the altered postoperative physiology after pneumonectomy interventions can cause severe implications , especially in patients receiving adjuvant therapy for advanced lung cancer .  
a 60 year - old man with malignant pleural mesothelioma underwent a thoracotomy through double incision ( 5 and 7 intercostal spaces ) for left pleuro - pneumonectomy and diaphragmatic resection after chemotherapy . the pre operative chest computed tomography scan showed a pattern of centrolobular emphysema .
a thoracic epidural catheter was placed before anaesthesia induction and a mixture of ropivacaine 0.375% and fentanyl was used during the intervention and postoperative period .  
parietal pleural dissection produced a significant blood loss and red blood cells and fresh frozen plasma transfused .
the patient did not meet the extubation criteria and was transferred to the intensive care unit .   on intensive care unit admission
the patient was hypotensive ( blood pressure= 90/60 mmhg ) and treated with fluids . chest x - ray was normal ( figure 1 ) and the patient was extubated 40 minutes thereafter .
this figure shows the first chest x - ray ( immediately after the admission in the intensive care unit ) .
an hypotensive episode ( blood pressure 60/40 mmhg ) and tachypnea ( respiratory rate = 32 breaths per minute ) were treated with fluids , dopamine ( 5 mcg / kg / min)and interruption of the epidural infusion .
a chest x - ray with contrast administration trough nasogastric tube was performed . respiratory arrest and asytolia
the chest x - ray showed gastric and spleen herniation through a diaphragmatic breach ( figure 2 ) .
this figure shows the diaphragmatic herniation ( the chest xray was performed immediately before cardiorespiratory arrest ) .
dopamine infusion was interrupted during the operation , the patient was extubated in the intensive care unit six hours later discharged from the hospital on the 6th post operative day without further complications .
the mortality rate after pneumonectomy is 6% , the major causes of death being pneumonia , pulmonary edema , pulmonary embolism , myocardial infarction , empyema and bronchopleural fistula .
gastric hernia is a rare postoperative complication usually diagnosed at the first postoperative chest xray .   in our case
the diagnosis was challenging because the hernia became evident only after intensive care unit admission and because the epidural analgesia confused the clinical scenario : this technique was considered the cause of persistent hypotension .
the left pneumonectomy likely created a vacant space into which the stomach acutely herniated compressing the heart and creating a cardiac tamponade .
in patients with hypotension after left pneumonectomy a high index of suspicion should be observed for diaphragmatic hernia during the whole postoperative period .
 patients undergoing pneumonectomy can suffer by cardiovascular and respiratory postoperative complications that can affect patient s outcome by increasing morbidity and mortality . 
 we describe a diaphragmatic hernia occurring after pneumonectomy . with late presentation and with epidural analgesia confusing the scenario suggesting that anesthesiologists should remain aware on this complication even in the late post operative period . 