Diagnostic and Surgical Management of Adult Right-Sided Bochdalek Hernias

Overview

This review analyzes 44 adult cases of right-sided Bochdalek hernias, highlighting differences in surgical approaches between emergency and non-emergency settings. Emergency surgeries were predominantly open laparotomies with direct suture repair, while non-emergency cases showed a mix of laparoscopic and open techniques with variable use of mesh and bowel resection.

Background

Right-sided Bochdalek hernias in adults are rare and often present diagnostic and therapeutic challenges. Surgical management varies widely, influenced by the urgency of the case, defect characteristics, and surgeon expertise. Existing literature is limited by moderate-to-low methodological quality, complicating the establishment of standardized treatment protocols. This review aims to clarify current management strategies and respond to critiques regarding surgical approach and repair techniques.

Data Highlights

Key Findings

• All emergency surgeries (16%) were performed via open laparotomy, predominantly with direct diaphragmatic suture repair.
• Non-emergency cases showed limited use of laparoscopy (9%) and a mix of open surgery and conservative management.
• Bowel resection was necessary in some emergency cases but was generally not required in non-emergency cases.
• There is no clear consensus on the use of mesh versus suture repair; decisions depend on defect size, contamination, and surgeon experience.
• Current literature is limited by low methodological quality and inconsistent reporting, hindering development of standardized management guidelines.
• Management principles emphasize rapid diagnosis, urgent repair of complicated hernias, pleural cavity decontamination, and scheduled long-term follow-up.

Clinical Implications

Clinicians should individualize surgical approach based on patient condition, hernia complexity, and available surgical expertise. Open laparotomy remains the standard in emergency settings, while minimally invasive techniques may be considered in stable, non-emergency cases. Careful assessment of defect characteristics and contamination is essential to guide repair method and the use of mesh. Long-term follow-up is recommended to monitor for recurrence or complications.

Conclusion

Adult right-sided Bochdalek hernias require tailored management strategies balancing urgency, surgical expertise, and patient factors. Despite limited high-quality evidence, prompt diagnosis and appropriate surgical intervention remain critical to optimize outcomes.

References

1. Tzortzis 2023 -- Comments on Systematic Review of Adult Right-Sided Bochdalek Hernias
2. Authors 2023 -- Systematic Review of Diagnostic Approaches and Surgical Interventions for Adult Right-Sided Bochdalek Hernias