Laparoscopic repair of strangulated Morgagni hernia
© Kelly; licensee BioMed Central Ltd. 2007
Received: 25 April 2007
Accepted: 12 October 2007
Published: 12 October 2007
A 73 year old man presented with vomiting and pain due to a strangulated Morgagni hernia containing a gastric volvulus. Laparoscopic operation allowed reduction of the contents, excision of necrotic omentum and the sac, with mesh closure of the large defect. A brief review of the condition is presented along with discussion of the technique used.
Morgagni hernia is a rare diaphragmatic hernia that develops through a congenital retrosternal defect. In adults they are generally asymptomatic and are found incidentally during laparoscopy or imaging for another condition. However, they may present as an emergency with abdominal pain due to strangulation of the hernia contents. An unusual case is reported of a strangulated Morgagni hernia, which presented with vomiting and abdominal pain due to a gastric volvulus.
He presented jaundiced six weeks later and an ERCP was done to treat a bile duct stone. Unfortunately two months later he presented with shortness of breath and was diagnosed with left pleural mesothelioma from which he subsequently died. There was no evidence of the mesothelioma on either the preoperative chest xray or at the time of operation (although the pleural cavities were not opened). Interestingly, on review of his medical records he had been noted to have a small Morgagni hernia on routine chest x-ray 21 years before however the patient was not informed and no action had been taken.
Morgagni, an Italian anatomist, described in 1769 a hernia through a defect in the diaphragm immediately behind the sternum . The hernial sac most commonly extends to the right and if large enough may contain colon, omentum and stomach. The defect lies between the sternal and anterior costal fibres of the diaphragm and is reported to represent around 3% of congenital diaphragmatic hernias . It may present in the newborn with respiratory distress however most are not diagnosed until later in life.
In the adult, Morgagni hernias are generally asymptomatic being an incidental finding on imaging or laparoscopy [1, 2]. Some authors recommend repair even in asymptomatic people to avoid the risk of strangulation and emergency surgery [2, 3]. If there were to be radiological evidence of incarcerated tissue then elective operation should be recommended. With the advent of effective laparoscopic repair it is likely that more asymptomatic patients will come to operation.
Morgagni hernias may become symptomatic and various upper GI complaints have been attributed to this type of hernia, including indigestion and flatulence. Rarely, the hernia may present acutely when its contents become strangulated and emergency operation will be necessary.
Laparoscopic repair of Morgagni hernia was first described by Kuster and colleagues in 1992 and has rapidly replaced open transabdominal or transthoracic approaches although most emergency cases are still managed by open operation [4, 1]. There is still some debate as to the merits of resecting the sac and whether primary closure of the defect is preferable to mesh placement. In the case detailed herein, the defect was large and primary closure was not feasible. Polypropelene mesh was carefully tacked in place with a wide overlap onto fascia. This is easily done and is likely to form a strong repair with tissue ingrowth into the mesh fixing it in place. Due to the position of the defect, which will be covered by stomach and omentum, it is unlikely that bowel would become adherent and the use of special mesh was not considered necessary. Fixation of the mesh may be achieved by sutures or tacks, although if tacks are used, care must be taken as there is a report of postoperative cardiac tamponade due to bleeding from an epicardial artery . Unfortunately no significant followup was possible on this patient and further reports will be needed to confirm the durability of this technique.
In hiatal hernia, the esophagus forms part of the wall of the sac. The sac should be dissected and reduced to allow the esophagus to be encircled and mobilised for crural dissection and repair, and to ensure an adequate length of intraabdominal esophagus. However, in a Morgagni hernia the sac is complete with only the falciform ligament and ligamentum teres in its wall and it may not be necessary to remove the sac. If it is to be left in place, it is important to circumcise the neck of the sac and reflect the peritoneum and fat to allow wide fixation of the mesh to muscle and aponeurosis.
It is important for clinicians to be aware of strangulated Morgagni hernia as a rare cause of the acute abdomen and prompt diagnosis will ensure a higher chance of laparoscopic repair. Strangulated cases can be treated laparoscopically even if necrotic tissue has to be resected. As the defect is anterior, it is advisable to use a 30° laparoscope with the patient in low stirrups so the surgeon can stand between the patients' legs.
While these hernias are usually considered to be benign it is logical to expect that they will enlarge with time as in the presently reported case. Caution is advised before dismissing Morgagni hernias in adults as being clinically insignificant.
Permission was obtained from the patient to make this report.
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