A 45-year-old female with no previous history of trauma presented with complaints of postprandial epigastric pain and dyspnea with left-sided chest pain of one-month duration. On examination, there were findings suggestive of left lower zone consolidation Chest x-ray revealed homogeneous left lower zone opacity with effusion and few air pockets with air-fluid levels suggestive of pneumonia.

Her blood counts, haemogram and biochemical investigations were normal. A flexible Oesophago-Gastro-Duodenoscopy (OGD-scopy) was performed. The stomach was seen deviating to the left with segmental narrowing; the pylorus could be seen but could not be negotiated, suggestive of a volvulus. Barium meal follow-through demonstrated a large part of the stomach, small bowel, transverse colon and splenic flexure in the left hemithorax.

The patient was taken up for exploratory laparotomy via a left subcostal incision. The stomach with the distal 2/3 of the transverse colon and the splenic flexure were seen in the left hemithorax. A 5x6cm defect was seen in the posterio-lateral diaphragm; there was no hernia sac.

The defect was closed primarily with No. 1 Nylon and reinforced with a Prolene mesh. The patient has been followed up and is doing well with no symptoms.

A 32-year-old male presented with abdominal pain and breathing difficulty following a large meal also associated with vomiting. He had a history of a similar episode 6 months back, which was relieved with medication. On examination, he was tachypnoeic with tachycardia. There was a tracheal and mediastinal shift to the right side with decreased air entry in the left lower zones with normal breath sounds.

Chest x-ray showed a herniated large-bowel loop in the left hemithorax with an air-fluid level. CT of the thorax demonstrated a completely compressed left lung with mediastinal shift to the right. The stomach and colon were seen in the left hemithorax.

He underwent an upper midline laparotomy and the caecum, ascending colon and parts of jejunum and ileum were seen herniating into the left hemithorax. There was an 8x6cm oval-shaped defect in the left hemidiaphragm, with deficient left crus. The defect was seen extending on to the central tendon. There were dense adhesions between hernial contents and surrounding structures, therefore necessitating a left antero-lateral thoracotomy in the 7th intercostal space. The left lung was seen fully collapsed. The hernial contents could be released and reduced back into the abdomen. The defect was closed with a Teflon patch.

Primary abdominal closure was not possible; therefore, the bowel loops were covered with omentum and peritoneum. A Marlex mesh was placed pre-peritoneally on the posterior rectus sheath and anchored to the anterior rectus sheath. As skin closure was not possible, an opened urosac was sutured to the skin edges with a suction drain in situ.

The patient was kept in ICU on ventilatory support. There was no evidence of abdominal compartment syndrome. The abdominal wound was covered with a sterile plastic sheath with a vacuum drain (Vacuum assisted closure) by the plastic surgeons. It was possible to remove the mesh 45 days later and close the rectus sheath and the skin primarily. At present, the patient is doing well with no complaints. There is a midline scar present with some weakness but there is no incisional hernia.

A 20-year-old male with no history of trauma presented to the emergency department with history of generalized abdominal pain, colicky in nature, along with absolute constipation for 48 hours. There was a history of occasional postprandial epigastric pain and breathlessness and of on-and-off left hypochondrial pain with radiation to the left shoulder.

There was no other significant history. On physical examination, the patient had normal vital signs but was mildly dehydrated. There was left hypochondrial tenderness with decreased air entry in the lower left chest but normal breath sounds. A clinical diagnosis of intestinal obstruction was made. The haemogram, serum electrolytes and renal functions were within normal limits. Abdominal x-ray revealed multiple air-fluid levels confirming intestinal obstruction. Chest x-ray showed presence of dilated bowel loops in the left hemithorax with air-fluid levels.(Figure 1)

Figure 1

An emergency laparotomy was done, via upper midline incision. The large bowel was dilated from caecum to the splenic flexure. The stomach was distended. There was herniation of the splenic flexure, the distal 1/3 of the transverse colon and the greater omentum into the left hemithorax. A defect of 4x3.5cm was present in the left postero-lateral diaphragm. There was a left pleural effusion.

Contents could be easily reduced transabdominally. The defect was closed primarily with 2.0 Prolene. The postoperative period was uneventful. On follow-up, complete re-expansion of the left lung was seen and at present the patient is totally asymptomatic.

A 65-year-old diabetic female with no history of trauma presented to the emergency department with severe dyspnea following a meal. There was no other significant history. On physical examination, the patient’s pulse and blood pressure were not recordable, she was acutely dyspnoeic, but conscious. On auscultation, there were no breath sounds on the left side of the chest and there was gross tracheal shift to the right side with a hyper-resonant note on percussion.

An urgent chest x-ray was taken and showed an air-filled cavity in the left hemithorax causing a mediastinal shift to the right. A diagnosis of tension pneumothrax was made. An intercostal drainage tube was immediately placed into the left pleural cavity. No air was drained. However, pulse and blood pressure was now recordable. The chest x-ray was repeated to confirm the position of the chest tube. The air-filled cavity was seen to persist in the left hemithorax. A nasogastric tube was placed and drained bile-stained fluid. A repeat chest x-ray showed the nasogastric tube coiled up in the left side of the chest (Figure 2); therefore, a diagnosis of a diaphragmatic hernia was made. The haemogram, serum electrolytes and renal functions were within normal limits. The patient had mild acidosis. CT of the thorax was done and confirmed a posterolateral diaphragmatic hernia on the left side of the chest. The contents were the stomach, which had undergone volvulus, the transverse colon and the spleen. The lung was compressed on the left side.

The patient was posted for emergency laparotomy. The stomach had organo-axial volvulus. The entire stomach, greater omentum, the entire transverse colon, the splenic flexure and the spleen had all herniated into the left thoracic cavity. The color of the stomach was slightly dusky. All the contents could be reduced easily into the abdominal cavity. After reduction, an oval defect measuring 7x8cm was seen on the posterolateral aspect of the left hemidiaphragm. There was no peritoneal sac. The left lung appeared hypoplastic. The stomach color returned to normal. The defect was closed in a single layer with 1.0 Prolene. A synthetic mesh was used to reinforce the repair. The chest tube placed earlier was repositioned and abdominal closure was attempted. However, during the closure the patient had severe hypotension; therefore, a total omentectomy was done to prevent abdominal compartment syndrome. The abdomen was then closed. There was no hypotension in the postoperative period.

However, the patient was not maintaining adequate saturation and therefore was electively ventilated for a period of 15 days. She was gradually weaned of the ventilator. The chest tube was removed on the 20th postoperative day. She was discharged on the 30th postoperative day without any symptoms. She is on regular follow-up.

Figure 2