A 3-day-old male child presenting with intestinal obstruction was operated for malrotation gut and eventration diaphragm. His post operative recovery was uneventful. He remained asymptomatic for next two years when he had an episode of abdominal pain and bilious vomiting which was managed conservatively with the diagnosis of adhesive intestinal obstruction. X-ray chest at this time was normal. Four months later the child presented with abdominal pain and vomiting for 2 days. Following day the child stopped vomiting. Colicky abdominal pain continued and the child started looking toxic. By the next evening the child had a large bilious vomitus and developed respiratory distress, seizures and altered sensorium when he was referred to our hospital. At the time of presentation the child was very toxic with severe respiratory distress, markedly decreased air entry on left side chest. Abdomen was distended with absent bowel sounds. Per rectal examination did not reveal any positive finding. Chest X-ray revealed a hazy left hemithorax with few cylindrical air shadows and mediastinal shift to right. Ultrasound abdomen showed dilated bowel loops with some loops extending into the left chest. Patient was placed on a ventilator, his condition stabilized and was taken up for emergency surgery with the diagnosis of incarcerated diaphragmatic hernia on the left side. A laparotomy was done through the previous operation site. There were gross adhesions allover. The sutures of the previous plication were seen in situ with a diaphragmatic rent of approximately 5 cm lateral to those sutures. Through the rent herniated the jejunum and transverse colon. The jejunal loop was tense, dusky with mesenteric hematoma and was intimately adherent to the margins of the diaphragmatic defect. The bowel loops could not be retracted abdominally and left anterolateral thoracotomy was done to release the bowel loops. The dusky bowel loop improved after release. Chest was closed in layers after inserting a chest tube. Abdomen was closed in layers after leaving in an abdominal drain. Post operative recovery was uneventful.

Plication of diaphragm is a standard treatment for eventration diaphragm with few short term and long term complications. Kizilcan, et al.(3) have reported near normal diaphragmatic functions and pulmonary functions at a follow up upto 11 years of age Secondary diaphragmatic hernia after plication of diaphragm is a rare complication. Another case presented at 2 years of age with acute intestinal obstruction. He had been operated at 6 months of life for eventration diaphragm left side via a left thoracotomy. Laparotomy revealed bowel herniating through a diaphragmatic defect at the site of previous diaphragm plication. The authors suggested possible injury to phrenic nerve and vessels leading to ischemia, necrosis and consequent breakdown of the suture line as a possible cause of the secondary diaphragmatic hernia(4).

Ciftci, et al.(5) reported a case similar to ours. The authors suggested that extreme tension of the diaphragm and accidental penetrating needle injury during plication might have caused a negligible small hole, which might have enlarged with the movements of the diaphragm resulting in secondary hernia. In our case also the suture line was intact with the diaphragmatic defect lateral to the suture line through which the bowel had incarcerated. We agree with the hypothesis put forth by Ciftci, et al.(5) but have an additional hypothesis to suggest. In eventration the diaphragm is attenuated with poorly developed muscles. Even a small rise in intra-abdorninal pressure resulting from a minor trauma e.g., while playing, which not be reported by the child to his/her caretakers, may result in rupture of the diaphragm and hence this could be labeled as a traumatic diaphragmatic hernia following plication for eventration diaphragm.