松波 光志朗

INTRODUCTION: Bochdalek hernia (BH) is a congenital diaphragmatic hernia that is rare among adults. It is difficult to treat especially with an incarcerated abdominal organ. Although surgery via laparotomy or thoracotomy to repair the hernia with or without mesh reinforcement is the gold standard of treatment for BH, conversion to open surgery is performed to obtain a good surgical view and sufficient working space. Herein, we describe a rare case of BH with incarcerated distal transverse colon treated by hand-assisted laparoscopic surgery (HALS). CASE PRESENTATION: A 74-year-old man visited the outpatient clinic with the chief complaints of anorexia and abdominal distension. Contrast-enhanced computed tomography scan showed incarcerated left diaphragmatic hernia, with the distal transverse colon trapped in the left hemithorax with ischemic change. The patient was diagnosed with large bowel obstruction because of BH. Thus, emergency laparoscopic surgery was performed. However, it was converted to HALS because the colon could not be easily pulled back to the abdominal cavity. The transverse colon was carefully removed without perforation. The surgical course was uneventful, and the patient was discharged 1 week after surgery. CONCLUSIONS: HALS can be used when laparoscopic surgery is difficult.

BACKGROUND: Small mesenteric hiatal hernias (SMHHs) are defined as a small group of internal hernias (IHs) that frequently diagnosed in children. However, SMHHs are relatively rare in adults. Bowel loop herniation via an abnormal mesenteric defect can lead to strangulated intestinal obstruction. Congenital SMHHs are commonly observed in pediatric patients, with some cases involving neonatal death. CASE PRESENTATION: A 24-year-old healthy male patient visited our hospital with a 2-day history of a sudden onset lower abdominal pain. He was initially diagnosed with enteritis. However, his symptoms worsened, and he was brought to our hospital. Contrast-enhanced computed tomography (CT) scan showed formation of a closed loop in the small intestine within the pelvis and signs of ischemia. As the patient was diagnosed with small bowel obstruction (SBO) caused by IH, emergency laparoscopic surgery was performed to loosen the obstruction. The patient was found to have ascites and small-bowel necrosis. A part of the small intestine that measured 30 cm was strangulated via a large-diameter defect (17 × 11 cm) in the ileal mesentery. Via a small abdominal incision, the necrotic bowel was resected, and the mesenteric defect was repaired. CONCLUSION: SMHHs are rare in adults, and they should be considered as potential causes of strangulated intestinal obstruction in adults without a history of laparotomy or trauma.