A spontaneous adult right-sided Bochdalek hernia containing perforated colon

A 37-year-old woman was admitted to a district general hospital with a five-day history of shortness of breath, vomiting and right upper quadrant and right shoulder tip pain. She was passing flatus but had not opened her bowels for five days with no relevant previous history, except a previous uneventful pregnancy by vaginal delivery three years previously. On examination she was tachycardic (110 bpm), normotensive and had saturations of 95% on 4 L of oxygen. Abdominal examination was unremarkable. Laboratory tests revealed: Hb 12.0 g/dl, WCC 18600/mm, CRP 453 mg/L, Bilirubin 46 μmol/L. An arterial blood gas demonstrated: pH 7.452, p02 10.4, Lactate 1.0 and B.E –3.7. No clear clinical diagnosis was made. Computed tomography (CT) performed two days later showed herniation of the right colon through a posterior defect in the right hemi-diaphragm with free gas in the thorax and abdomen suggesting perforation (Figures 1 and 2). The patient was transferred the same evening to our teaching hospital surgical unit for specialist care with a temperature of 37.5 ̊C, tachycardia 125 bpm, respiratory rate of 30/min and saturations of 98% on 35% of oxygen. Respiratory examination revealed absent breath sounds in her right chest. Immediate combined thoracotomy via a right thoracotomy incision and midline laparotomy revealed significant faecal contamination of the chest, a 4-cm Bochdalek hernia with a necrotic perforated right colon in the chest. No sac was found and the colon was reduced. The lung was debrided and decorticated. The necrotic bowel was resected and an ileocolic side to side primary stapled anastomosis was performed. The chest and abdomen were thoroughly lavaged with over 20 L of saline. A primary suture repair of the diaphragmatic defect was performed, both per abdomen and reinforced from the thorax, and chest drains were placed. After two days in intensive care, the patient made an uneventful recovery. At six-month follow-up, the patient was well and with no evidence of hernia recurrence on surveillance CT.