Thoracoscopic and laparoscopic repair of complicated Bochdalek hernia in adult.

Bochdalek's hernia is a congenital defect of the diaphragm that occurs predominantly in children. Perforation or necrosis of the involved organ is a feared complication and surgical repair constitutes the gold standard of treatment. We present a case of a 42-year-old female patient who presented with a 3-month history of left-upper-quadrant abdominal pain, nausea, tachycardia, and early postprandial vomit. Physical exploration was remarkable for audible peristalsis in the left hemithorax. Total white blood count was elevated and chest X-rays showed images of intestines in the left hemithorax. Tomography with double contrast reported left colon herniated to thorax. Left thoracoscopy was practised, finding a Bochdalek's hernia with presence of herniated descendent colon with a necrotic area, which was perforated and sealed. The herniated content was returned back in place, the diaphragmatic defect was corrected, and colostomy by laparoscopy was simultaneously performed. Her postoperative recovery was uneventful and she was discharged from the hospital. Combined thoracoscopy and laparoscopic surgery is effective in complicated cases of Bochdalek's hernia in adults, lessening surgical trauma and postsurgical morbidity.

Diminished morbidity and mortality in portal hypertension surgery: relocation in the therapeutic armamentarium.

Although several effective therapeutic options are available for bleeding from portal hypertension, surgery has a well-defined role in the management of patients with good liver function who are electively operated. The aim of this investigation was to evaluate the operative mortality and morbidity of portal blood flow-preserving procedures in a highly select patient population. The records of 148 patients operated on between 1996 and 2000 using one of two techniques (selective shunts or a Sugiura-Futagawa operation [complete portoazygos disconnection]) were analyzed with particular attention to operative mortality, postoperative rebleeding, and encephalopathy. Survival was calculated according to the Kaplan-Meier method. Sixty-one patients had distal splenorenal shunts placed, and 87 patients had a devascularization procedure. Operative mortality for the group as a whole was 1.2%. In the group with selective shunts, the rebleeding rate was 4.9%, the encephalopathy rate was 9.8%, and the shunt obstruction rate was 1.6%. Survival at 24 months was 94% and at 48 months was 92%. In those undergoing devascularization, the encephalopathy rate was 5% and the rebleeding rate was 14%. Survival at 24 months was 90% and at 48 months was 86%. Portal blood flow-preserving procedures have very low morbidity and mortality rates at specialized centers. In addition, a low rebleeding rate is associated with a good quality of life. Low-risk patients with bleeding portal hypertension should be considered for surgical treatment.