PMC6664163_01
Whole-body non-contrast CT scan (scout view): detection of left-sided posterior diaphragmatic hernia involving transverse colon.
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The next CT scan detected instead a left-sided posterior diaphragmatic hernia involving transverse colon (Fig. 1), although no sign of bowel obstruction or strangulation appeared.
Whole-body oral-contrast CT scan (coronal view with pulmonary window).
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Hence, a further thorax-abdomen oral-contrast CT scan was request (Fig. 2) and confirmed our previous suspect.
Double diaphragmatic injury.
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At first we performed a laparoscopic assessment of intra-abdominal organs, after that we noted a double diaphragmatic injury (Fig. 3) (retrocostal-xiphoid and left-sided postero-lateral).
Left-sided postero-lateral hernia.
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On the other hand, the left-sided postero-lateral injury was bigger (width: 8 cm - AAST grade III) with the edges looking fibrotic (Fig. 4) and the greater omentum, the stomach and the transverse colon were displaced inside.
Defects repaired with non-absorbable polypropylene suture.
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Thus we repaired the defects with non-absorbable polypropylene suture (Prolene  2-0, Ethicon Inc., Somerville, USA) in a running fashion (Fig. 5).
Polypropylene mesh with titanized surface (TiMesh strong , PFM Medical AG, Cologne, Germany) attached to the diaphragm.
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Inc., Somerville, USA) in an interrupted fashion (Fig. 6). In the end we achieved emostasis and inserted a 28 Fr drainage in the splenic lodge.