Massive symptomatic right-sided Bochdalek hernia in an adult man

A 22-year-old man presented to a rural hospital in Australia with right-sided pleuritic chest pain, right shoulder pain and dyspnoea. The patient had been receiving chronic asthma therapy without improvement. CT of the chest was performed after an abnormal X-ray, incidentally revealing one of the largest documented right-sided diaphragmatic hernias, with left lung compression due to mediastinal shift. The patient was definitively managed with thoracotomy alone. The contents of the hernia sac included colon and multiple loops of small bowel with a 10 cm neck. Definitive treatment was achieved with significant reduction in hernia size and formation of a neo-diaphragm with composite mesh. The postoperative period was complicated only by a wound infection. Two weeks after discharge the patient remained clinically well. Repeat chest X-ray showed no recurrence of the hernia. Congenital diaphragmatic hernias should be considered in patients with ongoing respiratory symptoms. Thoracotomy provides a safe approach.