Tokumoto et al. Journal of Medical Case Reports 2010, 4:366 http://www.jmedicalcasereports.com/content/4/1/366 Page 4 of 5 Figure 5 Postoperative enhanced chest and abdominal computed tomography (CT) scans. Two months postoperatively, an outpatient chest CT was performed. There was no recurrence of diaphragmatic hernia Bochdalek in 1848 [2]. The Bochdalek hernia has a female predominance and symptoms usually manifest during the first week of life [9]. Most Bochdalek hernias cause severe cardiorespiratory distress immediately after birth. Once diagnosed it is crucial to perform prompt surgical treatment. The hernia is very rare in adults. The prevalence of asymptomatic cases in a large adult population, retro- spectively reviewed with thin-slice CT scans, was only 0.17% based on 13,138 CT reports [4]. Among the surgi- cal findings, a hernia sac was identified in 20% of patients [10,11]. All abdominal organs, except the rec- tum and genitals, have been found to have entered the thorax through a defect in the diaphragm: the colon, stomach, small bowel, omentum, spleen, kidney and even the tail of the pancreas [7,10,12-15]. The Bochdalek hernia is secondary to the incomplete development of the pleuroperitoneal folds due to improper or absent diaphragmatic muscle migration. The canals resulting from these folds are normally closed by pleuroper- itoneal membranes in the eighth week of gestation. There are many symptoms of Bochdalek hernia. Typically, the diagnosis is based on dyspnea, recurrent chest infections and the absence of breath sounds in the thoracic region. In adults, gastrointestinal symptoms related to the obstruction of the herniated organ(s) are more common. These symp- toms include abdominal pain, intestinal obstruction and chest tightness [4]. Herniated organs determine the symp- toms. There are also reports of sepsis secondary to necrosis and perforation of a herniated colon [10,16]. Asymptomatic cases are difficult to diagnose. Bochda- lek hernias in adults are usually detected incidentally during routine chest radiography. Frontal and lateral chest radiographs are the most important diagnostic tools [16]. Many Bochdalek hernias are identified by gas-filled bowel loops or a soft tissue mass above the dome of the diaphragm. However, if the herniation is intermittent, radiographs may appear normal. In addi- tion, left middle lobe collapse, pneumonic consolidation, pericardial fat pad, pericardial cyst, mediastinal lipoma or an anterior mediastinal mass must be ruled out. A chest CT is necessary in order to make an accurate diagnosis. Chest CT shows the focal defect in the dia- phragm, herniated contents and thickening of the dia- phragm, or crus, as a result of edema or hematoma. Helical CT depicts these features even more clearly. The conventional method is to return the herniated organs to the abdominal cavity and close the diaphrag- matic defect through the thorax or the abdomen [5,17]. Thoracoscopic surgery facilitates the reduction of the herniated contents, allowing adhesion lysis and care of the herniated organs. With this procedure, bleeding con- trol and diaphragmatic defect closure are easier and safer [5,6]. In addition to this procedure, the reverse Trende- lenburg position and artificial pneumothorax facilitate the safe return of the herniated organs to their correct locations. Inflation-assisted bowel reduction with very low pressure for infants has been reported [18,19]. In our case, the artificial pneumothorax was maintained at 8 cm H2O under careful circulatory and respiratory monitor- ing. There was no change in cardiorespiratory status. With these innovations, the herniated organs were returned to the abdominal cavity. A treatment combina- tion with laparoscopy, for examining the abdominal cav- ity, is very useful and reduces surgical morbidity. In our case, we were able to insert the thoracoscope through the diaphragmatic defect into the abdominal cavity. We con- firmed the absence of ischemic change in the herniated organs and then closed the diaphragmatic defect with a primary suture. The patient was discharged on POD5 with minimal discomfort. This procedure is useful not only for congenital dia- phragmatic hernia but also for traumatic hernia, both blunt and penetrating. Generally, when the defect of the diaphragm is fairly large, tension-free repair using a prosthetic patch, such as composite or porcine mesh, is a very useful method which avoids a thoracotomy. We considered repairing it with a composite or porcine mesh but decided in this case to do a primary closure by suturing. The reasons for this were that: (1) our patient was still young; (2) repairing the diaphragmatic defect near the thoracic wall required unrolling and resuturing; and (3) there was no tension of the dia- phragm. After unrolling of the posterior diaphragmatic rim, the defect of diaphragm was closed and again sutured to the thoracic wall under small thoracotomy without a prosthetic patch. One of the advantages of a thoracoscopic repair of a Bochdalek hernia is that it is minimally invasive and the