PMC6157200_01
Coronal CT scan showing the massive transdiaphragmatic herniation of abdominal viscera in the left hemithorax. (a) The gastric conduit on the right of the herniated viscera (arrow). (b) The left hemithorax totally occupied by the abdominal viscera.
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After achieving satisfactory haemodynamic stability with high flow oxygen and iv fluid therapy, a CT scan with contrast was performed which documented the near-complete herniation of the small bowel, transverse colon, and greater omentum through a large defect (8.5 x 5 cm) of the left hemidiaphragm, resulting in ipsilateral massive lung collapse (Figure 1).
Intraoperative view of the diaphragmatic hernia. (a) The gastric conduit is visible to the right of the herniated viscera (arrow); (b) after the reduction of the hernia content, the diaphragmatic defect, the left lung (arrow), and the spleen (arrowhead) are clearly visible; (c) the diaphragmatic defect repaired by direct suture.
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The entire hiatal anatomy was initially hidden by the herniated small bowel and transverse colon, which were gradually reduced into the abdominal cavity with progressive gentle traction (Figure 2(a)). The left diaphragmatic pillar was not recognizable, and there was no evidence of hernia sac and diaphragmatic pleura (Figure 2(b)). The hernia orifice was primarily closed by approximating its anterior and posterior borders through a series of interrupted nonabsorbable stitches (0-Ethibond  , Ethicon, Somerville, NJ, USA) (Figure 2(c)).