adult onset diaphragmatic hernia ( dh ) is a rare condition with variable clinical manifestations . traditionally , dh is repaired by laparotomy or thoracotomy , or both . with the recent advent of minimally invasive surgery , herein , we report a case of adult onset diaphragmatic hernia that was successfully repaired via laparoscopy . a 27-year - old female presented with a 4-day history of epigastric discomfort , which was associated with repeated vomiting . physical examination and laboratory the initial chest radiograph on admission showed a large air - fluid level in the left thoracic cavity ( figure 1 ) . the patient received no nourishment by mouth , and the stomach was decompressed by nasogastric tube aspiration . computed tomography ( ct ) of the thorax and abdomen revealed disruption of the left diaphragm with herniation of the stomach and small intestine into the left thoracic cavity , and also a left lower lobe atelectasis was present . a contrast meal and follow - through revealed a wide - neck left diaphragmatic defect with herniation of the stomach ( the fundus and body ) and also the splenic flexure of the large bowel . oral contrast and follow through study showed herniation of abdominal contents into left thoracic cavity with no mechanical obstruction . laparoscopic repair of the diaphragmatic hernia was performed with the patient under general anesthesia and placed in the lithotomy position . nearly all of the stomach , the entire spleen , part of the small bowel , the splenic flexure of the colon and its omentum had herniated though this defect ( figure 3 ) . only mild intrathoracic adhesion was present , and the herniated contents were reduced to the abdomen without difficulty . the repair defect was buttressed by a gore - tex dualmesh ( gore - tex dualmesh , w. l. gore & associates , inc , usa ) , which was secured with tacker helical fasteners ( tyco health care , ltd , usa ) ( figure 4 ) . a chest drain was inserted to the left thoracic cavity at the end of the procedure . minimal intraoperative bleeding occurred , and the total duration of the operation was 95 minutes . laparoscopic view showed herniation of spleen , stomach , part of small bowel and splenic flexure of colon through the diaphragmatic defect . laparoscopic view showed the diaphragmatic defect repaired and buttressed with gore - tex dualmesh secured by helical staples the nasogastric tube was removed the day after the operation . a chest radiograph showed that the left lung was fully re - expanded . only 1 intramuscular injection of 50-mg pethidine was required for pain control . she remained symptom free 1 year after the operation , and no evidence of recurrence exists on chest radiograph . in our case , the chest radiograph with air - fluid level in the left thoracic cavity alerted us to the suspicion of dh , and the diagnosis was subsequently confirmed by ct scan and contrast meal . the diaphragmatic defect of our patient was located at the dome of the left diaphragm , which differed from bochdalek 's or morgagni 's type of hernia . the incidence of diaphragmatic injury occurs in up to 7% in those who suffer blunt abdominal / thoracic trauma and in 3% to 15% for those with penetrating injury . other causes of adult dh include delayed presentation of congenital dh ; iatrogenic injury during abdominal or thoracic surgery ; as a consequence of persistent infection ( pneumonia , empyema ) ; and also stress on the diaphragm from straining / coughing have been reported . these patients may present with a spectrum of symptoms and signs , ranging from minor chest / epigastric discomfort as in our case to major respiratory distress and intestinal obstruction from strangulation of the herniated contents . other imaging modalities include upper gastrointestinal contrast study , magnetic resonance imaging , and laparoscopy , all of which have produced variable results . the reported sensitivity of the ct scan in diagnosing diaphragmatic hernia ranges from 33% to 83% . traditionally , dh is repaired with the open method as first reported by riolfi in 1886 . laparoscopy was used to identify traumatic injury of the diaphragm by adamth - waite in 1984 . the debate on whether synthetic mesh or primary closure produce the safest and most durable repair for diaphragmatic hernia has yet to be decided . laparoscopic primary repair of diaphragmatic hernia is technically demanding when the defect communicates with the esophageal hiatus or close to pericardium . the placement of synthetic mesh repair in close proximity to the esophagus runs the risk of erosion . the diaphragmatic hernia sac was left intact in our patient as minimal sac redundancy occurred after primary suturing of the defect . for a sizable hernia sac after reduction , sac ligation followed by excision should be performed to reduce the chance of loculated fluid collection . it has a fascial side , which induces tissue ingrowth and thus results in better tissue fixation . on the other hand , on its peritoneal side it has a low - porosity smooth visceral surface that minimizes visceral adhesion . tension pneumothorax development is a concern for laparoscopic procedures in dh patients with pleuroperitoneal communication . the patient may become difficult to ventilate , which is not correctable by increasing the intrapleural pressure with peep .
adult onset diaphragmatic hernia is a rare condition with variable clinical manifestations . 
 the majority of adult - onset diaphragmatic hernia is associated with trauma . 
 blunt thoracic and abdominal trauma associated with a 5% to 7% incidence of diaphragmatic injury , and in 3% to 15% for those with penetrating injury . 
 these injuries may be left unrecognized when they occur but often are uncovered months later during work up for related symptoms . 
 prompt diagnosis and surgical repair is recommended by most authorities . 
 traditionally , diaphragmatic hernia is repaired by laparotomy or thoracotomy , or both . 
 herein , we report a case of adult onset diaphragmatic hernia presented with dyspepsia that was successfully repaired via laparoscopy . 
 operative approach and technique of diaphragmatic defect closure is elucidated .