Right-sided Congenital Diaphragmatic Hernia with Herniation of the Liver into the Thoracic Cavity: A Case Report

Right-sided Congenital Diaphragmatic Hernia with Herniation of the Liver into the Thoracic Cavity: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Right-sided Congenital Diaphragmatic Hernia with Herniation of the Liver into the Thoracic Cavity: A Case Report Majaliwa Bernard Ntazimila, Tao Zhang, Chunmeng Ning, Xingguang Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8645529/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Right-sided congenital diaphragmatic hernias (CDHs) with liver herniation into the thoracic cavity are rare clinical entities that may remain asymptomatic for extended periods. However, the systemic effects during observation are poorly documented. This case highlights that hernias appearing clinically stable may nevertheless lead to progressive physiological deterioration, ultimately necessitating urgent intervention. Case presentation: A 52-year-old male farmer presented with an incidentally discovered liver lesion during evaluation for drug allergy at a local hospital. Initial laboratory evaluation revealed normal hemoglobin (144 g/L) but elevated inflammatory markers (hsCRP 9.80 mg/L) and coagulation abnormalities (D-Dimer 4.01 µg/ml, FDP 9.60 µg/ml). Over a five-week observation period, the patient developed significant anemia, with hemoglobin decreasing to 93 g/L (a drop of 51 g/L), accompanied by worsening hypercoagulability (D-dimer 5.04 µg/ml, FDP 15.38 µg/ml). Progressive exertional dyspnea was noted. Computed tomography revealed a 7–8 cm defect in the right posterolateral diaphragm with extensive herniation of liver tissue into the thoracic cavity, initially misdiagnosed as a hepatic mass. Given the progressive laboratory deterioration, urgent surgical intervention was undertaken. The patient underwent laparoscopic diaphragmatic hernia repair with partial hepatectomy. About 9×5×4 cm segment of chronically herniated liver tissue was resected, and the diaphragmatic defect was repaired with continuous barbed sutures. The procedure lasted 4 hours and 10 minutes with minimal blood loss. Pathology confirmed fatty liver with incidental old schistosome egg deposition. Post-operatively, coagulation parameters normalized (D-Dimer 0.19 µg/ml, FDP 2.50 µg/ml) and the patient recovered uneventfully, being discharged on postoperative day 8. Conclusions Right-sided congenital diaphragmatic hernias with hepatic herniation into the thoracic cavity may lead to progressive systemic deterioration, including marked anemia and hypercoagulability, even in patients with minimal symptoms. Serial laboratory assessments are critical for detecting these changes and for guiding the optimal timing of surgical intervention.A successful outcome was achieved through laparoscopic partial liver resection and diaphragmatic hernia repair, thereby completely resolving the systemic abnormal symptoms. Congenital diaphragmatic hernia right-sided liver herniation thoracic cavity progressive anemia hypercoagulability laparoscopic repair hepatectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Congenital diaphragmatic hernias represent a clinically significant condition resulting from embryonic defects in diaphragmatic development. Right-sided congenital diaphragmatic hernias (CDHs) constitute a clinically significant condition arising from embryonic defects in diaphragmatic development. Right-sided CDHs with hepatic herniation into the thoracic cavity are substantially less common than left-sided hernias, a rarity largely attributed to the protective cushioning effect of the liver beneath the right hemidiaphragm [ 1 , 2 ]. These hernias, particularly Bochdalek hernias, may remain asymptomatic until adulthood, when increased intra-abdominal pressure or gradual enlargement of the defect precipitates herniation of abdominal organs-most frequently the liver-into the thoracic cavity [ 1 , 2 ]. The diagnostic challenge of right-sided CDHs with hepatic herniation is considerable. Right-sided hernias are far less common than left-sided ones, are often difficult to visualize on imaging studies, and typically present with subtle clinical features, increasing the risk of diagnostic delay [ 3 , 4 ]. Herniated hepatic tissue extending into the thoracic cavity may be misinterpreted on imaging as a primary hepatic mass, metastatic disease, or thoracic tumor [ 6 , 7 ]. This diagnostic difficulty is further compounded by the fact that many patients remain asymptomatic or exhibit only nonspecific symptoms. In CDHs, both the presence and extent of hepatic herniation into the thoracic cavity carry significant prognostic implications. Studies have shown that intrathoracic liver herniation is associated with cardiac anomalies and serves as a key predictor of postnatal disease severity [ 9 – 11 ]. The degree of liver herniation, often expressed as the percentage of hepatic tissue displaced, has been validated as a risk stratification tool in CDHs [ 10 , 11 ]. Reports of massive hepatic herniation into the thoracic cavity highlight the potential for extensive organ displacement, particularly in right-sided defects [ 8 ]. Although the acute presentation and management of CDHs with hepatic herniation are well documented, the natural history and systemic effects during periods of observation remain poorly understood. Most case reports emphasize diagnostic challenges and surgical outcomes, with limited data available regarding the physiological consequences of chronic hepatic herniation into the thoracic cavity over time. Elucidating these progressive changes is clinically important, as it informs the optimal timing and urgency of surgical intervention. We report the case of a 52-year-old male with a right-sided congenital diaphragmatic hernia and extensive hepatic herniation into the thoracic cavity, initially misdiagnosed as a hepatic mass. Notably, this case includes serial laboratory monitoring over a five-week observation period, which documented progressive anemia (a hemoglobin decline of 51 g/L) and worsening hypercoagulability. These longitudinal data provide rare insight into the systemic effects of chronic hepatic herniation into the thoracic cavity and underscore the importance of timely surgical intervention, even in patients with minimal symptoms. Case Presentation A 52-year-old Yi nationality male farmer presented to our hospital with the chief complaint of a “liver mass detected for more than five weeks.” The patient was married, with a height of 158 cm and a weight of 60 kg (BMI: 24.0 kg/m²).In early July 2024, approximately five weeks prior to admission, he visited a local hospital for evaluation of an amoxicillin allergy following treatment for an upper respiratory tract infection. During this assessment, routine imaging studies incidentally revealed a suspected hepatic mass. The patient had no history of significant trauma but had undergone laparoscopic cholecystectomy at a local hospital seven years earlier. Based on the imaging findings, clinical presentation, and medical history, the lesion was most consistent with a long-standing, asymptomatic congenital diaphragmatic hernia. Initial presentation and progressive deterioration Initial laboratory evaluation at a local hospital on July 3, 2024, revealed several concerning abnormalities despite the patient being relatively asymptomatic: hemoglobin 144 g/L (within normal range), elevated inflammatory markers (hsCRP 9.80 mg/L), and evidence of a hypercoagulable state, including D-dimer 4.01 µg/mL (normal < 0.55 µg/mL), fibrin degradation products (FDP) 9.60 µg/mL (normal < 5 µg/mL), and fibrinogen 4.10 g/L (normal 1.8–3.5 g/L).Over the subsequent month, the patient reported belching and a bitter or sour taste in the mouth along with dyspnea but denied abdominal pain, abdominal distension, cough, sputum production, nausea, vomiting, diarrhea, constipation, melena, chills, or fever. During the five-week interval between the initial evaluation and admission to our tertiary center, serial laboratory monitoring demonstrated progressive deterioration: the patient developed significant anemia, with hemoglobin declining from 144 g/L to 93 g/L (a drop of 51 g/L), and worsening hypercoagulability, with D-dimer rising from 4.01 to 5.04 µg/mL and FDP increasing from 9.60 to 15.38 µg/mL. This progressive laboratory deterioration prompted urgent referral to our tertiary care center for comprehensive evaluation and management. The patient was admitted on August 9, 2024. Physical examination On admission, vital signs were as follows: temperature 36.2°C, pulse 115 beats per minute (tachycardia, likely secondary to anemia), respiratory rate 20 breaths per minute, and blood pressure 117/83 mmHg. The patient appeared of medium build with pallor consistent with anemia. Respiratory examination revealed decreased breath sounds in the right lower lung field, consistent with compression of the right lung by herniated abdominal contents within the thoracic cavity. The abdomen was soft and non-tender, with no palpable masses, and bowel sounds were normal. Imaging findings Chest radiography demonstrated marked elevation of the right hemidiaphragm, accompanied by a leftward shift of the mediastinum, findings consistent with a right-sided diaphragmatic hernia and herniation of abdominal contents into the thoracic cavity(Fig. 1 ). Computed tomography of the chest and Chest X-ray revealed about 7cm defect in the right posterolateral diaphragm, associated with extensive herniation of hepatic tissue into the thoracic cavity (Fig. 2 ). The herniated liver measured approximately 72×44×70mm, occupying a substantial portion of the right thoracic cavity (Fig. 2 a- 2 c). Owing to the atypical appearance of liver tissue within the thoracic cavity, the lesion was initially misinterpreted as a hepatic mass or occupying lesion. Surgical intervention Given the progressive laboratory deterioration and the extensive herniation of hepatic tissue into the thoracic cavity, surgical intervention was undertaken. The patient underwent laparoscopic repair of the diaphragmatic hernia with partial hepatectomy on August 11, 2024. The procedure was performed laparoscopically with strategic trocar placement (Fig. 3 ). Initial exploration revealed a large defect in the right posterolateral diaphragm with substantial herniation of liver tissue into the thoracic cavity. After complete reduction of the herniated liver, the hepatic volume continued to cause significant compression of the thoracic cavity(Fig. 4 a-b); therefore, partial resection of the herniated liver tissue was deemed necessary. Subsequently, definitive diaphragmatic hernia repair was performed. The laparoscopic view clearly demonstrated a large diaphragmatic defect with herniated liver tissue extending into the thoracic cavity (Fig. 5 ). The liver had protruded through the posterior diaphragmatic defect and occupied a substantial portion of the right thoracic cavity. Following careful adhesiolysis, the herniated liver was fully mobilized and reduced from the thoracic cavity. Given the presence of chronic ischemic changes and the extent of herniation, partial hepatectomy of the affected segment was deemed necessary. Approximately 9 × 8 × 5 cm of chronically herniated hepatic tissue was resected (Fig. 6 a). Subsequently, the diaphragmatic defect was repaired using continuous barbed sutures, with meticulous attention to achieving a tension-free closure and preventing recurrence.The total operative time was 4 hours and 10 minutes, with minimal intraoperative blood loss estimated at approximately 200 mL.Pathological examination of the resected liver tissue confirmed fatty liver changes with incidental old schistosome egg deposition, likely related to the patient’s rural farming occupation and exposure to contaminated water sources (Fig. 6 b). The chronic ischemic changes in the liver tissue that had herniated into the thoracic cavity were consistent with prolonged compression and altered blood flow. There was no evidence of malignancy. Postoperative course The patient had an uneventful postoperative course. A postoperative chest radiograph demonstrated satisfactory anatomical repair, with re-expansion of the right lung and restoration of normal thoracic anatomy (Fig. 7 ). Laboratory parameters showed marked improvement, with normalization of coagulation abnormalities: D-dimer decreased to 0.19 µg/mL and fibrin degradation products (FDP) to 2.50 µg/mL. Hemoglobin levels gradually improved with supportive care. The patient was discharged on postoperative day 8 on a regular diet. At follow-up, the patient remained in good condition with no evidence of recurrent herniation into the thoracic cavity. Discussion The diaphragm is a muscular structure that separates the high-pressure abdominal cavity from the negative-pressure thoracic cavity. Right-sided congenital diaphragmatic hernias with liver herniation into the thoracic cavity are far less common than left-sided hernias. The functional anatomy of the diaphragm largely accounts for both the rarity and the diagnostic challenges associated with right-sided hernias. The close apposition of the liver to the undersurface of the right hemidiaphragm provides a physical barrier that reduces the likelihood of herniation; however, when a defect is present, the liver itself most commonly herniates into the thoracic cavity [ 2 , 4 ]. Congenital diaphragmatic hernias, particularly Bochdalek hernias, arise from failure of the pleuroperitoneal membrane to close during embryonic development. When such defects occur on the right side, the pressure gradient between the abdominal and thoracic cavities can drive gradual migration of the liver into the thoracic cavity. Clinical presentation is variable and corresponds to the anatomical progression of each case. Patients may remain asymptomatic until adulthood, sometimes decades after birth, when herniation becomes clinically apparent. In many instances, the initial presentation is related to compression of intrathoracic structures or systemic effects resulting from the chronically herniated liver [ 2 , 9 ]. This case is notable for several reasons. First, it provides rare longitudinal data on the systemic effects of chronic right-sided congenital diaphragmatic hernia with liver herniation into the thoracic cavity over a five-week observation period. Serial laboratory monitoring documented progressive anemia, with hemoglobin declining by 51 g/L, and worsening hypercoagulability, evidenced by an increase in D-dimer from 4.01 to 5.04 µg/mL and FDP from 9.60 to 15.38 µg/mL. These findings suggest that the herniated liver tissue underwent progressive ischemic changes, resulting in hemolysis and consumption coagulopathy. This evidence challenges the conventional view that stable, minimally symptomatic congenital diaphragmatic hernias with liver herniation can be safely observed, highlighting the need for timely surgical intervention. Second, the initial misdiagnosis of the herniated liver as a “hepatic mass” underscores the diagnostic challenges associated with right-sided congenital diaphragmatic hernias. Herniated hepatic tissue within the thoracic cavity may mimic primary hepatic tumors, metastatic lesions, or thoracic neoplasms on imaging studies [ 6 , 7 ]. A high index of clinical suspicion is essential, particularly when liver tissue is visualized in an abnormal thoracic location. Computed tomography, with careful evaluation of the diaphragmatic contour and utilization of multiplanar reconstruction, is crucial for accurate diagnosis and for identifying the diaphragmatic defect that permits liver herniation into the thoracic cavity. Third, the successful laparoscopic management in this case demonstrates that minimally invasive approaches can be safely employed even in complex congenital diaphragmatic hernias with extensive liver herniation into the thoracic cavity requiring partial hepatectomy. Laparoscopic repair has been successfully applied for right-sided congenital diaphragmatic hernias with hepatic incarceration [ 1 ]. The laparoscopic approach offers several advantages, including reduced postoperative pain, shorter hospital stay, and faster recovery. Key technical considerations include strategic trocar placement to optimize visualization of both the diaphragmatic defect and the herniated liver within the thoracic cavity, careful adhesiolysis to mobilize the liver without causing injury, and meticulous repair of the diaphragmatic defect to prevent recurrence. In particularly complex cases with massive liver prolapse into the thoracic cavity, combined laparoscopic and thoracoscopic approaches have also been described [ 2 ]. We decision to perform partial hepatectomy in addition to hernia repair was guided by the extent of chronic ischemic changes in the liver tissue herniated into the thoracic cavity. The resected specimen measured approximately 9 × 8 × 5 cm and demonstrated fatty degeneration with deposition of old schistosome eggs. Cases of massive liver herniation into the thoracic cavity requiring partial hepatectomy have been reported previously [ 8 ]. The incidental finding of schistosome eggs likely reflects the patient’s rural farming background and prior exposure to contaminated water, a common risk factor in certain regions of China. D-Dimer normalized from 5.04 to 0.19 µg/mL and FDP from 15.38 to 2.50 µg/mL-confirms that the chronically herniated liver tissue within the thoracic cavity was the source of the hypercoagulable state. This resolution supports the hypothesis that the herniated liver had been undergoing progressive ischemic injury, leading to the release of procoagulant factors. All cases of congenital diaphragmatic hernia with liver herniation into the thoracic cavity ultimately require surgical correction [ 1 ]. However, the specific approach may vary considerably depending on the extent and chronicity of the herniation. In the present case, a laparoscopic abdominal approach was sufficient to reduce the liver from the thoracic cavity and repair the diaphragmatic defect. The chronic nature of the herniation necessitated extensive adhesiolysis and partial hepatectomy, but the repair was successfully completed with excellent clinical outcomes. Conclusions This case illustrates several important clinical lessons regarding right-sided congenital diaphragmatic hernias with liver herniation into the thoracic cavity. First, such hernias can lead to progressive systemic deterioration, including significant anemia and hypercoagulability, even in minimally symptomatic patients, highlighting the importance of serial laboratory monitoring. Second, herniated liver tissue within the thoracic cavity can be misdiagnosed as a hepatic mass, emphasizing the need for high clinical suspicion and careful imaging interpretation to identify the diaphragmatic defect. Third, laparoscopic repair, including reduction of the liver and partial hepatectomy when necessary, is feasible and can achieve excellent outcomes with complete resolution of systemic abnormalities. Finally, the longitudinal data from this case support timely surgical intervention rather than prolonged observation in patients with congenital diaphragmatic hernias and liver herniation into the thoracic cavity. Abbreviations CDHs:Congenital diaphragmatic hernias;BMI: Body mass index; CT: Computed tomography; FDP: Fibrin degradation products; GGT: Gamma-glutamyl transferase; hsCRP: High-sensitivity C-reactive protein Declarations Acknowledgements The authors sincerely thank the patient for their permission to document and publish this case. Funding This study was supported by the project of the Yunnan Provincial Department of Education(2024J084)and the science and technology project of Dali City, Yunnan Province(2023KBG059). Ethics approval and consent to participants Ethical approval was not needed; however, the confidentiality of participants’ information was kept secret and was used only for this publication without patients’ identification. Consent for publication Written, informed consent for publication was obtained from all participants in this study. Competing interests The authors declare no competing interests Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Authors’ contributions Majaliwa Bernard Ntazimila: Conceptualization,Writing-original draft. Tao Zhang:Writing-original draft. Chunmeng Ning:Pathology Image Acquisition. Xing-Guang Yang: Writing-original draft, Writing – review & editing. References Alexi B, et al. Right sided posterior diaphragmatic hernia with liver incarceration: A case report. Clin Case Rep. 2024;12(8):e9296. https://doi.org/10.1002/ccr3.9296 . Mikami S, et al. Combined laparoscopic and thoracoscopic repair of adult right-sided Bochdalek hernia with massive liver prolapse: A case report. World J Clin Cases. 2024;12(14):2420–5. https://doi.org/10.12998/wjcc.v12.i14.2420 . Kuppusamy A, et al. Delayed diagnosis of traumatic diaphragmatic rupture with herniation of the liver: a case report. Ulus Travma Acil Cerrahi Derg. 2012;18(2):175–7. https://doi.org/10.5505/tjtes.2012.79477 . Jain N, et al. Delayed presentation of a post-traumatic large right diaphragmatic hernia displacing liver and gallbladder - A case report. Asian J Endosc Surg. 2022;15(2):388–92. https://doi.org/10.1111/ases.13015 . Søreide K, Reite A, Haaverstad R. Missed diagnosis of a large, right-sided diaphragmatic rupture with herniated liver and concomitant liver laceration after blunt trauma: consequences for delayed surgical repair. J Surg Case Rep. 2017;2017(8). https://doi.org/10.1093/jscr/rjx157 . Ikeda T, et al. Liver herniation mimicking a thoracic tumor with restoration of the liver surface structure on closure of the hernia orifice under thoracoscopic surgery. Asian J Endosc Surg. 2022;15(4):805–8. https://doi.org/10.1111/ases.13067 . Huang IH, et al. Non-Traumatic Diaphragmatic Hepatic Hernia: A Rare Case of Liver Herniation Into the Lung. Respirol Case Rep. 2025;13(6):e70250. https://doi.org/10.1002/rcr2.70250 . Kesavaramanujam S, et al. Total thoracic herniation of the liver: a case of delayed right-sided diaphragmatic hernia after blunt trauma. Surg Case Rep. 2020;6(1):178. https://doi.org/10.1186/s40792-020-00941-7 . Stressig R, et al. Intrathoracic herniation of the liver (‘liver-up’) is associated with predominant left heart hypoplasia in human fetuses with left diaphragmatic hernia. Ultrasound Obstet Gynecol. 2011;37(3):272–6. https://doi.org/10.1002/uog.7747 . Olutoye OO 2, et al. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res. 2023;282:168–73. https://doi.org/10.1016/j.jss.2022.09.002 . Mullassery D, et al. Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2010;35(5):609–14. https://doi.org/10.1002/uog.7586 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Apr, 2026 Reviews received at journal 04 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviews received at journal 28 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers invited by journal 13 Mar, 2026 Editor invited by journal 26 Feb, 2026 Editor assigned by journal 22 Jan, 2026 Submission checks completed at journal 22 Jan, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8645529","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":579484186,"identity":"dfa609f7-e131-4a7a-9a22-53e5b91a804f","order_by":0,"name":"Majaliwa Bernard Ntazimila","email":"","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":false,"prefix":"","firstName":"Majaliwa","middleName":"Bernard","lastName":"Ntazimila","suffix":""},{"id":579484191,"identity":"d26c09a2-37b9-466a-880d-8f3f7de970bb","order_by":1,"name":"Tao Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Zhang","suffix":""},{"id":579484192,"identity":"4af84640-5435-4c8d-9932-f012e2afc8fc","order_by":2,"name":"Chunmeng Ning","email":"","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":false,"prefix":"","firstName":"Chunmeng","middleName":"","lastName":"Ning","suffix":""},{"id":579484193,"identity":"847323f8-8342-4306-b98e-f12cf6306df1","order_by":3,"name":"Xingguang Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYBADxgYG5gMHPvwgTQtb4sGZPaRp4TE+zMFGhFKDG+nXJH7uqJXtZz/z4TADD4M8v9gBAlrOnCmT7D1z3HhmT+6GwwUWDIYzZycQ0HK8J02Ct+1Y4oYbvBsOz+BhSDC4TUjLYZ40yb9gLTwPDvOwEaPlePsxad62GpAWBuK0SJ45w2wt23YA6Jc0A2AgSxD2C9+N9Ic337bVAUPs8OMPH37YyPNLE9CicIDHAEgdhvEl8CsHAfkG9gdAqo6wylEwCkbBKBi5AAD1UE2yFlOK4wAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Dali University","correspondingAuthor":true,"prefix":"","firstName":"Xingguang","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-01-20 06:11:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8645529/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8645529/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101881371,"identity":"4cffcaef-f9c6-4b5e-b2a7-cb6ce8cfded4","added_by":"auto","created_at":"2026-02-04 15:11:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":455204,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative chest radiograph showing elevation of the right hemidiaphragm and leftward mediastinal shift, consistent with right-sided diaphragmatic hernia with herniation of abdominal contents into the thoracic cavity. (White arrow)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/af0430fcf2aa825b5573de25.png"},{"id":101880897,"identity":"f1d55f9b-fbaf-4310-9900-db12471ef64d","added_by":"auto","created_at":"2026-02-04 15:07:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":465921,"visible":true,"origin":"","legend":"\u003cp\u003eChest X-ray(a-b)and axial chest CT examination (c) showing extensive liver herniation into the right thoracic cavity.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/ab871a133723c721efe24ce3.png"},{"id":101942889,"identity":"b2842530-5d72-4d80-9fbd-239000d227cd","added_by":"auto","created_at":"2026-02-05 09:39:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1564091,"visible":true,"origin":"","legend":"\u003cp\u003eDiagram illustrating trocar placement sites for the laparoscopic approach. Strategic port placement allowed optimal visualization and access for mobilizing the herniated liver from the thoracic cavity, performing adhesiolysis, hepatectomy, and diaphragmatic repair.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/5ff4a26c614bb3533bd12fb8.png"},{"id":101881718,"identity":"35ac66ec-d1c5-4919-a02d-b8d9d48353d4","added_by":"auto","created_at":"2026-02-04 15:15:21","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":1355781,"visible":true,"origin":"","legend":"\u003cp\u003eLaparoscopic retrieval of the liver from the chest cavity back into the abdominal cavity (a-b,white arrow),the hepatic volume continued to cause significant compression of the thoracic cavity.The hernia contents consisted of the liver, and the neck of the hernia sac is indicated (b,blackarrow).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/269749e3373fe6f551321d0f.png"},{"id":101881237,"identity":"e5bf6f8f-1dcd-4280-8ae5-d1b582c98b18","added_by":"auto","created_at":"2026-02-04 15:11:04","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1867446,"visible":true,"origin":"","legend":"\u003cp\u003eLaparoscopic view showing the large right posterolateral diaphragmatic defect with extensive liver herniation into the thoracic cavity,and the lung within the thoracic cavity can be seen (white arrow).\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/23bf48c2da654de8ff0e85bf.png"},{"id":101880484,"identity":"1d140765-a41e-40c7-94b5-b9cca0b78c84","added_by":"auto","created_at":"2026-02-04 15:02:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":3002550,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Resected liver specimen (9 × 8 × 5 cm) that had been chronically herniated into the thoracic cavity, showing fatty changes and chronic ischemic injury. (b) Pathology confirmed fatty liver (white arrow) .(c) Pathological examination confirmed the presence of incidental old schistosome egg deposition (black arrow),H\u0026amp;E staining × 400.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/ae5527c37a7bdcf9e50632a1.png"},{"id":101880836,"identity":"364145d3-8f0e-488b-a043-f58f6004d15d","added_by":"auto","created_at":"2026-02-04 15:06:50","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":390409,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative chest radiograph showing successful diaphragmatic repair with re-expansion of the right lung and restoration of normal thoracic anatomy. No residual herniation into the thoracic cavity is present.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/a8c23e8d1e0ffd02c9285143.png"},{"id":102397212,"identity":"ff11dc17-abbf-4e7a-b8f9-d532cd5a512b","added_by":"auto","created_at":"2026-02-11 10:10:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11648079,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8645529/v1/33bf7d71-1dbc-4089-b45d-110d80ee43fa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Right-sided Congenital Diaphragmatic Hernia with Herniation of the Liver into the Thoracic Cavity: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eCongenital diaphragmatic hernias represent a clinically significant condition resulting from embryonic defects in diaphragmatic development. Right-sided congenital diaphragmatic hernias (CDHs) constitute a clinically significant condition arising from embryonic defects in diaphragmatic development. Right-sided CDHs with hepatic herniation into the thoracic cavity are substantially less common than left-sided hernias, a rarity largely attributed to the protective cushioning effect of the liver beneath the right hemidiaphragm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These hernias, particularly Bochdalek hernias, may remain asymptomatic until adulthood, when increased intra-abdominal pressure or gradual enlargement of the defect precipitates herniation of abdominal organs-most frequently the liver-into the thoracic cavity [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe diagnostic challenge of right-sided CDHs with hepatic herniation is considerable. Right-sided hernias are far less common than left-sided ones, are often difficult to visualize on imaging studies, and typically present with subtle clinical features, increasing the risk of diagnostic delay [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Herniated hepatic tissue extending into the thoracic cavity may be misinterpreted on imaging as a primary hepatic mass, metastatic disease, or thoracic tumor [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This diagnostic difficulty is further compounded by the fact that many patients remain asymptomatic or exhibit only nonspecific symptoms.\u003c/p\u003e \u003cp\u003eIn CDHs, both the presence and extent of hepatic herniation into the thoracic cavity carry significant prognostic implications. Studies have shown that intrathoracic liver herniation is associated with cardiac anomalies and serves as a key predictor of postnatal disease severity [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The degree of liver herniation, often expressed as the percentage of hepatic tissue displaced, has been validated as a risk stratification tool in CDHs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Reports of massive hepatic herniation into the thoracic cavity highlight the potential for extensive organ displacement, particularly in right-sided defects [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the acute presentation and management of CDHs with hepatic herniation are well documented, the natural history and systemic effects during periods of observation remain poorly understood. Most case reports emphasize diagnostic challenges and surgical outcomes, with limited data available regarding the physiological consequences of chronic hepatic herniation into the thoracic cavity over time. Elucidating these progressive changes is clinically important, as it informs the optimal timing and urgency of surgical intervention.\u003c/p\u003e \u003cp\u003eWe report the case of a 52-year-old male with a right-sided congenital diaphragmatic hernia and extensive hepatic herniation into the thoracic cavity, initially misdiagnosed as a hepatic mass. Notably, this case includes serial laboratory monitoring over a five-week observation period, which documented progressive anemia (a hemoglobin decline of 51 g/L) and worsening hypercoagulability. These longitudinal data provide rare insight into the systemic effects of chronic hepatic herniation into the thoracic cavity and underscore the importance of timely surgical intervention, even in patients with minimal symptoms.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 52-year-old Yi nationality male farmer presented to our hospital with the chief complaint of a \u0026ldquo;liver mass detected for more than five weeks.\u0026rdquo; The patient was married, with a height of 158 cm and a weight of 60 kg (BMI: 24.0 kg/m\u0026sup2;).In early July 2024, approximately five weeks prior to admission, he visited a local hospital for evaluation of an amoxicillin allergy following treatment for an upper respiratory tract infection. During this assessment, routine imaging studies incidentally revealed a suspected hepatic mass. The patient had no history of significant trauma but had undergone laparoscopic cholecystectomy at a local hospital seven years earlier. Based on the imaging findings, clinical presentation, and medical history, the lesion was most consistent with a long-standing, asymptomatic congenital diaphragmatic hernia.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInitial presentation and progressive deterioration\u003c/h2\u003e \u003cp\u003eInitial laboratory evaluation at a local hospital on July 3, 2024, revealed several concerning abnormalities despite the patient being relatively asymptomatic: hemoglobin 144 g/L (within normal range), elevated inflammatory markers (hsCRP 9.80 mg/L), and evidence of a hypercoagulable state, including D-dimer 4.01 \u0026micro;g/mL (normal\u0026thinsp;\u0026lt;\u0026thinsp;0.55 \u0026micro;g/mL), fibrin degradation products (FDP) 9.60 \u0026micro;g/mL (normal\u0026thinsp;\u0026lt;\u0026thinsp;5 \u0026micro;g/mL), and fibrinogen 4.10 g/L (normal 1.8\u0026ndash;3.5 g/L).Over the subsequent month, the patient reported belching and a bitter or sour taste in the mouth along with dyspnea but denied abdominal pain, abdominal distension, cough, sputum production, nausea, vomiting, diarrhea, constipation, melena, chills, or fever.\u003c/p\u003e \u003cp\u003eDuring the five-week interval between the initial evaluation and admission to our tertiary center, serial laboratory monitoring demonstrated progressive deterioration: the patient developed significant anemia, with hemoglobin declining from 144 g/L to 93 g/L (a drop of 51 g/L), and worsening hypercoagulability, with D-dimer rising from 4.01 to 5.04 \u0026micro;g/mL and FDP increasing from 9.60 to 15.38 \u0026micro;g/mL. This progressive laboratory deterioration prompted urgent referral to our tertiary care center for comprehensive evaluation and management. The patient was admitted on August 9, 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePhysical examination\u003c/h3\u003e\n\u003cp\u003eOn admission, vital signs were as follows: temperature 36.2\u0026deg;C, pulse 115 beats per minute (tachycardia, likely secondary to anemia), respiratory rate 20 breaths per minute, and blood pressure 117/83 mmHg. The patient appeared of medium build with pallor consistent with anemia. Respiratory examination revealed decreased breath sounds in the right lower lung field, consistent with compression of the right lung by herniated abdominal contents within the thoracic cavity. The abdomen was soft and non-tender, with no palpable masses, and bowel sounds were normal.\u003c/p\u003e\n\u003ch3\u003eImaging findings\u003c/h3\u003e\n\u003cp\u003eChest radiography demonstrated marked elevation of the right hemidiaphragm, accompanied by a leftward shift of the mediastinum, findings consistent with a right-sided diaphragmatic hernia and herniation of abdominal contents into the thoracic cavity(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComputed tomography of the chest and Chest X-ray revealed about 7cm defect in the right posterolateral diaphragm, associated with extensive herniation of hepatic tissue into the thoracic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The herniated liver measured approximately 72\u0026times;44\u0026times;70mm, occupying a substantial portion of the right thoracic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea-\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). Owing to the atypical appearance of liver tissue within the thoracic cavity, the lesion was initially misinterpreted as a hepatic mass or occupying lesion.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSurgical intervention\u003c/h3\u003e\n\u003cp\u003eGiven the progressive laboratory deterioration and the extensive herniation of hepatic tissue into the thoracic cavity, surgical intervention was undertaken. The patient underwent laparoscopic repair of the diaphragmatic hernia with partial hepatectomy on August 11, 2024.\u003c/p\u003e \u003cp\u003eThe procedure was performed laparoscopically with strategic trocar placement (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Initial exploration revealed a large defect in the right posterolateral diaphragm with substantial herniation of liver tissue into the thoracic cavity. After complete reduction of the herniated liver, the hepatic volume continued to cause significant compression of the thoracic cavity(Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003ea-b); therefore, partial resection of the herniated liver tissue was deemed necessary. Subsequently, definitive diaphragmatic hernia repair was performed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe laparoscopic view clearly demonstrated a large diaphragmatic defect with herniated liver tissue extending into the thoracic cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The liver had protruded through the posterior diaphragmatic defect and occupied a substantial portion of the right thoracic cavity. Following careful adhesiolysis, the herniated liver was fully mobilized and reduced from the thoracic cavity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGiven the presence of chronic ischemic changes and the extent of herniation, partial hepatectomy of the affected segment was deemed necessary. Approximately 9 \u0026times; 8 \u0026times; 5 cm of chronically herniated hepatic tissue was resected (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ea). Subsequently, the diaphragmatic defect was repaired using continuous barbed sutures, with meticulous attention to achieving a tension-free closure and preventing recurrence.The total operative time was 4 hours and 10 minutes, with minimal intraoperative blood loss estimated at approximately 200 mL.Pathological examination of the resected liver tissue confirmed fatty liver changes with incidental old schistosome egg deposition, likely related to the patient\u0026rsquo;s rural farming occupation and exposure to contaminated water sources (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003eb). The chronic ischemic changes in the liver tissue that had herniated into the thoracic cavity were consistent with prolonged compression and altered blood flow. There was no evidence of malignancy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003ePostoperative course\u003c/h3\u003e\n\u003cp\u003eThe patient had an uneventful postoperative course. A postoperative chest radiograph demonstrated satisfactory anatomical repair, with re-expansion of the right lung and restoration of normal thoracic anatomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e). Laboratory parameters showed marked improvement, with normalization of coagulation abnormalities: D-dimer decreased to 0.19 \u0026micro;g/mL and fibrin degradation products (FDP) to 2.50 \u0026micro;g/mL. Hemoglobin levels gradually improved with supportive care. The patient was discharged on postoperative day 8 on a regular diet. At follow-up, the patient remained in good condition with no evidence of recurrent herniation into the thoracic cavity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe diaphragm is a muscular structure that separates the high-pressure abdominal cavity from the negative-pressure thoracic cavity. Right-sided congenital diaphragmatic hernias with liver herniation into the thoracic cavity are far less common than left-sided hernias. The functional anatomy of the diaphragm largely accounts for both the rarity and the diagnostic challenges associated with right-sided hernias. The close apposition of the liver to the undersurface of the right hemidiaphragm provides a physical barrier that reduces the likelihood of herniation; however, when a defect is present, the liver itself most commonly herniates into the thoracic cavity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCongenital diaphragmatic hernias, particularly Bochdalek hernias, arise from failure of the pleuroperitoneal membrane to close during embryonic development. When such defects occur on the right side, the pressure gradient between the abdominal and thoracic cavities can drive gradual migration of the liver into the thoracic cavity. Clinical presentation is variable and corresponds to the anatomical progression of each case. Patients may remain asymptomatic until adulthood, sometimes decades after birth, when herniation becomes clinically apparent. In many instances, the initial presentation is related to compression of intrathoracic structures or systemic effects resulting from the chronically herniated liver [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case is notable for several reasons. First, it provides rare longitudinal data on the systemic effects of chronic right-sided congenital diaphragmatic hernia with liver herniation into the thoracic cavity over a five-week observation period. Serial laboratory monitoring documented progressive anemia, with hemoglobin declining by 51 g/L, and worsening hypercoagulability, evidenced by an increase in D-dimer from 4.01 to 5.04 \u0026micro;g/mL and FDP from 9.60 to 15.38 \u0026micro;g/mL. These findings suggest that the herniated liver tissue underwent progressive ischemic changes, resulting in hemolysis and consumption coagulopathy. This evidence challenges the conventional view that stable, minimally symptomatic congenital diaphragmatic hernias with liver herniation can be safely observed, highlighting the need for timely surgical intervention.\u003c/p\u003e \u003cp\u003eSecond, the initial misdiagnosis of the herniated liver as a \u0026ldquo;hepatic mass\u0026rdquo; underscores the diagnostic challenges associated with right-sided congenital diaphragmatic hernias. Herniated hepatic tissue within the thoracic cavity may mimic primary hepatic tumors, metastatic lesions, or thoracic neoplasms on imaging studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A high index of clinical suspicion is essential, particularly when liver tissue is visualized in an abnormal thoracic location. Computed tomography, with careful evaluation of the diaphragmatic contour and utilization of multiplanar reconstruction, is crucial for accurate diagnosis and for identifying the diaphragmatic defect that permits liver herniation into the thoracic cavity.\u003c/p\u003e \u003cp\u003eThird, the successful laparoscopic management in this case demonstrates that minimally invasive approaches can be safely employed even in complex congenital diaphragmatic hernias with extensive liver herniation into the thoracic cavity requiring partial hepatectomy. Laparoscopic repair has been successfully applied for right-sided congenital diaphragmatic hernias with hepatic incarceration [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The laparoscopic approach offers several advantages, including reduced postoperative pain, shorter hospital stay, and faster recovery. Key technical considerations include strategic trocar placement to optimize visualization of both the diaphragmatic defect and the herniated liver within the thoracic cavity, careful adhesiolysis to mobilize the liver without causing injury, and meticulous repair of the diaphragmatic defect to prevent recurrence. In particularly complex cases with massive liver prolapse into the thoracic cavity, combined laparoscopic and thoracoscopic approaches have also been described [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe decision to perform partial hepatectomy in addition to hernia repair was guided by the extent of chronic ischemic changes in the liver tissue herniated into the thoracic cavity. The resected specimen measured approximately 9 \u0026times; 8 \u0026times; 5 cm and demonstrated fatty degeneration with deposition of old schistosome eggs. Cases of massive liver herniation into the thoracic cavity requiring partial hepatectomy have been reported previously [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The incidental finding of schistosome eggs likely reflects the patient\u0026rsquo;s rural farming background and prior exposure to contaminated water, a common risk factor in certain regions of China.\u003c/p\u003e \u003cp\u003eD-Dimer normalized from 5.04 to 0.19 \u0026micro;g/mL and FDP from 15.38 to 2.50 \u0026micro;g/mL-confirms that the chronically herniated liver tissue within the thoracic cavity was the source of the hypercoagulable state. This resolution supports the hypothesis that the herniated liver had been undergoing progressive ischemic injury, leading to the release of procoagulant factors.\u003c/p\u003e \u003cp\u003eAll cases of congenital diaphragmatic hernia with liver herniation into the thoracic cavity ultimately require surgical correction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the specific approach may vary considerably depending on the extent and chronicity of the herniation. In the present case, a laparoscopic abdominal approach was sufficient to reduce the liver from the thoracic cavity and repair the diaphragmatic defect. The chronic nature of the herniation necessitated extensive adhesiolysis and partial hepatectomy, but the repair was successfully completed with excellent clinical outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case illustrates several important clinical lessons regarding right-sided congenital diaphragmatic hernias with liver herniation into the thoracic cavity. First, such hernias can lead to progressive systemic deterioration, including significant anemia and hypercoagulability, even in minimally symptomatic patients, highlighting the importance of serial laboratory monitoring. Second, herniated liver tissue within the thoracic cavity can be misdiagnosed as a hepatic mass, emphasizing the need for high clinical suspicion and careful imaging interpretation to identify the diaphragmatic defect. Third, laparoscopic repair, including reduction of the liver and partial hepatectomy when necessary, is feasible and can achieve excellent outcomes with complete resolution of systemic abnormalities. Finally, the longitudinal data from this case support timely surgical intervention rather than prolonged observation in patients with congenital diaphragmatic hernias and liver herniation into the thoracic cavity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCDHs:Congenital diaphragmatic hernias;BMI: Body mass index; CT: Computed tomography; FDP: Fibrin degradation products; GGT: Gamma-glutamyl transferase; hsCRP: High-sensitivity C-reactive protein\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank the patient for their permission to document and publish this case.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study was supported by the project of the Yunnan Provincial Department of Education(2024J084)and the science and technology project of Dali City, Yunnan Province(2023KBG059).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not needed; however, the confidentiality of participants\u0026rsquo;\u0026nbsp;information was kept secret and was used only for this publication without patients\u0026rsquo;\u0026nbsp;identification.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten, informed consent for publication was obtained from all participants in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMajaliwa Bernard Ntazimila: Conceptualization,Writing-original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTao Zhang:Writing-original draft.\u003c/p\u003e\n\u003cp\u003eChunmeng Ning:Pathology Image Acquisition.\u003c/p\u003e\n\u003cp\u003eXing-Guang Yang: Writing-original draft, Writing \u0026ndash; review \u0026amp; editing. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlexi B, et al. 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Intrathoracic herniation of the liver (\u0026lsquo;liver-up\u0026rsquo;) is associated with predominant left heart hypoplasia in human fetuses with left diaphragmatic hernia. Ultrasound Obstet Gynecol. 2011;37(3):272\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/uog.7747\u003c/span\u003e\u003cspan address=\"10.1002/uog.7747\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlutoye OO 2, et al. Risk Stratification by Percent Liver Herniation in Congenital Diaphragmatic Hernia. J Surg Res. 2023;282:168\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jss.2022.09.002\u003c/span\u003e\u003cspan address=\"10.1016/j.jss.2022.09.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMullassery D, et al. Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2010;35(5):609\u0026ndash;14. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/uog.7586\u003c/span\u003e\u003cspan address=\"10.1002/uog.7586\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Congenital diaphragmatic hernia, right-sided, liver herniation, thoracic cavity, progressive anemia, hypercoagulability, laparoscopic repair, hepatectomy","lastPublishedDoi":"10.21203/rs.3.rs-8645529/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8645529/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRight-sided congenital diaphragmatic hernias (CDHs) with liver herniation into the thoracic cavity are rare clinical entities that may remain asymptomatic for extended periods. However, the systemic effects during observation are poorly documented. This case highlights that hernias appearing clinically stable may nevertheless lead to progressive physiological deterioration, ultimately necessitating urgent intervention.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 52-year-old male farmer presented with an incidentally discovered liver lesion during evaluation for drug allergy at a local hospital. Initial laboratory evaluation revealed normal hemoglobin (144 g/L) but elevated inflammatory markers (hsCRP 9.80 mg/L) and coagulation abnormalities (D-Dimer 4.01 \u0026micro;g/ml, FDP 9.60 \u0026micro;g/ml). Over a five-week observation period, the patient developed significant anemia, with hemoglobin decreasing to 93 g/L (a drop of 51 g/L), accompanied by worsening hypercoagulability (D-dimer 5.04 \u0026micro;g/ml, FDP 15.38 \u0026micro;g/ml). Progressive exertional dyspnea was noted. Computed tomography revealed a 7\u0026ndash;8 cm defect in the right posterolateral diaphragm with extensive herniation of liver tissue into the thoracic cavity, initially misdiagnosed as a hepatic mass. Given the progressive laboratory deterioration, urgent surgical intervention was undertaken. The patient underwent laparoscopic diaphragmatic hernia repair with partial hepatectomy. About 9\u0026times;5\u0026times;4 cm segment of chronically herniated liver tissue was resected, and the diaphragmatic defect was repaired with continuous barbed sutures. The procedure lasted 4 hours and 10 minutes with minimal blood loss. Pathology confirmed fatty liver with incidental old schistosome egg deposition. Post-operatively, coagulation parameters normalized (D-Dimer 0.19 \u0026micro;g/ml, FDP 2.50 \u0026micro;g/ml) and the patient recovered uneventfully, being discharged on postoperative day 8.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eRight-sided congenital diaphragmatic hernias with hepatic herniation into the thoracic cavity may lead to progressive systemic deterioration, including marked anemia and hypercoagulability, even in patients with minimal symptoms. Serial laboratory assessments are critical for detecting these changes and for guiding the optimal timing of surgical intervention.A successful outcome was achieved through laparoscopic partial liver resection and diaphragmatic hernia repair, thereby completely resolving the systemic abnormal symptoms.\u003c/p\u003e","manuscriptTitle":"Right-sided Congenital Diaphragmatic Hernia with Herniation of the Liver into the Thoracic Cavity: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 16:15:27","doi":"10.21203/rs.3.rs-8645529/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T13:35:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-05T02:25:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-03T18:21:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250000598909578872924828610900075846969","date":"2026-04-02T08:37:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-28T11:08:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259699104423072660356145284150601184654","date":"2026-03-14T19:48:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139122402913840502609782394073888150484","date":"2026-03-14T19:18:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-13T11:14:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-26T15:04:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T10:42:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-22T10:41:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2026-01-20T05:52:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4537fc6-721d-4827-a854-1bbf2c18c129","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T07:38:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 16:15:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8645529","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8645529","identity":"rs-8645529","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}