RIGHT-SIDED BOCHDALEK HERNIA IN ADULT ASSOCIATED WITH CHOLESTATIC SYNDROME: CASE REPORT

INTRODUCTION

The congenital diaphragmatic hernia (CDH) is defined as an anatomical defect on diaphragm, which permits the herniation of abdominal viscera into the thorax⁴. The hernia occurs due to an incomplete occlusion of the pleuroperitoneal channel during the embrionary period. The main cause of the incomplete closure can be a genetic mutation, a teratogen or both.

In terms of anatomic location, the CDH can be classified as Bochdalek type when an incomplete pleuroperitoneal channel occlusion is found posterolaterally; as Morganni type, while the defect is seen retrosternally; and yet as a congenital transhiatal esophagic type hernia. Among them, the Bochdalek type is the most common, found in 78-90% of patients; the Morganni type, in 1,5-6% of cases; and transhiatal, 14-24%¹¹.

In most cases, the clinical impact occurs in the neonatal period, since only 10% of hernias are diagnosed after this period⁷. In neonates, the clinical presentation is acute, providing a higher morbidity and mortality. In adulthood, symptoms, if any, are more insidious, vague and intermittent, affecting not only the pulmonary dynamics, but also the gastrointestinal function⁵.

Chest X-ray and CT scan may be used^2,8,12.Nevertheless, CDH findings are incidental when performing radiological examinations for other reasons, with the right-sided Bochdalek hernia accounting for 68% of cases.^9,13

In elective situations, the minimally invasive surgery, either via laparoscopic or thoracoscopic can be used, but with limited application in cases of right-sided hernia^3,8. Minor defects, technically easier to fix, can be sutured normally; in the case of larger apertures, or even hemidiaphragmatic agenesis, the use of nonabsorbable polypropylene mesh is the only solution.