Cases Of Congenital Diaphragmatic Hernia Research Articles

Ретроспективный анализ результатов диагностики и лечения врожденной диафрагмальной грыжи плода, по данным перинатального консилиума

Study Objective: Analysis of the detection of congenital diaphragmatic hernia (CDH) in the fetus at the antenatal stage and perinatal outcomes of newborns with CDH in the Russian Federation in a sample of women who applied to the perinatal consultation of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov. Study Design: Retrospective study. Materials and Methods. The study included 235 cases of CDH in fetuses and newborns were selected by the federal perinatal consultation of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after academician V.I. Kulakov. The following were retrospectively analyzed: medical and social characteristics of pregnant women, results of ultrasound and MRI examination of fetuses, delivery features and perinatal outcomes. Study Results. The number of women with fetal CDH in the perinatal consultation of the Center continues to grow every year. In 3/4 of the treated patients, fetal CDH was detected in the 2nd trimester of pregnancy, which exceeds the European level of detection. But against this background, an extremely low level of invasive prenatal diagnosis was noted. Detection using ultrasound and MRI of liver infection in the chest, including a group with a prognosis of high neonatal survival of 2.2–4 times. The perinatal mortality rate with CDH in the Centers detection is 43.4%. The most common method of delivery is the natural birth. The optimal term of delivery with the least increase in postnatal loss should be considered the period of 38–39 weeks of pregnancy. Forecast of survival of newborns. At the same time, the Apgar score does not have statistical indicators of differences in surviving and deceased newborns, regardless of the method of delivery, which is associated with a violation of child development. Conclusion. The level of detection of CDH and perinatal mortality of newborns is similar to the data of foreign perinatal centers that provide assistance to mothers and their newborns. Increasing the survival rate of newborns with CDH is possible with the development and implementation of an integrated system for diagnosing the severity of CDH, as this will open up the possibility of a personalized approach to the treatment of CDH. Keywords: congenital diaphragmatic hernia, perinatal mortality, perinatal consultation, pulmonary hypoplasia, cardiac compression.

Antenatal Ultrasound Should Be For All; Congenital Diaphragmatic Hernia - A Case Report

Congenital diaphragmatic hernia is an anatomical defect of the diaphragm, which allows protrusion of abdominal viscera into the chest, causing serious pulmonary and cardiac complications in the neonate. In this study we aimed to present a case of congenital diaphragmatic hernia. We investigated a 35-36 weeks of pregnancy, with a pregnancy carried out in a public hospital in Padang, West Sumatera. We suggest that if diagnosis occurs in the prenatal period, the prognosis of this disease improves.

Prediction of neonatal survival according to lung-to-head ratio in fetuses with right congenital diaphragmatic hernia (CDH): A multicentre study from the Latin American CDH Study Group registry.

To evaluate survival outcomes of fetuses with right sided congenital diaphragmatic hernia (CDH) treated in Latin American centres and to assess the utility of left lung area to predict neonatal survival. A retrospective cohort including isolated right sided CDH cases managed expectantly during pregnancy in six tertiary centers from five Latin American countries. The utility of the observed/expected lung-to-head ratio (O/E-LHR) in predicting neonatal survival was assessed, and the best cut-off to predict prognosis was automatically selected by decision tree analysis. A total of 99 right sided CDH cases were recruited, 58 isolated fetuses were selected at a median gestational age of 26.2weeks, showing an overall survival rate of 26.2%. A linear trend was observed between survival and the O/E-LHR, showing that at higher O/E-LHR, the greater probability of survival (r=0.56, p<0.001). O/E-LHR discriminates two groups with different survival outcomes: fetuses with an O/E-LHR ≥65% showed a significantly higher survival rate than those with an O/E-LHR <65% (81.8% vs. 15.6%, p<0.01). Overall survival rate in right sided CDH is lower in Latin American countries. The severity category of pulmonary hypoplasia should be classified according to lung area and the survival rate in such population.

A case of congenital diaphragmatic hernia with malrotation of gut, delayed presentation in adult

Congenital diaphragmatic hernia (CDH), which mainly occurs in the new born or in childhood with severe respiratory distress and is associated with high mortality, is rarely found in adult. Pulmonary hypoplasia and pulmonary hypertension contribute to the high mortality and morbidity due to CDH. These patients adjust their lifestyle to manage symptoms associated with frank herniation of the large bowel, omentum, and other viscera inside the diaphragmatic hernia. We report a 25-year-old male who presented with shortness of breath on exertion diagnosed as having CDH. The disease was detected using chest X-ray (CXR) and was confirmed on contrast enhanced CT scan. A defect was noted in the posterolateral right diaphragm with omentum, small bowel, caecum, appendix, and colon herniating through it with malrotation (incomplete rotation) of gut. CT scan and CXR were the two useful methods in diagnosis of CDH in this patient, but sometimes becomes challenging because of rare incidence and types prior to surgery. For better outcome of CDH patients long term follow up and more investigations are needed. In some cases, where conventional CT scan and ultrasonography fails to diagnose a case of CDH &amp; malrotation of gut, diagnostic laparoscopy plays a key role in facing such situations. Keywords: diaphragmatic hernia; malrotation of gut

Inborn Versus Outborn Delivery in Neonates With Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a morbid and potentially fatal condition that challenges providers. The aim of this study is to compare outcomes in neonates with prenatally diagnosed CDH that are inborn (delivered in the institution where definitive care for CDH is provided) versus outborn. Prenatally diagnosed CDH cases were identified from the Congenital Diaphragmatic Hernia Study Group (CDHSG) database between 2007 and 2019. Using risk adjustment based on disease severity, we compared inborn versus outborn status using baseline risk and multivariable logistic regression models. The primary endpoint was mortality and the secondary endpoint was need for extracorporeal life support (ECLS). Of 4195 neonates with prenatally diagnosed CDH, 3087 (73.6%) were inborn and 1108 (26.4%) were outborn. There was no significant difference in birth weight, gestational age, or presence of additional congenital anomalies. There was no difference in mortality between inborn and outborn infants (32.6% versus 33.8%, P = 0.44) or ECLS requirement (30.9% versus 31.5%, P = 0.73). Among neonates requiring ECLS, outborn status was a risk factor for mortality (OR 1.51, 95% CI 1.13-2.01, P = 0.006). After adjusting for post-surgical defect size, which is not known prenatally, outborn status was no longer a risk factor for mortality for infants requiring ECLS. Risk of mortality and need for ECLS for inborn CDH patients is not different to outborn infants. Future studies should be directed to establishing whether highest risk infants are at risk for worse outcomes based on center of birth.

A nationwide database analysis of demographics and outcomes related to Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia.

The aim of the study was to understand the use of Extracorporeal Membrane Oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and its outcomes. The 2016 Kid's Inpatient Database (KID) obtained from the national Healthcare Cost and Utilization Project (HCUP) was used to obtain CDH birth, demographic, and outcome data associated with ECMO use. Categorical variables were analyzed and odds ratios (OR) with 95% confidence intervals (CI) are reported for variables found to have significance (p < 0.05). Appropriate regressions were used for comparing categorical and continuous data using SPSS 25 for Macintosh. The database contained 1189 cases of CDH, of which 133 (11.2%) received ECMO. The overall mortality of neonates with CDH was 18.9% (225/1189). Newborns with CDH on ECMO had a survival of 46% (61/133) compared to 85.5% without ECMO (903/1056) (OR 6.966, p < 0.001, 95% CI 4.756-10.204). ECMO increased length of stay from 24.6 to 69.8days (OR 2.834, p < 0.001, 95% CI 2.768-2.903) and average cost from $375,002.20 to $1641,586.83 (OR 4.378, p < 0.001, 95% CI 3.341-5.735). Increased length of stay, costs, and outcomes with ECMO use in CDH should prompt an examination of criteria necessitating ECMO.

Clinical case of congenital diaphragmatic hernia

Congenital diaphragmatic hernia is a rare congenital anomaly of diaphragmatic development with a frequency of approximately 1 in 2,500 live births. The structural defect is accompanied by pathophysiological disorders, in particular, pulmonary hypertension, as well as pulmonary hypoplasia of various degrees, which actually determine the severity of the defect. In 84% of cases, the diaphragmatic hernia is located on the left dome of the diaphragm, possible right-sided and left-sided localization of the malformation, which is 14 and 2%, respectively.The defect can be either isolated or combined with other congenital anomalies, such as congenital heart disease or chromosomal abnormalities. Violation of the closure of the diaphragm during the 4-10th week of fetal development leads to the formation of the diaphragmatic grid. During the same period (5th week of gestation) is the formation of lungs and bronchs. Three-dimensional ultrasound diagnosis allows to detect prenatal defect in almost 60% of fetuses. Fetal MRI is a method of choosing the anatomical assessment of the lungs, determining their volume allows you to more accurately predict the development of complications and the required amount of care after birth. The article is devoted to the description of clinical observation of ENT with a description of the features of perinatal diagnosis and organization of postnatal care. The defect was diagnosed at 31 weeks, vaginal delivery occurred during full-term pregnancy. The complex of resuscitation measures, preoperative preparation, the course of the postoperative period is described. Timely prenatal diagnosis of EDC and its anatomical variant makes it possible to correctly develop the patient’s route, starting with the tactics of pregnancy, method of delivery, as well as to predict the algorithm of staff actions at birth and subsequent treatment of the newborn.

Редкий случай благоприятного исхода диагностики и лечения врожденной диафрагмальной грыжи (грыжа Бохдалека)

The article presents a rare case of congenital diaphragmatic hernia (Bohdalek's hernia) in a 1.5 month old child. There are indications of the difficulty of diagnosing this pathology. SKT, as well as the presence of a well-organized telemedicine consultation has made it possible to make the diagnosis in a timely manner and prescribe a propper treatment

Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia

Aim: The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37–38 weeks 6 days) versus full term (39–40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated. Material and Methods: A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life. Results: A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups – 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13–1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis. Conclusions: Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.

Stereological Lung Parameters After Fetoscopic Abdominal Decompression of Congenital Diaphragmatic Hernia in an Ovine Model: A Pilot Study.

Background: Fetoscopic endoluminal tracheal occlusion (FETO) improves lung maturation in severe cases of congenital diaphragmatic hernia (CDH) but it does not ameliorate lung compression by herniated abdominal organs. Surgically opening the fetal abdomen (abdominal decompression [AD]) reduces the intrathoracic pressure by diverting the abdominal organs into the amniotic cavity-a probable causal therapy for lung hypoplasia and pulmonary hypertension in CDH. Open surgical abdominal decompression has been reported: we describe a minimally invasive approach in an ovine model of CDH as a probable fetoscopic intervention. Materials and Methods: Eight fetuses were included, 2 were kept as HEALTHY controls. A CDH (left side, liver down) was created by open fetal surgery at midgestation in 6 fetuses, 2 were taken as CDH controls. Fetoscopic abdominal decompression (fAD) was performed 21 days later in 4 animals. The fetuses were retrieved at the end of gestation and evaluated by lung stereology. Results: fAD led to a near total evacuation of the thoracic cavity in 2 of the 4 animals. Fetuses with CDH had a lower total volume and fraction of alveolar air space, a lower volume fraction of the parenchyma, and an increase of the volume fraction of the alveolar septa and atelectasis, as well as an increased mean thickness of alveolar septa compared with HEALTHY fetuses. Fetuses treated with abdominal decompression showed an improvement of stereological parameters. Conclusions: In spite of relevant limitations (pilot study, small groups, spontaneous closure of the abdominal incision) we were able to demonstrate that abdominal decompression for CDH can be performed by fetoscopy. Our results support the hypothesis of causally improving lung development by abdominal decompression, thus implying increased survival in extreme cases of CDH. A refinement of the fetoscopic techniques and direct comparison to FETO appears warranted.

CONGENITAL DIAPHRAGMATIC HERNIA: OUR INSTITUTIONAL EXPERIENCE

Background: Congenital diaphragmatic hernia (CDH) is a developmental defect, in which there is herniation of abdominal contents into the thoracic cavity. This causes pulmonary hypoplasia and pulmonary hypertension to varying degrees. The clinical prole of CDH neonates at a tertiary care institute were studied over a period of 22 months between October 2018 to June 2020. Aims and objectives: To study the demography, including Age, Sex, birth weight, types, associated anomalies, surgery, complications and survival in CDH patients at a tertiary care referral centre in Rajasthan, India. Materials and methods: This was a prospective observational study between October 2018 and June 2020, over 1 year and 9 months, at tertiary referral centre in North-Western India. Clinical data, radiological ndings, pre-operative conditions were studied, intra-operative ndings were noted and post-operative course was studied. Intravenous Sildenal was administered and their effects on clinical improvement was noted. Results:102 cases of CDH were admitted, of which 62 were male and 40 were female. Of these cases, 78 underwent surgical repair, while the rest died prior to surgery. Majority (99) were left sided CDH. And majority (59) were without sac. Contents which were commonly encountered included Stomach, small and large intestine, spleen, liver. Patients who were administered with intravenous sildenal showed clinical improvement in the pulmonary hypertension. Patients with CDH require urgent management of the respiratory distress and pulmonary hypertension, in order to improve their survival.

Neurodevelopmental outcomes in children with isolated congenital diaphragmatic hernia: A systematic review and meta-analysis.

Congenital diaphragmatic hernia (CDH) reportedly has neurologic consequences in childhood however little is known about the impact in isolated CDH. Herein we aimed to describe the risk of neurodevelopmental complications in children born with isolated CDH. We systematically reviewed literature for reports on the neurological outcome of infants born with isolated CDH. The primary outcome was neurodevelopmental delay. Secondary outcomes included, motor skills, intelligence, vision, hearing, language and behavior abnormalities. Thirteen out of 87 (15%) studies reported on isolated CDH, including 2624 out of 24,146 children. Neurodevelopmental delay was investigated in four studies and found to be present in 16% (3-34%) of children. This was mainly attributed to motor problems in 13% (2-30%), whereas cognitive dysfunction only in 5% (0-20%) and hearing in 3% (1-7%). One study assessed the effect of fetal surgery. When both isolated and non-isolated children were included, these numbers were higher. This systematic review demonstrates that only a minority of studies focused on isolated CDH, with neurodevelopmental delay present in 16% of children born with CDH. To accurately counsel patients, more research should focus on isolated CDH cases and examine children that underwent fetal surgery.

Fetal cardiac dimensions in congenital diaphragmatic hernia: relationship with gestational age and postnatal outcomes.

To serially assess fetal cardiac dimensions in congenital diaphragmatic hernia (CDH) and their relation to disease severity. Retrospective analysis of CDH cases and matched controls. Mitral (MVd) and tricuspid (TVd) valve diameters, left (LV) and right (RV) ventricular length and area, Z-scores, were serially assessed at 24-26, 30-32, and 35-37 weeks gestational age (GA). In CDH cases MVd, MVd Z-score, and LV area were significantly reduced at 24-26 and 35-37 weeks GA. TVd, TVd Z-score, and RV area were significantly reduced at 24-26 weeks. RV area Z-score increased with advancing GA. MVd and MVd Z-score were significantly lower at 24-26 weeks GA in CDH who had a combined outcome of death and/or ECMO. LV hypoplasia in CDH is characterized by reduced MVd from 24 weeks GA. MVd, and the ratio of mitral and tricuspid valve diameters at later gestations, may be potential predictors of disease severity.

Perspective on Similarities and Possible Overlaps of Congenital Disease Formation-Exemplified on a Case of Congenital Diaphragmatic Hernia and Neuroblastoma in a Neonate.

The coincidence of two rare diseases such as congenital diaphragmatic hernia (CDH) and neuroblastoma is exceptional. With an incidence of around 2–3:10,000 and 1:8000 for either disease occurring on its own, the chance of simultaneous presentation of both pathologies at birth is extremely low. Unfortunately, the underlying processes leading to congenital malformation and neonatal tumors are not yet thoroughly understood. There are several hypotheses revolving around the formation of CDH and neuroblastoma. The aim of our study was to put the respective hypotheses of disease formation as well as known factors in this process into perspective regarding their similarities and possible overlaps of congenital disease formation. We present the joint occurrence of these two rare diseases based on a patient presentation and immunochemical prognostic marker evaluation. The aim of this manuscript is to elucidate possible similarities in the pathogeneses of both disease entities. Discussed are the role of toxins, cell differentiation, the influence of retinoic acid and NMYC as well as of hypoxia. The detailed discussion reveals that some of the proposed pathophysiological mechanisms of both malformations have common aspects. Especially disturbances of the retinoic acid pathway and NMYC expression can influence and disrupt cell differentiation in either disease. Due to the rarity of both diseases, interdisciplinary efforts and multi-center studies are needed to investigate the reasons for congenital malformations and their interlinkage with neonatal tumor disease.

Diagnostic challenges in late presenting diaphragmatic hernia

Background: The incidence of congenital diaphragmatic hernia (CDH) has been reported to be 1 in 2000-5000 newborns. The late presentation can occur in 5-30% of all cases and it can be harder to diagnose, as symptoms are usually vague and non-specific. Methods: We performed a retrospective review of chart files of all patients admitted to our hospital with the diagnosis of congenital diaphragmatic hernia between 2010 and 2021. Result: Of the ninety-two cases of CDH treated in our hospital between 2010 and 2021, twenty-six (28%) were late presenting. In the late-presenting CDH group, we found a slight female preponderance, with fifteen female patients (58%) and eleven male patients. A posterolateral left defect in the diaphragm was noted in fifteen cases (58%), a right defect was noted in just one case (4%) and ten patients (38%) were diagnosed with an anterior diaphragmatic hernia. The age at diagnosis varied from 2 months to 14 years. Associated anomalies were noted in just four cases. In all cases, a thoracoabdominal radiograph was performed and ten patients also had a CT scan. Primary repair was performed in 25 of the 26 patients. The mortality rate in our study population was 11%, we reported 3 cases with unfavorable evolution. Conclusion: CDH presenting beyond the neonatal period is a usual finding and it represents a true diagnostic challenge.

An Infantile Case of Congenital Diaphragmatic Hernia Incidentally Detected on Left Upper Arm Fracture

An Infantile Case of Congenital Diaphragmatic Hernia Incidentally Detected on Left Upper Arm Fracture

Prevalence and mortality in children with congenital diaphragmatic hernia: a multicountry study

PurposeThis study determined the prevalence, mortality, and time trends of children with congenital diaphragmatic hernia (CDH). MethodsTwenty-five hospital- and population-based surveillance programs in 19 International Clearinghouse for Birth Defects Surveillance and Research member countries provided birth defects mortality data between 1974 and 2015. CDH cases included live births, stillbirths, or elective termination of pregnancy for fetal anomalies. Prevalence, cumulative mortality rates, and 95% confidence intervals (CIs) were calculated using Poisson regression and a Kaplan–Meier product-limit method. Joinpoint regression analyses were conducted to assess time trends. ResultsThe prevalence of CDH was 2.6 per 10,000 total births (95% CI: 2.5–2.7), slightly increasing between 2001 and 2012 (average annual percent change = 0.5%; 95% CI:−0.6 to 1.6). The total percent mortality of CDH was 37.7%, with hospital-based registries having more deaths among live births than population-based registries (45.1% vs. 33.8%). Mortality rates decreased over time (average annual percent change = −2.4%; 95% CI: −3.8 to 1.1). Most deaths due to CDH occurred among 2- to 6-day-old infants for both registry types (36.3%, hospital-based; 12.1%, population-based). ConclusionsThe mortality of CDH has decreased over time. Mortality remains high during the first week and varied by registry type.

Epithelial cell-adhesion protein cadherin 26 is dysregulated in congenital diaphragmatic hernia and congenital pulmonary airway malformation.

Congenital diaphragmatic hernia (CDH) and congenital pulmonary airway malformation (CPAM) are two inborn pathologies of the lung of unknown origin. Alterations of gene expression in airway epithelial cells are involved in the pathobiology of both diseases. We previously found decreased expression of the epithelial cell adhesion protein cadherin 26 (CDH26) in hypoplastic mice lungs. Here, our objective was to describe the expression and localization of CDH26 in hypoplastic CDH lungs and hyperproliferative CPAM tissues. After ethical approval, we used human lung tissues from CDH and CPAM cases and age-matched control samples from a previously established biobank. Furthermore, lungs from the nitrofen rat model of CDH were included in the study. We performed immunohistochemistry and western blot analysis with antibodies against CDH26 to examine protein localization and abundance. Statistical analysis was performed using Mann-Whitney U test with significance set at p < 0.05. We observed an overexpression of CDH26 within the epithelium of cystic CPAM lesions compared to normal airways within the same lung and compared to control lungs. Western blot demonstrated a downregulation of CDH26 in the nitrofen rat model of CDH compared to healthy controls. Immunohistochemistry could not show consistent differences between CDH and control in human and rat lungs. In the studied human lung samples, CDH26 was localized to the apical part of the airway epithelial cells. CDH26 is differentially expressed in human CPAM lung tissues and may be downregulated in nitrofen-induced hypoplastic rat lungs compared to control lungs. Disruption of CDH26 associated pathways in lung development may be involved in the pathogenesis of lung hypoplasia or cystic lung disease.

Optimal timing of surgery in infants with prenatally diagnosed isolated left-sided congenital diaphragmatic hernia: a multicenter, cohort study in Japan.

To date, there is no compelling evidence of the optimal timing of surgery for congenital diaphragmatic hernia (CDH). This study aimed to establish the optimal timing of surgery in neonates with isolated left-sided CDH. This multicenter cohort study enrolled 276 patients with isolated left-sided CDH at 15 institutions. Based on the timing of surgery, the patients were classified into four groups [< 24h (G1), 24-47h (G2), 48-71h (G3), and ≥ 72h (G4)]. The clinical outcomes were compared among the groups using a logistic regression model, after adjusting for potential confounders, such as disease severity. Multivariate analyses showed that G2 also had a lower mortality rate than the other groups. In mild and severe cases, there were no significant differences in mortality across the four groups. In moderate cases, G2 resulted in significantly increased survival rates, compared with G1. The study results suggest that surgery within 24h of birth is not recommended for patients with moderate severity CDH, that there is no benefit in the delay of surgery for more than 72h in mild severity CDH patients, and that there is no definite optimal time to perform surgery in severe cases of CDH.

A rare case of congenital diaphragmatic hernia in adult: an incidental finding during an elective procedure

Congenital diaphragmatic hernia consists of a defect of the diaphragm that allows the passage of abdominal viscera into the thorax. Congenital diaphragmatic hernia most commonly present in infancy and childhood due to respiratory distress. However, a few of them may escape into adulthood. A very few of these adult cases may be identified during a routine medical checkup for various other reasons without any cardio-respiratory problems. In our case report, we have diagnosed incidentally an asymptomatic left diaphragmatic hernia with cardio-mediastinal shifting in a 38 years old female admitted for left breast fibroadenoma excision during a routine pre-anesthetic check-up and underwent breast surgery without any cardio-respiratory problems.