Tokumoto et al. Journal of Medical Case Reports 2010, 4:366 http://www.jmedicalcasereports.com/content/4/1/366 Page 2 of 5 Figure 1 Preoperative chest radiograph. The chest radiograph shows elevation of the left diaphragm. In this case, the lateral chest radiography was important for the detection of an abnormality in the thoracic cavity. lumen trachea-tube. Thoracoscopic surgery was per- formed in the right lateral position. The first trocar for the thoracoscope was placed at the seventh intercostal space over the midaxillary line. We then checked the thoracic cavity and the herniated organs. The left colon and spleen were located in the left thoracic cavity, as seen on the preoperative chest CT (Figure 3A and 3B). No hernia sac was found. We examined the herniated organs carefully. There was neither adhesion nor necrotic change. Second and third trocars were placed at the eighth intercostal space over the anterior and pos- terior axillary lines, respectively. We used an Excel trocar® for CO2 gas insufflation to increase intrathoracic pressure. The herniated organs, Figure 2 Preoperative enhanced chest and abdominal computed tomography (CT) scans. The chest CT shows a diaphragmatic hernia. The spleen and left colon have herniated into the left thoracic space through a left posterior diaphragmatic defect. Figure 3 Surgical findings with thoracoscopy. A) The left colon and spleen were identified in the left thoracic cavity under thoracoscopy. No hernia sac was found. B) The left colon and spleen appeared to have herniated through a left posterior diaphragmatic defect, as indicated by the preoperative chest computed tomography. C) The diaphragmatic defect, 5 cm × 6 cm in size, had a smooth circular edge and showed gradual expansion at the thoracic wall. D) The defect was closed using a single layer primary closure method with interrupted non-absorbable sutures.