Transthoracic repair of Morgagni's hernia: a 20-year experience from open to video-assisted approach

Incidental Discovery of a Morgagni Hernia in a 72-Year-Old Woman After COVID-19 Pneumonia: A Case Report

Morgagni hernia is a rare condition characterized by a congenital retrosternal defect of the diaphragm, leading to the protrusion of abdominal organs into the thoracic cavity. Here, we report the case of a 72-year-old woman with a Morgagni hernia incidentally discovered during evaluation for persistent dyspnea following COVID-19 pneumonia. The diagnosis was made by imaging, including a chest X-ray and a thoracic CT scan, which showed an ascent of the transverse colon and omentum through an anterior retrosternal defect. Surgical exploration via right posterolateral thoracotomy revealed an anterior diaphragmatic hernia with a small defect containing the greater omentum and transverse colon, which was repaired by resecting the hernia sac and closing the diaphragmatic defect by fixing the anterior rim of the diaphragm to the retrosternal fascia with interrupted silk sutures. Postoperative recovery was uneventful, and follow-up examinations revealed no abnormalities on chest X-rays obtained at one, three, and six months. This case highlights the incidental discovery and successful surgical management of a Morgagni hernia in an elderly patient through a thoracic approach.

Bilateral incarcerated Morgagni hernia with bowel obstruction: A case report

Morgagni hernia is a rare congenital diaphragmatic hernia associated with the minor retro-xiphoid region between the sternal and costal attachments. The bilateral and complicated Morgagni hernia occurred exceptionally rarely, at a rate of 4% and 6.5%. An 81-year-old woman with occasional constipation went to the emergency department for epigastric pain and vomiting 3 days before. She could no longer pass gas that caused abdominal distention. Clinical examination and ultrasound showed partial bowel obstruction, an unspecified cause. She received nil per os, nasogastric decompression. The abdominal and chest computed tomography Scan showed the bilateral diaphragmatic hernia, and the dilated loops of the cecum and ascending colon were 7 cm. She required an emergency operation to resolve the etiology of bowel obstruction. The midline incision was chosen to release the hernia contents and repair the posterior sternal defects with Polypropylene mesh. An abdominal approach can solve a bilateral incarcerated Morgagni hernia.

Laparoscopic management of symptomatic congenital diaphragmatic hernia of Morgagni in the adult

BACKGROUND

Currently, there is a relative paucity of literature regarding the management of symptomatic congenital diaphragmatic hernia of the foramen of Morgagni in the adult. This study aims to describe our unique surgical technique and outcomes in adult patients undergoing laparoscopic repair of symptomatic Morgagni hernia.

METHODS

This is a retrospective review of adult patients from 2003 to 2020 who underwent a laparoscopic Morgagni hernia repair at our institution. All patients underwent a similar laparoscopic approach, utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect and mesh reinforcement with permanent mesh if the primary repair was subjectively under tension.

RESULTS

The study population consisted of 12 consecutive patients with a Morgagni hernia. Patients presented with a variety of symptoms attributed to the hernia, including pain 83% (n = 10), respiratory symptoms and shortness of breath 58% (7), and gastrointestinal obstruction 25% (3). Other complaints included: nausea 33% (4), reflux 50% (6), early satiety 8% (1), palpitations 16% (2), a gurgling sensation in the chest 8% (1), and weight loss 8% (1). Primary repair was possible in all patients following complete reduction of hernia contents including the hernia sac. Mesh reinforcement was used in 5 of 12 patients. Average surgical operative time was 93 (± 37) min. Median length of stay was 1.3 days (range 0.5-5.5 days). At a median follow-up of 10.9 months (IQR 8.0-41.5 months), all symptoms attributed to the hernia had resolved. No recurrences were identified.

CONCLUSIONS

Adults with symptomatic Morgagni hernia should undergo surgical repair. A laparoscopic approach utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect (when possible), with or without mesh reinforcement can be performed safely and effectively.

Laparoscopic assisted anterior transabdominal wall closure using loop suture removing technique in Morgagni hernia: safe and easy method

PURPOSE

The treatment of MH entails surgical repair either by open abdominal or thoracic approaches or by minimal invasive surgery. The aim of this study is to evaluate the surgical and clinical outcomes of children who underwent laparoscopic assisted transabdominal wall closure and subcutaneous knot placement technique.

METHODS

This retrospective study includes pediatric patients who underwent surgery for MH between January 2015 and February 2019. The patients' demographic data, symptoms, operative findings and technique and postoperative outcomes were recorded.

RESULTS

A total of 17 children with MH were treated. There were 13 boys (76.5%) and four (23.5%) girls. Six patients had trisomy 21 (37%). The mean operation time was 40 min (25-90 min). The hernia sac was removed in all patients and there was no need for prosthetic patch in any of the children. Mean time to start feeding was 10 h (6-24 h). The mean hospitalization time was 2 days (1-5 days). There were no complications intraoperatively or postoperatively. The mean follow-up time was 24 months (6-40). No recurrence occurred during the follow-up time.

CONCLUSION

Laparoscopic assisted transabdominal wall closure and subcutaneous knot placement technique is a preferable method with excellent outcomes and short hospitalization and feeding time postoperatively. This technique may be performed easily and safely without requiring any additional experience other than basic laparoscopy skills.

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.

Gastric volvulus through Morgagni hernia and intestinal diverticulosis in an adult patient: a case report

BACKGROUND

Morgagni's hernia (MH) is a rare type of congenital diaphragmatic hernia with limited available literature. Late presentations are infrequent and the ones complicated due to gastric volvulus are even rarer. Another uncommon association of MH is with small bowel diverticulosis. We herein discussed a case of gastric volvulus as the content of MH, and small bowel diverticulosis present in a patient concomitantly.

CASE PRESENTATION

A 30 year old woman, who presented with a one year history of epigastric burning and indigestion, occasionally associated with pain and vomiting. On clinical examination, no clue to the diagnosis could be ascertained. Her chest and abdominal x-ray indicated an abnormal air-fluid level at right hemithorax, which prompted a Computed Tomography (CT) scan, showing organo-axial gastric volvulus. MH with gastric volvulus was observed during laparotomy and trans-thoracic reduction of the contents was performed, along with repair of the defect. Multiple intestinal diverticuli were also found and the largest diverticulum was excised.

CONCLUSIONS

Gastric volvulus through MH is a rare but potentially life-threatening condition. Non-specific symptoms like epigastric pain and vomiting can delay the diagnosis and management, however, advanced imaging techniques like CT scan can speed up this process. After the diagnosis is made, surgical repair should be attempted regardless of symptoms.

[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.

A huge Morgagni hernia with compression of the right ventricle

A 21 year old male with no relevant medical history presented to our Institution for further assessments of a right paracardiac mass founded on a chest X-ray. Chest computed tomography revealed a wide median defect of the diaphragm at the level of xiphoid process of the sternum, with the herniation of omental fat tissue in the mediastinum. Cardiac magnetic resonance confirmed the presence of a huge hernia originating from the foramen of Morgagni (sterno-costal hiatus), displacing the heart leftwards and posteriorly and compressing the right ventricle (RV), giving to it a tubular shape.The signal characteristics were typical of fat tissue, with hyperintense signal in T1 and T2 weighted black blood images and homogeneus signal suppression on STIR T2 black blood images. Short axis real time cine images, performed during deep inspiration, showed an early diastolic ventricular septal bounce, with flattening of the interventricular septum during mid-late diastole: they represented signs of diastolic dysfunction of the right ventricle, resembling a sort of “pseudo-constrictive” pathophysiological model. The patient was thus referred to surgical repair of the diaphragmatic defect.

Open Versus Laparoscopic Approach for Morgagni's Hernia in Infants and Children: A Systematic Review and Meta-Analysis

INTRODUCTION

The laparoscopic repair of Morgagni's hernia (MH) has been reported to be safe and feasible. However, it is still unclear whether laparoscopy is superior to open surgery in repairing MH.

MATERIALS AND METHODS

Using a defined search strategy, three investigators independently identified all comparative studies reporting data on open and laparoscopic MH repair in patients <18 years of age. Case reports and opinion articles were excluded. Meta-analysis was conducted according to PRISMA guidelines and using RevMan 5.3. Data are expressed as mean ± SD.

RESULTS

Systematic review - Of 774 titles/abstracts screened, 51 full-text articles were analyzed. Three studies were included (92 patients), with 53 (58%) open approaches and 39 (42%) laparoscopy. Meta-analysis - The length of surgery was shorter in laparoscopy (50.5 ± 17.0 min) than in open procedure (90.0 ± 15.0 min; P < .00001). Laparoscopy shortened the length of hospital stay (2.1 ± 1.4 days) versus open surgery (4.5 ± 2.1 days; P < .00001). There was no difference with regards to complications (laparoscopy: 8.8% ± 5.5%, open: 9.4% ± 1.6%; P = .087) and recurrences (laparoscopy: 2.9% ± 5.0%, open: 5.7% ± 1.8%; P = .84).

DISCUSSION

Comparative studies indicate that laparoscopic MH repair can be performed in infants and children. Laparoscopy is associated with shortened length of surgery and hospital stay in comparison to open procedure. Prospective randomized studies would be needed to confirm present data.

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.

Video-assisted thoracoscopic surgery for adult Bochdalek hernia: a case report

Background

Bochdalek hernia is a type of congenital diaphragmatic hernia that typically presents in childhood, while this diseases is extremely rare in adults.

Case presentation

We review a case of a 63-year-old man with a left-sided Bochdalek hernia who was experiencing occasional pain at the left side of his chest for 8 months. The diagnosis of Bochdalek hernia was made by chest computed tomography. A part of the retroperitoneal adipose tissue was herniated into the left thoracic cavity through the diaphragmatic defect. The hernia was treated via video-assisted thoracoscopic surgery and he made an uneventful recovery.

Conclusions

We report a rare case of a left-sided Bochdalek hernia for which our patient was treated successfully via video-assisted thoracoscopic surgery. Even though rare, this disorder should be recognised, examined and treated appropriately to avoid complications.

Morgagni hernia: A rare case report and review of literature

Morgagni hernias (MHs) are rare and constitute about 2% of all diaphragmatic hernias. Although uncommon, it has potential for considerable morbidity if the diagnosis is missed. An elderly woman with known history of chronic asthma and constipation presented to us with vague right-sided chest pain. General physical examination was unremarkable and coincidentally diagnosed to have diabetes mellitus. Chest roentgenogram posteroanterior view revealed a right paracardiac opacity and right lateral view showed the opacity in the peridiaphragmatic area of anterior mediastinum. Computed tomographic scan of the chest and abdomen revealed a right-sided MH containing omental fat. Standard right posterolateral thoracotomy was done, and there was a rent at the medial end of the xiphoid process with hernia sac containing the omentum, which was compressing adjacent lungs and heart. The sac was opened; redundant omentum was resected, and rent closed with intercostal muscle with prolene. MH being rare must be addressed with appropriate investigation to prevent unnecessary morbidity and mortality.

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.

Advantages of video-assisted thoracoscopic surgery for adult congenital hernia with severe adhesion: report of two cases

Adults who have undergone surgical repair of congenital diaphragmatic hernia have a prolonged illness. They usually have severe adhesions around the intrathoracic hernial sac; therefore, the adhesion itself as well as misidentification of the hernial defect can make surgical repair difficult, even in open surgery. Here, we present the successful video-assisted thoracoscopic surgical repairs of Bochdalek and Morgagni hernias in patients with severe adhesions of the hernial sac (peritoneum) to the parietal pleura lying over the thoracic wall and diaphragm. An 18-year-old woman with a Bochdalek hernia and a 28-year-old woman with a Morgagni hernia underwent thoracoscopic division of severe adhesions, proper minithoracotomy, and precise repairs of diaphragmatic defects. Postoperative courses of both patients were uneventful with no signs of recurrence of the hernia. Thus, we recommend the thoracoscopic approach as the first choice over an open or laparoscopic approach in the management of adult patients with Bochdalek or Morgagni hernias and severe adhesion.

Bilateral congenital Morgagni-Larrey's hernia

BACKGROUND

Congenital Morgagni-Larrey's hernia (CMLH) is rare and known to be associated with a high incidence of bilaterality and associated anomalies. This study aimed to review our patients with bilateral CMLH and evaluate their presentation, associated anomalies, diagnostic difficulties and therapy.

METHODS

From January 1989 to December 2007, we treated 8 children with bilateral CMLH at our hospital. Their medical records were retrospectively reviewed for age, sex, symptoms, associated anomalies, diagnosis, operative findings, treatment and outcome.

RESULTS

Among the 8 children, 4 were male and 4 female, with a mean age of 22.74 months (range: 0.93-108 months). Six of them sustained repeated attacks of pneumonia. In 5 children, bilaterality was diagnosed at surgery. Associated anomalies were observed in all children, including congenital heart disease in 5, Down's syndrome in 4, malrotation in 3, inguinal hernia in 2, umbilical hernia in 1, and pyloric stenosis in 1. All of these children were operated on transabdominally. All of them did well postoperatively and on follow-up ranging from 1.5 years to 5 years (mean: 3 years), one had recurrence of the hernia as well as an incisional hernia.

CONCLUSIONS

The diagnosis of bilateral CMLH may be difficult preoperatively, especially if one of the hernial sacs is empty. CT scan is valuable to diagnose bilateral hernias. To repair these hernias, we advocate a transabdominal approach, which allows easy reduction and inspection of contents, access and repair of bilateral hernias, and correction of associated malrotation if present.

Systematic review of general thoracic surgery articles to identify predictors of operating room case durations

BACKGROUND

Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies).

METHODS

General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times.

RESULTS

There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management.

CONCLUSIONS

Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these data become available. The case series did not reveal additional data which could be cost-effectively integrated with OR information systems data to improve the accuracy of predicted durations for general thoracic surgery cases.