surgery (3%) [
48]. More recently, successful laparoscopic [
49] and thoracoscopic repairs of the left sided Bochdalek hernia have both been described [
5,
50]. Some authors have also described hand assisted thoracoscopic repair of Bochdalek hernia [
51]. Minimal invasive surgery is reported to be ideal for Morgagni defects, with a success rate of 90.9% with only one recurrence in a series, whereas it cannot be recommended in newborns with Bochdalek hernia because of high failure rates. It can be and should be considered for adults since the success rate increases with increasing age [
52]. As our patient was operated on in a surgical emergency set-up caused by intestinal obstruction and hollow viscus perforation, a laparoscopic intervention was not possible.
Table 1
Summary of cases of Bochdalek hernia involving colon published in literature
15 | 1 | 76 y | M | Dyspnoea/intestinal obstruction | Right | Strangulation of a portion of transverse colon | Resection-anastomosis; primary repair |
16 | 1 | 45 y | F | Pain abdomen | Right | Volvulus of colon | Right hemicolectomy; Primary repair |
17 | 1 | 3 days | M | Respiratory distress | Right | Herniated small bowel, colon and liver | Thoracoscopic patch repair |
18 | 1 | Young | M | Abdominal pain | Left | Incarcerated colon | Primary repair |
19 | 1 | 42 y | F | Abdominal pain, post prandial vomiting | Left | Sealed perforation of colon | Combined thoracoscopic and laparoscopic repair |
20 | 1 | 16 y | M | Vomiting | Left | Stomach, spleen, part of the small intestine and colon in left hemithorax. | Primary repair |
21 | 1 | 6 m | M | Bilious vomiting | Left | Herniated stomach, small intestine, part of colon and spleen | Laparoscopic repair |
22 | 1 | 35 y | F | Intestinal obstruction | Right | Herniated colon with concurrent appendicitis | Appendicectomy, primary repair |
23 | 1 | 2 y | M | Recurrent pulmonary infections | Right | Dilated colon loops and right kidney | Thoracotomy, primary repair |
3 | 1 | 21 y | M | -- | Left | Colonic necrosis | Resection anastomosis; primary repair |
5 | 1 | 46 y | F | Abdominal pain, vomiting | Left | Colonic perforation (following chest tube insertion) | VATS combined with laparotomy; resection anastomosis with primary repair |
24 | 1 | 25 y | F | -- | Left | Herniated stomach, transverse colon, spleen | Laparoscopic repair |
25 | 1 | 41 y | F | Abdominal pain, vomiting | Left | Herniated stomach, transverse colon, spleen | Primary repair |
26 | 1 | -- | -- | -- | Right | -- | -- |
13 | 1 | 63 y | F | Abdominal pain, dyspnoea | Right | Strangulated colon; kidney | Resection anastomosis; primary repair |
27 | 1 | Adult | F | Pain abdomen | Left | Gastric volvulus; colon | Laparoscopic repair |
28 | 1 | 9 y | F | Cough, vomiting, anorexia | Right | Colon | Primary repair |
29 | 2 | Infants | | Cough, vomiting | Right/Left | Colon, small intestine and stomach | Primary repair |
30 | 1 | 49 y | F | Chronic cough | Left | Small intestine, colon | Hand assisted thoracoscopic prolene mesh repair |
31 | 1 | 38 y | F | Abdominal pain, nausea | Left | Incarcerated transverse colon | Thoracotomy, primary repair |
32 | 2 | 9 y | F | Abdominal pain, vomiting | Left | Small intestine, colon and stomach | Thoracotomy, primary repair |
| | 35 y | M | Dyspnoea | Left | Small intestine, colon and stomach | Thoracotomy, primary repair |
33 | 1 | 53 y | M | Intestinal obstruction | -- | Obstructed colon | Primary repair |
4 | 1 | 1 y | F | Fever, left pleural effusion, vomiting | Left | Colonic hernia | Primary repair |
34 | 1 | 17 y | F | -- | Left | Stomach, colon; hemorrhage | Primary repair |
43 | 1 | 70 y | M | Dyspnoea | Left | Perforated colon following thoracic drain insertion | Combined thoracotomy and laparotomy; primary repair and colostomy |
35 | 1 | 70 y | F | Abdominal pain, right chest pain | Right | Colopleural fistula due to Strangulated colon | Colostomy; primary repair |
36 | 1 | 40 y | M | Mild nonspecific left chest pain | Left | Patient declined surgery | |
37 | 1 | 5 y | M | Asymptomatic | Right | Stomach, colon | Primary repair |
38 | 1 | -- | F | Abdominal pain, vomiting | -- | Incarcerated colon | Primary repair |
39 | 1 | 5 y | M | Dyspnoea, abdominal pain | Left | Herniated colon | Primary repair |