Up to the chest in bowels: case of strangulated right diaphragmatic hernia with paraesophageal hernia in a non-trauma patient

TL;DR

A 78-year-old woman had a rare right-sided diaphragmatic hernia with bowel strangulation and a paraesophageal hernia, requiring emergency surgery.

Contribution

This case report presents a rare atraumatic presentation of a right-sided congenital diaphragmatic hernia with strangulated small bowel in an elderly patient.

Findings

The patient had a right-sided posterolateral diaphragmatic hernia with strangulated small bowel and a type 4 paraesophageal hernia.

Emergency surgery included resection of the strangulated bowel, enteroenterostomy, hernia repair, and gastropexy.

The patient recovered well post-surgery and was discharged to a skilled nursing facility.

Abstract

A Bochdalek hernia is a rare congenital diaphragmatic hernia often diagnosed in infancy and classically occurring on the left side. We report a case of a 78-year-old female who presented with a right-sided posterolateral diaphragmatic hernia containing multiple loops of bowel with evidence of ischemia as well as a type 4 paraesophageal hernia. The stomach was rotated on the organoaxial plane, and the duodenum was within the mediastinum. The patient was taken emergently for an exploratory laparotomy. A posterolateral hernia defect containing 50 cm of strangulated small bowel was identified and resected, a primary stapled enteroenterostomy was performed and the hernia defect was repaired primarily. The stomach was reduced, a primary crura repair was performed, and gastropexy was performed with a gastrojejunostomy tube. The patient was transferred to the intensive care unit, and subsequently extubated, enteral feeds were initiated, and had anticipated discharge to a skilled nursing facility. This case highlights an uncommon atraumatic presentation of an adult with a congenital diaphragmatic hernia. Its rarity is further denoted due to its right-sided laterality and strangulated small bowel as the usual herniated abdominal organs are the liver or colon.

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