LAUSR

We report a unique case of a congenital diaphragmatic hernia unveiled following a right nephrectomy in a 74-year-old woman, presenting 9 months later as a large bowel obstruction. A previously well 74-year-old woman underwent a laparoscopic right nephrectomy in March 2013 for a 39-mm right renal cell carcinoma. The operation went well with no diaphragmatic injury sustained and the patient recovered without incident. The patient presented in December, 9 months later, with several weeks of colicky lower abdominal pain and nausea. Her bowels were opening daily. She was haemodynamically stable with normal biochemical markers including a normal white cell count and Creactive protein. A computed tomography (CT) abdomen showed caecal dilatation with an ‘unusual mass lesion containing gas pockets in the posterior aspect of the right upper quadrant’. A contrast enema study showed contrast up to the hepatic flexure, with no significant flow beyond. A colonoscopy was performed, but was unable to pass the hepatic flexure due to a kink or external compression. No mucosal abnormality was seen. In the following days, the patient experienced progressively worse symptoms, with increasing colicky pain and cessation of flatus. Due to clinical progression to a complete large bowel obstruction and the uncertain aetiology, the decision was made to proceed with an exploratory laparotomy. Laparotomy revealed herniation of the hepatic flexure through a diaphragmatic defect, in a position typical of a Bochdalek hernia. There was a well-formed sac associated with the hernia and the neck of the defect was thick, requiring incision to release the hepatic flexure. The colon remained viable. An intercostal chest tube was inserted, and the defect was subsequently primarily closed. The patient recovered well and was discharged on day 14 of admission. Retrospective review of imaging performed prior to nephrectomy reveals a probable Bochdalek hernia over which lies perinephric fat and the right kidney (Fig. 1). Surveillance CT scans for monitoring of a pulmonary nodule incidentally shows progressive herniation