This morning, early, we had the chance of regarding accurately a chest XRay of the pt. and it was possible to see that, in lateral view, there was a backward occupation of the right supradiaphragmatic space with something that resembled colon.
That was important as it changed the whole context of the primary pathology.
The pt seemed in an excellent shape and had no signs of any sort of complication.
Once in OR, we practiced a medium upper laparotomy and, to our surprise, at exploration there was a big right Bochdalek diaphragmatic hernia, some 12 cms in diameter and inside it there was, rotated in 180 degrees, the stomach and a good part of the transverse colon.
Once liberated both viscerae from adhesions, it was quite easy to restore them to the abdominal cavity.
No hiatal hernia was found and an active, non sthenotic, peptic duodenal ulcer was confirmed.
Closure of the Bochdalek hernia was performed with a patch of Marlex and a supraselective vagotomy was done uneventfully.
Gastropexia or gastrostomy as a medium of fixing the stomach appeared not to be necesary as the stomach returned to it's normal anatomic position and the diaphragmatic hole was closed.
So, we were in front of a Bochdalek diaphragmatic hernia, a wide one, with a volvulated stomach inside of it, without isquemic or necrotic compromise, that also included partial transverse colon.Besides, a duodenal ulcer that was treated surgically with the SSV.
Must tell you that the operation was uneventfull.
If any comments or observations do deserve this case, please let me know.