Morgagni hernia: an unexpected cause of respiratory complaints and a chest mass

Acute Respiratory Failure, Ischemic Modifications on Electrocardiogram: Alternative Etiology—A Case of Morgagni Hernia

We discovered a rare pathology described in adulthood, followed by the development of a long asymptomatic evolution, which underlined the importance of multidisciplinary collaboration. We present the case of a 62-year-old female smoker patient, with a known previous medical history of chronic ischemic heart disease, hypertension, chronic obstructive pulmonary disease (COPD), gastric ulcer and gastritis. The patient was rushed to the emergency room (ER) with acute respiratory failure, chest discomfort, ankle and facial edema and a chest X-ray showing a right lower pulmonary lobe consolidation, with an alarming ischemic electrocardiogram (ECG) modification without increasing myocardial cytolysis indicators. This led our medical team to investigate a possible cardiovascular event that might have been in development. After immediate admission, thoracic computer tomography (CT) imaging was carried out, which found a Morgagni diaphragmatic hernia, containing adipose tissue and the hepatic flexure of the colon with approximate dimensions of 50/100 mm. We faced differential diagnostic problems. We knew the subject’s existing cardiac and chronic respiratory tract pathologies from their previous medical history; therefore, multiple investigations and check-ups were carried out. A chest CT and surgery intervention were needed to resolve this case. Subsequently, the acute respiratory failure and alarming ischemic ECG modification disappeared.

Morgagni hernia repair in children over two decades: Institutional experience, systematic review, and meta-analysis of 296 patients

BACKGROUND/PURPOSE

Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch.

METHODS

We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P<0.05.

RESULTS

In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months). Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p=0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p=0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p=0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p=0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair.

CONCLUSION

In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence.

TYPE OF STUDY

Systematic review LEVEL OF EVIDENCE: 3A.

Morgagni's hernia: believing is seeing

The original description by Morgagni of the anterior diaphragmatic defect that bears his name implies a paramedian defect and this may be true when acquired in adulthood. In contrast, the anterior diaphragmatic defect that is observed in children is central rather than paramedian, as is often assumed. Its central retrosternal location has been confirmed by various methods, but is most clearly evident on laparoscopy.

Associated malformations in Morgagni hernia

Morgagni hernia (MH) is a congenital herniation of the abdominal organs through the subcostosternal portion of the diaphragm. It is a rare type of diaphragmatic hernia that has been associated with other congenital anomalies. The purpose of this clinical review was to determine the incidence of associated anomalies in patients with MH at a major pediatric referral center. The medical records of all patients with the diagnosis of MH were reviewed retrospectively between 1983 and 2006. The age, sex, side of herniation, presenting symptoms and signs, associated anomalies, radiologic features, intraoperative findings, postoperative course, complications, and mortality were recorded. There were 11 males and 5 females. The average age of the patients was 34.5 months (range 2 months-14 years). Twelve patients (75%) had at least one associated congenital malformation and eight (66.6%) of them had multiple anomalies. Six (37.5%) patients had a chromosomal anomaly, Down's syndrome in five and Turner syndrome in one. MH has a high incidence of associated congenital malformations.

Lesions of the cardiophrenic space: findings at cross-sectional imaging

Cross-sectional imaging techniques allow excellent visualization of the cardiophrenic space. Under normal conditions, the cardiophrenic space is occupied by fat, the amount of which is usually increased in overweight individuals. It has been suggested that this fat accumulation correlates with the risk of cardiovascular disease. Several alterations originating above or below the diaphragm can affect the cardiophrenic space. Inflammatory lesions such as pericardial fat necrosis and tumoral masses are sometimes seen. Lymphoma is a major but not exclusive cause of cardiophrenic adenopathy and must be differentiated from lymphatic seeding of supradiaphragmatic and infradiaphragmatic malignancies. In patients with portal hypertension, cardiophrenic space varices are not uncommon. Other masses or pseudomasses occurring in this region include pericardial cysts, mediastinal tumors, and diaphragmatic hernia. Computed tomography and magnetic resonance imaging of the thorax are helpful in characterizing cardiophrenic lesions initially identified at plain radiography. Such characterization helps narrow the differential diagnosis when lesions are detected in this location.

Is hernial sac removal necessary? Retrospective evaluation of eight patients with Morgagni hernia in 5 years

Eight children with Morgagni hernia were operated between January 2000 and May 2005. Medical records of the patients were evaluated retrospectively. Ages of the patients were between 3.5 months and 9 years. The diaphragmatic defect was on the right in all patients except one. One patient had bilateral diapragmatic hernia. All of the patients were operated by abdominal approach. All patients had hernial sacs. During operation sac of hernia was everted to peritoneal space without removal and the defect was closed by using nonabsorbable material. There was no intraoperative complication. The patients were discharged on the sixth day in uneventful condition. There was no complication or recurrence during follow up. Excision of sac of hernia is recommended in majority. Most of the published studies favour the removal of hernial sac. In our practise, in the treatment of Morgagni hernia we did not remove the hernia sac during the last 5 years.

Colonic necrosis because of strangulated recurrent Morgagni's hernia in a child with Down's syndrome

Postoperative bowel obstruction complicating a recurrent Morgagni's hernia (MH) is an uncommon condition and hence the presentation. Nonspecific symptoms and misleading radiologic image may result in misdiagnosis and severe complications. We report the case of a child with a transverse colon necrosis because of strangulation in a misdiagnosed recurrent MH. The child presented with bowel obstruction and repeated chest infections. Colonic necrosis could be avoided by timely diagnosis and repair of MH. This severe and rare occurrence complicating a recurrent MH should be kept in mind in children with respiratory tract infections and vomiting.

Intestinal Obstruction Caused by a Strangulated Morgagni Hernia in an Adult Patient

A Morgagni hernia is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The reported incidence of congenital diaphragmatic hernias is estimated to be 1 in between 2000 to 5000 births. Morgagni hernias comprise 2% of diaphragmatic hernias. Most Morgagni hernias are found and repaired in children, but 5% are found in adults. They are usually asymptomatic and often found incidentally on chest radiography. Symptoms of these hernias are attributable to the herniated viscera. Morgagni hernias containing bowel may require repair on presentation because of the risk of incarceration. We present a case of an incarcerated and strangulated Morgagni hernia in a 71-year-old woman admitted to our clinic for abdominal pain and symptoms of intestinal obstruction. The diagnosis was made preoperatively by chest radiography, sonography, and computed tomography. Emergent laparotomy was performed, with the herniated transverse colon and omentum reduced into the abdomen. The diaphragmatic defect was repaired, followed by resection of the strangulated omentum. In conclusion, a Morgagni hernia may cause intestinal obstruction. Routine radiographic studies are usually sufficient to arrive at the diagnosis, but a CT scan and sonography may be necessary. Laparotomy is appropriate for the management of symptomatic adult patients with Morgagni hernias, particularly those with findings of intestinal strangulation, with laparoscopic treatment an alternative approach in selected cases.

Clinical presentation and operative repair of hernia of Morgagni

A 77 year old woman who presented with an incarcerated hernia of Morgagni was successfully treated without complications. A Medline search (1996 to date) along with cross referencing was done to quantify the number of acute presentations in adults compared to children. Different investigating modalities--for example, lateral chest and abdominal radiography, contrast studies or, in difficult cases, computed tomography or magnetic resonance imaging--can be used to diagnose hernia of Morgagni. The favoured method of repair--laparotomy or laparoscopy--is also discussed. A total of 47 case reports on children and 93 case reports on adults were found. Fourteen percent of children (seven out of 47) presented acutely compared with 12% of adults (12 out of 93). Repair at laparotomy was the method of choice but if uncertain, laparoscopy would be a useful diagnostic tool before attempted repair. Laparoscopic repair was favoured in adults especially in non-acute cases.

Unusual case of Morgagni hernia associated with malrotation

Morgagni herniae are rare congenital diaphragmatic hernia, which normally present late in adult life with minimal symptoms. They are always associated with a peritoneal hernial sac, and often contain transverse colon or stomach. We present an unusual case of a Morgagni hernia containing caecum in an 81-year-old woman, post ruptured aortic aneurysm repair.

Laparoscopic repair of a Morgagni hernia presenting with syncope in an 85-year-old woman: case report and update of the literature

An 85-year-old woman was transferred from her local hospital for cardiac evaluation after presenting with repeated episodes of syncope during bowel movements. A thorough evaluation revealed no cardiac abnormalities but did reveal a Morgagni hernia with transverse colon in the mediastinum. She underwent laparoscopic reduction of the colon and repair of the hernia with mesh and had a rapid and uneventful recovery.