Congenital diaphragmatic hernias (CDH) occur due to abnormal pleuro-parietal Operative Findings Discussion In patients with subclinical congenital diaphragmatic hernias incidental imaging or separation during weeks 4-8 of development and are identified in an estimated 1:2,500 live births. They are generally left-sided (80-90%) and posterolateral (90%), graded by size of defect1,2. Traumatic diaphragmatic hernias are uncommon, and while incidence in penetrating and blunt trauma is highly variable, the majority are reported in penetrating trauma. They are often identified surgically due to poor imaging sensitivity and 14-66% are identified in a delayed fashion either incidentally or secondary to obstruction, gastrointestinal, or cardiopulmonary symptoms3. 

We present the case of a 30-year-old female with history of longstanding gastroesophageal reflux disease in whom an atypical diaphragmatic hernia was identified during hernia repair. She presented with longstanding symptoms of typical reflux. She had undergone esophagogastroduodenoscopy at the age of 13 for post-prandial left upper quadrant pain which demonstrated a small hiatal hernia and was placed on a proton-pump inhibitor with symptom improvement. However, she had recent progression in her symptoms prompting re-evaluation with EGD demonstrating a large hiatal hernia and robotic hernia repair was offered.

A typical robotic hiatal hernia repair approach was taken. Intraoperatively thestomach was difficult to reduce. Once reduced, a complex diaphragmatic defect wasrevealed with a type II paraesophageal hernia and a separate defect just to the leftof the hiatus divided by a pillar of diaphragm muscle (Fig 2). The hiatal defect andthe separate diaphragm defect were closed en masse posteriorly with interruptedposterior sutures (Fig 3). The anterior portion of the diaphragmatic portion wasclosed primarily with permanent suture (Fig 4). A Gore Bio-A  mesh was positioned ina reverse "C" fashion overlying both defects.  

In patients with subclinical congenital diaphragmatic hernias incidental imaging orintraoperative identification is not uncommon.  As this patient has no knownhistory of trauma, we assume this to be a congenital defect. This patient'sdiaphragmatic hernia is somewhat atypical in its location as it does not appear tooriginate as posteriorly as would be expected in a Bochdalek hernia, though isclearly within the muscular body of the diaphragm as opposed to located withinthe central tendon.