PMC8639588_01
(A) Computed tomography (CT) scan (coronal plane) of the chest and upper abdomen showing elevated right hemi-diaphragm (arrowhead), right-sided diaphragmatic herniation of ascending colon (star), and mediastinal shift to the left side (arrow). (B) CT scan (axial plane) of the chest showing herniated right-sided ascending colon (star), pleural effusion (arrowhead), and mediastinal shift to the left side (arrow). (C) Intra-operative abdominal situs showing the right posterolateral defect (arrow) of the bulged diaphragm (star) with herniation of the ascending colon (arrowhead). (D) Intra-operative situs showing the colon perforation (arrow).
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F1
Computed tomography (CT) imaging was added and showed a right-sided Bochdalek hernia with right-sided lung compression, pleural effusion on the right, and mediastinal shift to the left (Figures 1A,B). A 2 cm right posterolateral diaphragmatic hernial orifice containing an incarcerated and partially necrotic loop of the ascending colon without any intraabdominal signs of infection was detected (Figure 1C). Right-sided hemicolectomy and a side-to-side anastomosis from the ileum to the transverse colon was necessary due to intestinal ischemia and colon perforation (Figure 1D).
(A,B) Computed tomography (CT) scan [axial (A) and coronal plane (B)] of the chest showing pleural effusion rim enhancement (arrow) with distributed gas (arrowhead) suspicious of pleural empyema. (C,D) Intra-operative thoracic situs showing the pleural empyema (star) before (C) and after (D) intrathoracic lavages were performed.
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F2
As laboratory infection signs remained elevated and the patient became febrile a further thoracic CT scan was performed, which showed increasing rim enhancement now suspicious of pleural empyema (Figures 2A,B). Due to solid pleuritic formations this approach had to be converted to open thoracotomy following empyema (stage II-III) evacuation (Figures 2C,D) and right-sided pleural decortication.
(A,B) Posteroanterior (A) and lateral (B) chest X-ray one month after right-sided Bochdalek hernia repair and empyema evacuation. A right-sided pleural effusion (arrowhead) and opacity due to basal hypoventilation (star) accompanied by a moderate elevation of the right hemidiaphragm without any signs of hernia recurrence can be detected. (C,D) Posteroanterior (C) and lateral (D) chest X-ray one year after right-sided Bochdalek hernia repair and empyema evacuation. No signs of hernia recurrence and only a slight right-basal hypoventilation (star) can be detected.
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F3
No signs of residual empyema or hernia recurrence were detected (Figures 3A,B). Follow-up clinical examination and chest X-ray one year after initial surgical repair of right-sided Bochdalek hernia did not show any signs of recurrence and only slight right-basal hypoventilation (Figures 3C,D).
Timeline of pre-operative workup, hospitalization, and follow-up. Computed tomography (CT), video-assisted thoracoscopy (VATS).
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F4
The summary of the preoperative workup, hospitalization, and follow-up is shown in Figure 4.