COMBINED LAPAROSCOPIC REDO BOCHDALEK HERNIA AND HIATAL HERNIA REPAIRS

Objectives: A 43-year-old patient with a history of GERD and diaphragmatic hernia repair in 2013 presented to our clinic in 2021 with recurrent symptoms. He complained of epigastric pain that was particularly worse after eating. Preoperative workup with a CT demonstrated a left-sided Bochdalek hernia containing the majority of the stomach.

Methods: We planned a laparoscopic operative repair for his recurrent hernia and recorded our operation with instructive intent.

Results: We utilized a four-port approach, utilizing a 10 mm port 15 cm below the xiphoid process and to the left of midline for our camera, and with two additional 5 mm ports and a 12 mm port for laparoscopic instruments. First, omental adhesions from the prior repair site at the diaphragm were taken down. We then reduced the stomach from the diaphragmatic defect. At this point, we identified both a large Bochdalek hernia as well as a small hiatal hernia. We elected to close both sides of the Bochdalek hernia toward the middle using interrupted, pledgeted sutures with intracoporeal knot tying. Our closure appeared to be under no significant tension and therefore a mesh was not placed. We then performed an anterior closure of the hiatus using a single interrupted suture.
Our patient experienced an uneventful postoperative course. His symptoms improved and his pain was well-controlled. He has not had recurrence of symptoms after eight months of follow-up.

Conclusion: Bochdalek hernias are an uncommon finding in adult patients. There is not a clear recommendation for the use of a primary repair vs mesh placement, but rather varies depending upon the anatomic circumstance for each patient. Recurrent Bochdalek hernias are particularly rare, occurring with rates of only 1-2%. Our repair for this patient, in combination with a hiatal hernia repair, represents a very unique surgical approach.