Clinical and radiologic evaluation of foramen of Morgagni hernias and the transthoracic approach

Open Versus Minimally Invasive Morgagni Hernia Repair in Pediatric Surgery: A Review

Background: Morgagni hernia (MH), a rare type of congenital diaphragmatic hernia, does not have an established protocol for surgical repair. Materials and Methods: A MEDLINE search with terms related to various surgical approaches to repair MH in children was conducted. Articles comprising robotic-assisted surgery, laparoscopy, laparotomy, thoracoscopy, and thoracotomy over the last 20 years were assessed. Results: This narrative review provides an overview of MH in the pediatric population, covering the epidemiology, diagnosis, and management of this rare diaphragmatic hernia. We discuss various surgical techniques, including open and minimally invasive approaches, and compare their advantages and limitations in childhood MH repair. In addition, we address arguments for and against controversial topics such as hernia sac excision and patch reinforcement. Conclusions: Regarding MH in children, transabdominal repair is superior to transthoracic due to improved visualization of bilateral defects and easier reduction of the hernia contents. Laparoscopy has been reported as a popular approach. Single-site laparoscopy has gained attention due to better outcomes than standard three-port laparoscopy. Considering a limited number of children in the literature who underwent robotic MH repair, perioperative complications were reported to be minor.

Morgagni Hernia: Management in a 77-Year-Old Female With a Robotic Approach

Morgagni hernias are rare congenital diaphragmatic defects. While often asymptomatic, they can present with nonspecific abdominal or respiratory symptoms, leading to incidental diagnosis through imaging. Surgical repair is the standard treatment to prevent complications such as bowel incarceration or strangulation, though the optimal approach remains a matter of debate. We present the case of a 77-year-old female who was found to have a Morgagni hernia involving the transverse colon. She underwent successful robotic-assisted repair with plication, approximation, and mesh placement. This report highlights the feasibility and safety of robotic-assisted repair for a Morgagni hernia, emphasizing its role in optimizing patient outcomes. As surgical techniques continue to evolve, further studies comparing long-term outcomes of robotic, laparoscopic, and open approaches will help refine best practices for managing this rare congenital defect.

Tips and Tricks in Thoracic Radiology for Beginners: A Findings-Based Approach

This review has the purpose of illustrating schematically and comprehensively the key concepts for the beginner who approaches chest radiology for the first time. The approach to thoracic imaging may be challenging for the beginner due to the wide spectrum of diseases, their overlap, and the complexity of radiological findings. The first step consists of the proper assessment of the basic imaging findings. This review is divided into three main districts (mediastinum, pleura, focal and diffuse diseases of the lung parenchyma): the main findings will be discussed in a clinical scenario. Radiological tips and tricks, and relative clinical background, will be provided to orient the beginner toward the differential diagnoses of the main thoracic diseases.

Incarcerated Larrey hernia with small bowel obstruction: A case report

INTRODUCTION AND IMPORTANCE

Morgagni-Larrey hernias (MLHs) are rare diaphragmatic hernias that can cause incarceration or strangulation of the hernia contents in some cases. Here we report a case of incarcerated Larrey hernia with small bowel obstruction, which was successfully treated with emergent laparoscopic surgery.

CASE PRESENTATION

An 87-year-old woman presented to our hospital with abdominal pain and nausea. Computed tomography scan revealed an MLH comprising an obstructed intestinal loop. The patient underwent emergency laparoscopic surgery. Surgical findings showed incarceration of the small bowel on the left side of the falciform ligament. The small bowel was laparoscopically reduced and does not show signs of intestinal ischemia or perforation. The hernia orifice, which was approximately 15 mm in diameter, was closed with a surgical suture without the need for sac excision. The patient was discharged on postoperative day 7 without postoperative complications.

CLINICAL DISCUSSION

There are no established surgical techniques for the treatment of MLH due to its rarity. Our experience in the present case suggests that the laparoscopic approach might be considered as a feasible method even for incarcerated MLH.

CONCLUSION

Surgical techniques for MLH should be selected on a case-by-case basis.

Morgagni hernia in adult: A case report

INTRODUCTION AND IMPORTANCE

Morgagni Hernia is a congenital diaphragmatic hernia but can rarely present in adults. It occurs due to a congenital defect in the development of the diaphragm. Here we present a case of symptomatic Morgagni hernia diagnosed in a 53 years' female.

CASE PRESENTATION

A 53 years' female presented with recurrent chest symptoms and was found to have bowel contents herniated into the right hemithorax on chest X-ray and CECT. Reduction of hernia was done laparoscopically and the hernia was repaired with non-absorbable suture in an interrupted manner.

CLINICAL DISCUSSION

Morgagni hernias are mostly diagnosed incidentally on a chest radiograph or can present with cardiorespiratory or abdominal symptoms. Our case was an adult who was diagnosed to have Morgagni hernia presenting with chest symptoms. The investigation of choice to diagnose and evaluate this condition is CECT of chest and repair of hernia without the use mesh is advised in asymptomatic cases also due to feared complications like strangulation and incarceration.

CONCLUSION

The treatment of Morgagni Hernia is primary surgical repair which can be done either transthoracically or transabdominally. It is advised that surgical repair should be done even in asymptomatic cases.

Management of Morgagni's Hernia in the Adult Population: A Systematic Review of the Literature

BACKGROUND

Morgagni's hernia (MH) is defined by the protrusion of abdominal viscera through an anterior retrosternal diaphragmatic defect. The objective of this study was to systematically review current literature on MHs in adult population and assess their clinical characteristics and therapeutic approach.

METHODS

PubMed and Cochrane bibliographical databases were searched (last search: 15^th January 2021) for studies concerning MHs.

RESULTS

Inclusion criteria were met by 189 studies that included 310 patients (61.0% females) with an age of 57.37 ± 18.41 (mean ± SD) years. Pulmonary symptoms, abdominal pain, and nausea-vomit were among the most frequent symptomatology. MHs were predominantly right-sided (84.0%), with greater omentum (74.5%) and transverse colon (65.1%) being the most commonly herniated viscera. The majority of cases underwent an open procedure, while 42.3% of patients had a minimally invasive procedure. Abdominal approach was mostly preferred, while a thoracic one was chosen at 20.6% of cases and a thoracoabdominal at 3.2%. Thirty-day postoperative complications were recorded at 29 patients and 30-day mortality was 2.3%.

CONCLUSIONS

MH is a rare type of congenital diaphragmatic hernia which rarely manifests in adult population with atypical pulmonary and gastrointestinal symptoms. Surgery is the gold standard for their management. Open surgical approach is preferable in emergency cases, while laparoscopic surgery is favored in elective setting and is associated with shorter hospitalization. Further studies are crucial in order to elucidate etiology and optimal therapeutic approach.

Imaging of the mediastinum: Mimics of malignancy

In the imaging of the mediastinum, benign lesions mimicking malignancy constitute potential pitfalls in interpretation. Localization and characteristic imaging features are key to narrow the differential diagnosis and avoid potential pitfalls in interpretation. Based on certain anatomic landmarks, the mediastinal compartment model enables accurate localization. Depending on the anatomic origin, mediastinal lesions can have various etiologies. The anatomic location and structures contained within each mediastinal compartment are helpful in generating the differential diagnoses. These structures include thyroid, thymus, parathyroid, lymph nodes, pericardium, embryogenic remnants, and parts of the enteric tracts, vessels, and nerves. Imaging characteristics on computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT), including attenuation (fluid, fat, calcification), contrast enhancement, and metabolic activity, aid in narrowing the differential diagnoses. Understanding the roles and limitations of various imaging modalities is helpful in the evaluation of mediastinal masses. In this review, we present potential pitfalls in the imaging of mediastinal lesions with emphasis on the mimics of malignancy.

Morgagni-Larrey diaphragmatic hernia repair in adult patients: a retrospective single-center experience

PURPOSE

Morgagni-Larrey congenital diaphragmatic hernia (MLH) is rare in adult patients and surgery is performed infrequently. The evidence regarding the most beneficial treatment modality is low. Nevertheless, with increasing experience in minimally-invasive surgery, the literature proves the laparoscopic approach as being safely feasible. However, knowledge on the disease as well as treatment options are based on single surgeon's experiences and small case series in the literature.

METHODS

Retrospective single-center analysis on adult patients (≥ 18 years) with MLH from 01/2003 to 06/2019 regarding symptoms, hernia sac contents, surgical technique and perioperative outcome.

RESULTS

4.0% of diaphragmatic hernia repair procedures were performed for MLH (n = 11 patients). 27.3% of these patients were asymptomatic. Dyspnea or gastrointestinal symptoms were frequently observed (both in 45.5% of the patients). Colon transversum (63.6%), omentum majus (45.5%) and/or stomach (27.3%) were the most common hernia sac contents. Correct diagnosis was achieved preoperatively in 10/11 patients by cross-sectional imaging. All procedures were performed by trans-abdominal surgery (laparotomy in four and laparoscopy in seven patients). All hernias were reinforced by mesh after primary closure. No differences were observed in the perioperative outcome between patients who underwent hernia repair by laparotomy versus laparoscopy. Pleural complications requiring drainage were the most common postoperative complications.

CONCLUSION

MLH repair seems to be safely feasible by laparoscopic surgery. The benefit of mesh augmentation in MLH repair is not clear yet. In contrast to the current literature, all patients in this study received mesh augmentation after primary closure of the hernia. This should be evaluated in larger patient cohorts with long-term follow-up.

Laparoscopic repair of Morgagni hernia in children

Aim

We aimed to present our laparoscopic treatment experience in Morgagni hernia repair.

Methods

The patients who underwent laparoscopic surgery with diagnosis of Morgagni hernia between 2016 and 2019 were evaluated retrospectively.

Results

Their mean age at diagnosis was 4,1 ± 2,6 years (1 year-13 years). All patients were male. The presenting complaints were respiratory tract infection in 3 patients and vomiting in 3. Two patients were diagnosed incidentally. Associated Down's Syndrome was detected in 3 (38%) cases. The defect was left-sided in 7 (87.5%) patients and bilateral in 1 (12,5%). Omentum was herniated in 2 patients, colon and omentum were in 6 and colon, omentum and stomach were in one. All patients underwent primary repair extracorporeally by removing sutures from single incision, without removal of the hernia sac. There were no complications or recurrence in the mean 19,2 ± 15,8 months (6-42 months) follow-up period.

Conclusions

Minimal invasive repair of Morgagni hernia is efficient and safe. It should be the first choice because of fast recovery and better cosmetic results. In this series, it was seen that leaving the hernia sac had no effect on early and late complications. Leaving the hernia sac may prevent potential complications due to unnecessary dissection.

[Diaphragmatic hernia in elective thoracic surgery]

AIM

To clarify the indications for reconstructive surgery in patients with diaphragmatic hernia.

MATERIAL AND METHODS

Retrospective trial has included 36 patients with diaphragmatic hernia for the period 1963-2017. There were 23 (63.9%) women and 13 (36.1%) men. The majority of patients (83%) underwent surgery at able-bodied age (18-60 years). 27 (75%) patients had hernia of weak diaphragmatic zones, 9 (25%) - posttraumatic hernia. Diaphragm repair was performed with primary suture. In 2 cases of posttraumatic hernia mesh endoprosthesis was used.

RESULTS

All patients were discharged. Postoperative complications arose in 4 (11.1%) patients, including 2 cases of mesh endoprosthesis deployment. Long-term outcome was followed-up in 15 patients from 6 months to 17 years. Recurrent hernia was absent in all cases.

CONCLUSION

Primary suture is acceptable for diaphragmatic hernia repair. Alloplastic repair is indicated for large defect, when primary suture is impossible or risk of its failure is high.

Pediatric Morgagni diaphragmatic hernia: a descriptive study

INTRODUCTION

The Morgagni hernia (MH) accounts for 3-4% of congenital diaphragmatic hernias. There is a paucity of data regarding this rare defect. The purpose of this study is to describe the characteristics of children with MH, surgical approaches for repair, and patient outcomes.

METHODS

Pediatric patients (ages 0-18) with a MH from 2002 to 2014 at a single, freestanding pediatric hospital were retrospectively reviewed. Patient presentation, demographics, operative methods and findings, and outcomes were evaluated.

RESULTS

Twenty-six infants and children with a congenital MH were treated. There were 20 males (77%) and six females (23%) with a median age at diagnosis of 14.75 months (range 1 week to 13 years). Half were symptomatic. Sixteen hernias were repaired laparoscopically, nine by an open approach, and one laparoscopic converted to open. Colon was the most commonly herniated organ (N = 14). Hernia sacs were found in 22 patients of which, 20 were resected. Two patients underwent treatment with ECLS. There was one mortality in a patient who underwent repair on ECLS in the setting of an omphalocele and SVC obstruction. There were no recurrences in our sample.

CONCLUSION

In this series, congenital MH appears to have a male predominance, frequently presents with pulmonary symptoms, and has excellent outcomes regardless of operative approach.

Right-sided diaphragmatic rupture after repair of a large Morgagni hernia

We present a case of a combination of primary and secondary diaphragmatic hernia in a 63-year male patient. For progressive dyspnea and palpitations caused by a large and symptomatic Morgagni hernia resulting in a right-sided enterothorax, an open tension-free mesh repair was performed. The postoperative course was complicated by a secondary hepatothorax through a spontaneous rupture of the right diaphragm. Primary mesh repair of the Morgagni hernia, however, proved to be sufficient. This recurrent herniation might be a consequence of (1) preexisting atrophy of the right diaphragm caused by disposition and/or long-term diaphragmatic dysfunction due to the large hernia, combined with (2) further thinning out of the diaphragm by intraoperative hernia sac resection, and (3) postoperative increase of intra-abdominal pressure.

Morgagni-larrey hernia- a review of 20 cases

Morgagni-Larrey hernia is an uncommon entity. The majority of the literature describes hernia occurring mostly on the right side, a few on the left side and rarely bilateral. Retrospective chart review was done for the patients with the diagnosis of adult diaphragmatic hernia from January 1997 to December 2010. Post-operative course was evaluated for outcome, morbidity and mortality. Out of 20 patients, 13 (65 %) were males and 7 (35 %) were females. Their age ranged from 17 to 50 years (mean = 29.6). Abdominal discomfort was the most common presentation. Eight patients (40 %) were asymptomatic at presentation. Plain X-Ray chest was done for all. Ten patients (50 %) underwent suture repair, 6 (30 %) had mesh placement and the other 4 (25 %) underwent both: suture repair buttressed with mesh. Volvulus of stomach was noted in 5 (25 %) cases. All patients had left sided hernia. There was insignificant morbidity and no mortality. There was no recurrence in 16 patients followed up for a mean duration of 20 months (range = 8 to 32 months). In Morgagni-Larrey hernia, abdominal approach gives good accessibility to reduce the hernia and to undertake repair. When complicated with incarceration, perforation, gangrene or volvulus of the herniated bowel; this can be dealt with ease. Plain X Ray of the chest is fairly accurate in suggesting the diagnosis of Morgagni-Larrey hernia.

Congenital diaphragmatic hernia: review of current concept in surgical management

CONGENITAL DIAPHRAGMATIC HERNIAS (CDHS) OCCUR MAINLY IN TWO LOCATIONS: the foramen of Morgagni and the more common type involving the foramen of Bochdalek. Hiatal hernia and paraesophageal hernia have also been described as other forms of CDH. Pulmonary hypertension and pulmonary hypoplasia have been recognized as the two most important factors in the pathophysiology of congenital diaphragmatic hernia. Advances in surgical management include delayed surgical approach that enables preoperative stabilization, introduction of fetal intervention due to improved prenatal diagnosis, the introduction of minimal invasive surgery, in addition to the standard open repair, and the use of improved prosthetic devices for closure.

Down's syndrome as a factor in the diagnosis, management, and outcome in patients of Morgagni hernia

PURPOSE

The purpose was to study the impact of Down's syndrome (DS) in the diagnosis, management, and outcomes of patients with Morgagni hernia (MH).

METHODS

Twenty-two (22) patients with MH treated at a tertiary center were retrospectively studied for history, findings, associated anomalies, referral diagnoses, hospital admissions, radiological procedures for diagnosis, age at which operated on, operative procedure, complications, and recurrences. Eleven did not have DS (group 1); 11 others had associated DS (group 2). The ages at operation were compared in the 2 groups using the Mann-Whitney test. More than 3 hospital admissions for symptoms and signs relevant to MH before a diagnosis of MH were considered a "delayed diagnosis."

RESULTS

Twenty-two patients (7 females, 15 males) aged 3 months to 10 years were seen. They presented with respiratory distress (n = 16), with vomiting (n = 5), with intestinal obstruction (n = 1), by serendipity (n = 2), and with recurrence from another hospital (n = 1). The mean age of group 1 was 14.5 months, and that of group 2 was 29.18 months; the difference was not significant (P = .621). Nine patients of group 2 were "delayed diagnosis" compared with 2 in group 1. Both delays from group 1 had severe associated anomalies. All patients underwent operative correction (17 open and 5 laparoscopic repairs). Two had recurrences, one operated on by the open method by us and another laparoscopically by the Lima technique at another center. Both had DS. Both were reoperated on by the open method.

CONCLUSIONS

The diagnosis of MH may be strikingly delayed when associated with DS or other severe congenital anomalies. Morgagni hernia should be strongly considered in patients with DS admitted repeatedly for chest infections. Chest x-rays in 2 planes may avoid misdiagnosis of MH. Both open and laparoscopic methods have proven satisfactory as operative treatment of MH. Recurrences were seen in patients with DS, which may be corrected by laparotomy or laparoscopically. We feel that resecting the sac and approximating the posterior lip of the defect to the anterior abdominal wall, whether in open or laparoscopic methods, may give stronger repairs, which may avoid recurrence.

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.

Life-Threatening Vomiting Caused by Large Morgagni Hernia in an Octogenarian

An 84-year-old woman presented with frequent severe vomiting, dyspnea and generalized muscle weakness associated with diaphragmatic hernia. Her poor general condition and muscle weakness resembling cranial pathology were considered to be due to severe vomiting caused by a Morgagni hernia. An urgent subcostal laparotomy confirmed the diagnosis. The critical role of urgent surgery, even in advanced age, is emphasized.

Imaging of anterior mediastinal masses

Multiple different types of anterior mediastinal masses may be encountered on computed tomography (CT) imaging, and many of these lesions are neoplastic in etiology. These include masses arising from the thymus, thyroid and parathyroid glands, as well as lymph nodes, pericardium, and vessels and nerves. Often, the CT attenuation of the mass can be helpful in narrowing down the differential diagnosis, and attenuation values suggesting fat, water or calcium may suggest certain diagnoses; significant enhancement of the mass with intravenous contrast may also be a helpful feature. Lesions with fatty attenuation include teratomas, thymolipomas and Morgagni hernias. Lesions that may manifest the attenuation of water include pericardial and thymic cysts, abscesses, and lymphangiomas, as well as neurogenic and germ cell tumors. Multiple types of lesions may contain calcium, including thyroid goiters and cancers, thymomas, thymic carcinomas and carcinoids, treated lymphoma, germ cell tumors, parathyroid adenomas, and lymph nodes involved with silicosis, sarcoid, tuberculosis, fungal diseases and pneumocystis. Contrast enhancement may be seen in lesions of vascular origin and in vascular neoplasms, such as parathyroid adenomas and Castleman's disease. In addition to CT attenuation values, the exact location and morphology of the mass in question, in conjunction with clinical features such as patient age, gender, signs, symptoms, and laboratory values, can usually lead to a short list of possible etiologies, thereby directing appropriate additional diagnostic procedures or therapeutic approaches.