Clinical and Medical Case Reports

Case: A 29y old male presents with intermittent low retrosternal pain and progressive dyspnea with exercise since a couple of months. Cardiac investigation was negative and gastroscopy showed a grade B esophagitis. He was treated medically but with only partial response. On a thoraco-abdominal CAT-scan the diagnosis of a left sided Bochdaleks’ hernia was made. The hernia includes the left kidney (with blood vessels and ureter), transverse colon and small intestine which are positioned in the left lower thoracic cavity with the left lung considerably compressed.

Method: Given the clear correlation between the patients’ complaints and these anatomical findings, he was referred to our service of abdominal surgery.

 

We performed a laparoscopy with the patient in lithotomy position and the surgeon between the legs. The patient was tilted to his right side. Mobilization of the spleen was necessary to gain maximal access to the hernia. We were able to reduce all the herniated content, freed the margins of the defect, reduced the hernia sac and repositioned the kidney intra-abdominally. The defect was manually closed with non-resolvable stitches and covered with a mesh which was secured with tackers.

 

Result: Postoperatively the patient recovered well with adequate pain relief and pulmonary support. He could leave the hospital after 6 days. Control CAT-scan on day 5 postoperatively shows an intact lining of the diaphragm with normal positioning of the intra-abdominal organs. On follow-up 6 weeks after surgery the patient had regained normal activities and was symptom free.

 

Conclusion: A symptomatic left sided Bochdaleks’ hernia in adults with an ectopic intrathoracic kidney is extremely rare. We hereby state that, during a laparoscopic repair, the kidney can also be safely reduced, which has almost never been described in literature yet, enhancing pulmonary recovery, improving access for mesh placement and thus diminishing recurrence rate.