Diaphragmatic hernias are defects in the muscular or tendinous structures of the diaphragm. Although commonly congenital and diagnosed in the pediatric population, they may also be caused by blunt or penetrating trauma. Less commonly, they occur postsurgically or spontaneously.1,2,3

We present a case of a diaphragmatic hernia diagnosed during a routine elective laparoscopy in a previously healthy 55-yr-old woman undergoing right donor nephrectomy under general anesthesia. Intraoperatively, multiple fenestrations were noted in the central tendon (the fibrous insertion point of the diaphragmatic musculature adjacent to the liver) (Figure). With the liver retracted, lung tissue could be seen through the diaphragmatic defect during mechanical ventilation (see video, available as Electronic Supplementary Material).

Figure
figure 1

This image obtained during laparoscopy shows fenestrations in the central fibrous tendon of the diaphragm (A). Lung tissue (B) can be seen through the diaphragmatic defects (C). The muscular portion of the diaphragm (D) and liver (E) are also pictured in this view

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To prevent the communicating diaphragmatic hernia from causing a pneumothorax (with possible tension physiology) in the setting of a pneumoperitoneum, intraabdominal insufflation pressures were decreased. Euvolemia was maintained to mitigate potential consequences of increased intrathoracic pressure and the patient’s vital signs were closely monitored for evidence of increased airway pressures and impaired ventilation that might indicate a developing pneumothorax. The patient remained hemodynamically stable throughout and tolerated the procedure without complication. Prior to closure of the surgical incisions, suction was used to remove insufflation gas. In the postanesthesia care unit, a chest x-ray ruled out any residual pneumothorax. The remainder of her postoperative course was uncomplicated.

This image highlights the importance of being vigilant for abnormal and incidental findings while performing otherwise routine anesthetic care.