Massive Bochdalek Hernia in an Adult Presenting With Cardiac Arrhythmias: A Case Report

Adult Bochdalek hernia is a rare and often misdiagnosed congenital diaphragmatic anomaly that poses significant clinical risks due to the potential for visceral incarceration and strangulation. We report a case of a 20-year-old female patient with no prior medical history who presented with non-specific arrhythmias, an atypical clinical onset that led to the identification of a massive left-sided diaphragmatic hernia. Diagnostic imaging, specifically multidetector computed tomography, confirmed migration of the stomach, spleen, and bowel loops into the thoracic cavity, associated with pulmonary hypoplasia. The patient underwent an exploratory laparotomy, which revealed a 10-cm posterolateral diaphragmatic defect. Surgical management included hernia reduction, splenectomy due to vascular pedicle laxity, and diaphragmatic repair using a polytetrafluoroethylene prosthesis. Given the massive visceral volume and the resulting loss of abdominal domain, a staged surgical strategy with an open abdomen and negative pressure wound therapy was employed, ultimately achieving definitive closure with a split-thickness skin graft. This case underscores the diagnostic challenge posed by Bochdalek hernia in the adult population and highlights the importance of maintaining a high index of suspicion in the presence of atypical thoracic symptoms. Furthermore, it demonstrates that a timely, multidisciplinary approach involving advanced surgical techniques is essential to manage complications such as loss of abdominal domain and to ensure a favorable long-term prognosis.