Minimally Invasive Repair of a Congenital Right-sided Diaphragmatic Hernia in an Adult Jason D. Fraser, MD, Randall O. Craft, MD, Kristi L. Harold, MD, and Dawn E. Jaroszewski, MD Abstract: A 75-year-old woman who presented with a cough was found on investigation to have a large right-sided diaphragmatic hernia with intrathoracic herniation of the colon, small bowel, and right kidney. The patient denied any history of trauma and therefore the hernia was felt to be congenital in nature. The patient underwent a combined laparoscopic repair with polytetrafluoro- ethylene mesh and a thoracoscopic lysis of adhesions of the posterior right-sided diaphragmatic hernia. To our knowledge, this is the first reported case of a combined laparoscopic and thoracoscopic repair of a congential diahphragmatic hernia. Although successful repair can be accomplished laparoscopically, the addition of a thoracoscopic lysis of adhesions facilitated the early reexpansion of our patient’s chronically scarred lung. Key Words: diaphragmatic hernia, thoracoscopic, laparoscopic (Surg Laparosc Endosc Percutan Tech 2009;19:e5–e7) A 75-year-old woman presented with a cough concerning for pneumonia. A chest radiograph was obtained, which was suspicious for intrathoracic hernia or right diaphragmatic paralysis (Fig. 1). Subsequent computed tomography scan of the chest and abdomen demonstrated a large right-sided broad-based diaphragmatic hernia with intrathoracic herniation of the hepatic flexure of the colon, small bowel, and right kidney (Figs. 2–6). The right kidney was noted to be malrotated, but showed normal perfusion. The right lung lower lobe was atelectatic. There were no other significant abnormalities found and the left dia- phragm was normal. The patient denied any history of trauma and her primary symptom was chronic cough. The patient was taken to the operating room where she underwent a combined laparoscopic and thoracoscopic repair of the posterior right-sided diaphragmatic hernia. The patient was positioned in the left lateral decubitus position. The peritoneum was entered with the Veress needle at the right subcostal margin where a 5 mm trocar was placed. Two additional 5 mm trocars were placed under the right costal margin. She was found to have a defect of approximately 8  5 cm in her right posterior diaphragm. The hepatic flexure of the colon, and also the right kidney, was herniated into the thoracic cavity. The hernia sac was found to have significant adhesions to the thoracic pleura requiring a right video-assisted thoracoscopic lysis of adhesions to reduce the abdominal contents back into the abdomen. This was accomplished using two 5-mm and one 10-mm port through the fifth and sixth rib spaces encompassing a triangle about the midaxillary and sub- scapular regions. A 23-French chest tube was placed. From a laparoscopic approach then the contents were reduced back into the abdomen and the hernia sac was excised. The defect was closed with a 15  13 cm polytetrafluoroethylene mesh. The mesh was secured with interrupted polyester sutures, and placed to provide an approximate overlap of 4 cm beyond the defect. The patient’s postoperative course was uneventful, and she was discharged home on postoperative day 3. After 11 months of follow-up, the patient continues to do well without complication (Fig. 7). FIGURE 1. Preoperative chest radiograph and computed tomo- graphy demonstrating a right-sided diaphragmatic hernia con- taining small bowel, colon, and right kidney. Copyright r 2009 by Lippincott Williams & Wilkins Received for publication January 3, 2008; accepted August 14, 2008. From the Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ. Reprints: Kristi L. Harold, MD, Department of Surgery, Mayo Clinic Arizona, 5777 East Mayo Blvd, Phoenix, AZ 85054 (e-mail: Harold.Kristi@mayo.edu). CASE REPORT Surg Laparosc Endosc Percutan Tech  Volume 19, Number 1, February 2009 e5