Tokumoto et al. Journal of Medical Case Reports 2010, 4:366 http://www.jmedicalcasereports.com/content/4/1/366 the left colon and spleen, were carefully returned to the abdominal cavity. These innovations, aimed at safely returning the herniated organs to the abdominal cavity, were performed with the patient in the head-up (reverse Trendelenburg) position with artificial pneumothorax. First, the patient was placed in the right lateral position and then he was shifted into a reverse Trendelenburg position. Whilst he was in this position, the artificial pneumothorax with CO2 gas was maintained at 8 cm H2O. The patient’s circulatory and respiratory status was carefully monitored. These innovations facilitated safe hernia reduction. Fortunately, there were no adhesions in the left thoracic cavity. We were able to insert the thoracoscope through the diaphragmatic defect into the abdominal cavity and confirm the safe placement of the herniated organs. There was neither torsion of the bowel nor bleeding in the abdominal cavity. The diaphragmatic defect, 5 cm × 6 cm in size, with a smooth circular edge was located posterolaterally (Figure 3C). The defect appeared to have gradually expanded at the thoracic wall. As he was a young man, we decided to perform primary closure of the diaphragmatic defect. We thought closing the defect of the diaphragm near the thoracic wall required unrol- ling and resuturing and we thought that it would be dif- ficult to close the defect by thoracoscopic surgery alone. We thus added a small incision thoracotomy (5 cm in Page 3 of 5 length) near the defect and repaired the diaphragm with a primary suture. The defect was closed using a single layer primary closure method with interrupted non- absorbable sutures (Figure 3D). The diaphragm near the thoracic wall required unrolling of the posterior diaphragmatic rim. After detachment, the defect near the thoracic wall was closed and again sutured to the thoracic wall. The thoracic cavity was drained with a single chest tube. The operative time was 144 min and there was no significant blood loss. The patient recovered uneventfully from anesthesia. A chest radiograph obtained 24 hours after surgery indicated adequate expansion of the left lung. On the first postoperative day (POD1), the chest tube was removed and he was put on a normal diet. After obtain- ing a final chest radiograph (Figure 4), he was discharged on POD5. Two months later an outpatient chest CT was performed and revealed that there had been no diaphrag- matic hernia recurrence (Figure 5). Discussion The incidence of CDH is reportedly 1 in 2200 to 12,500 live births and they occur more often on the left [7]. CDH was first described in 1679 by Lazarus Riverius, who incidentally noted a CDH during postmortem examination of a 24-year-old [8]. Bochdalek hernia is one of the CDHs first reported by Victor Alexander Figure 4 Postoperative chest radiography. There were no abnormalities on postoperative chest radiography.