Tokumoto et al. Journal of Medical Case Reports 2010, 4:366 http://www.jmedicalcasereports.com/content/4/1/366 patient experiences less pain. In addition, the thoracic cavity and herniated organs can be examined in detail for ischemic change, necrosis and perforation. The pre- sence of lung hypoplasia can also be confirmed. Thirdly, if herniated organs are attached to the thoracic wall or lung, lysis of the adhesions can be carried out safely. However, there are disadvantages to the thoracoscopic procedure. First, it can be difficult to manipulate her- niated organs. The spleen is especially prone to bleeding which is why we employed the reverse Trendelenburg position and artificial pneumothorax with CO2 gas insufflation. These innovations facilitated the safe return of the herniated organs to the abdominal cavity. Sec- ondly, abdominal cavity visualization might be insuffi- cient. We inserted the thoracoscope through the diaphragmatic defect into the abdominal cavity and were able to confirm the safe placement of the herniated organs. Conclusion Bochdalek hernias are very rare in adults. We performed the surgical treatment under thoracoscopy. The reverse Trendelenburg position and artificial pneumothorax are useful innovations for reducing the herniated contents. The diaphragmatic defect was rather large. Generally, hernia repair using mesh is useful if one needs to avoid performing a thoracotomy. We considered this method but the patient was young; closing the diaphragmatic defect near the thoracic wall required unrolling and resuturing and there was no tension of the diaphragm which is necessary when resuturing. A small incision thoracotomy was therefore added and the primary clo- sure of the diaphragmatic defect was performed. We inserted the thoracoscope through the diaphragmatic defect into the abdominal cavity and confirmed the safe placement of the herniated organs. Our patient was dis- charged on POD5. There has been no recurrence to date. We consider Bochdalek hernia repair with thoraco- scopic-assisted surgery to be a safe and useful technique. Consent Written informed consent was obtained from the patient and the parent of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in- Chief of this journal. Abbreviations CDH: congenital diaphragmatic hernia; CT: computed tomography; POD: postoperative day. Author details 1Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551. 2Department of Page 5 of 5 Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. Authors’ contributions NT, KT, TS and YM were the surgeons and attending physicians. HY and HO supplemented the data about case reports and analyzed the patient’s data. NT and KT were the main contributors to the writing of the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 23 March 2010 Accepted: 17 November 2010 Published: 17 November 2010 References 1. Taskin M, Zengin K, Unal E, Eren D, Korman U: Laparoscopic repair of congenital diaphragmatic hernias. Surg Endosc 2002, 16:869. 2. Cosenza UM, Raschella GF, Giacomelli L, Scicchitano F, Simone M, Cancrini G, Zofrea P, Cancrini A: The Bochdalek hernia in the adult: case report and review of the literature. G Chir 2004, 25:175-179. 3. Puri P, Wester T: Historical aspects of congenital diaphragmatic hernia. Pediatr Surg Int 1997, 12:95-100. 4. Mullins ME, Stein J, Saini SS, Mueller PR: Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol 2001, 177:363-366. 5. Willemse P, Schutte PR, Plaisier PW: Thoracoscopic repair of a Bochdalek hernia in an adult. Surg Endosc 2003, 17:162. 6. Silen ML, Canvasser DA, Kurkchubasche AG, Andrus CH, Naunheim KS: Video-assisted thoracic surgical repair of a foramen of Bochdalek hernia. Ann Thorac Surg 1995, 60:448-450. 7. Robb BW, Reed MF: Congenital diaphragmatic hernia presenting as splenic rupture in an adult. Ann Thorac Surg 2006, 81:e9-e10. 8. Al-Emadi M, Helmy I, Nada MA, Al-Jaber H: Laparoscopic repair of Bochdalek hernia in an adult. Surg Laparosc Endosc Percutan Tech 1999, 9:423-425. 9. Esmer D, Alvarez-Tostado J, Alfaro A, Carmona R, Salas M: Thoracoscopic and laparoscopic repair of complicated Bochdalek hernia in adult. Hernia 2008, 12:307-309. 10. Kocakusak A, Arikan S, Senturk O, Yucel AF: Bochdalek’s hernia in an adult with colon necrosis. Hernia 2005, 9:284-287. 11. Losanoff JE, Sauter ER: Congenital posterolateral diaphragmatic hernia in an adult. Hernia 2004, 8:83-85. 12. Cuschieri RJ, Wilson WA: Incarcerated Bochdalek hernia presenting as acute pancreatitis. Br J Surg 1981, 68:669. 13. Dingeldein MW, Kane D, Kim AW, Kabre R, Pescitelli MJ Jr, Holterman MJ: Bilateral intrathoracic kidneys and adrenal glands associated with posterior congenital diaphragmatic hernias. Ann Thorac Surg 2008, 86:651-654. 14. Harrington DK, Curran FT, Morgan I, Yiu P: Congenital Bochdalek hernia presenting with acute pancreatitis in an adult. J Thorac Cardiovasc Surg 2008, 135:1396-1397. 15. Mohammadhosseini B, Shirani S: Incarcerated Bochdalek hernia in an adult. J Coll Physicians Surg Pak 2008, 18:239-241. 16. Hung YH, Chien YH, Yan SL, Chen MF: Adult Bochdalek hernia with bowel incarceration. J Chin Med Assoc 2008, 71:528-531. 17. Rice GD, O’Boyle CJ, Watson DI, Devitt PG: Laparoscopic repair of Bochdalek hernia in an adult. ANZ J Surg 2001, 71:443-445. 18. Schaarschmidt K, Strauss J, Kolberg-Schwerdt A, Lempe M, Schlesinger F, Jaeschke U: Thoracoscopic repair of congenital diaphragmatic hernia by inflation-assisted bowel reduction, in a resuscitated neonate: a better access? Pediatr Surg Int 2005, 21:806-808. 19. Becmeur F, Jamali RR, Moog R, Keller L, Christmann D, Donato L, Kauffmann I, Schwaab C, Carrenard G, Sauvage P: Thoracoscopic treatment for delayed presentation of congenital diaphragmatic hernia in the infant: a report of three cases. Surg Endosc 2001, 15:1163-1166. doi:10.1186/1752-1947-4-366 Cite this article as: Tokumoto et al.: Thoracoscopic-assisted repair of a bochdalek hernia in an adult: a case report. Journal of Medical Case Reports 2010 4:366.