Presentation and management of Morgagni hernias in adults: a review of 298 cases

Robotic-assisted repair of an anterior diaphragmatic hernia secondary to Xiphoidectomy

Anterior diaphragmatic hernias manifest when a diaphragmatic defect permits abdominal contents to enter the thoracic cavity. They may be congenital or acquired; when acquired, the typical etiology is traumatic injury. Without treatment, they risk incarceration or strangulation. A 55-year-old male with a history of xiphoidectomy during sternotomy for cardiac disease was incidentally found to have an anterior diaphragmatic hernia on a screening chest CT (computed tomography) scan. He developed gastric obstruction shortly after an outpatient surgical consultation. He was admitted to the hospital, and further workup revealed a right-sided type-4 diaphragmatic hernia with an incarcerated colon, antrum, and pylorus. Nasogastric decompression was performed, followed by robotic-assisted transabdominal preperitoneal (r-TAPP) repair with mesh. He recovered without complications. There are currently no reports in the literature of an anterior diaphragmatic hernia secondary to a xiphoidectomy. This case demonstrates the successful use of r-TAPP for this rare presentation of an anterior diaphragmatic hernia.

Right-sided Morgagni diaphragmatic hernia presenting as isolated left shoulder pain

A woman in her 60s presented to the emergency department with excruciating, deep left shoulder pain and was found to have a right-sided Morgagni hernia, a rare type of congenital diaphragmatic hernia (CDH). She did not have chest pain, palpitations, shortness of breath, cough, abdominal pain, constipation, diarrhoea, nausea, vomiting or other symptoms classically associated with CDHs in adults. Laparoscopic robotic-assisted repair with mesh placement was performed, and the patient's recovery was uncomplicated, with no recurrence of shoulder pain. Our patient's presentation was unusual due to the absence of symptoms typically seen with CDHs in adults, and the presence of contralateral, left-sided shoulder pain with a right-sided Morgagni hernia.

The surgical treatment of Morgagni hernias in adults: a systematic review for the standardization of laparoscopic surgical repair

A Morgagni hernia is a congenital diaphragmatic hernia that is rarely diagnosed in adults, and the technique for its repair has not yet been standardized. This review will give an overview of the different laparoscopic methods reported by other authors, highlighting the key points indicating a good repair to help standardize the technique. A systematic review of the available articles on PubMed was conducted according to PRISMA 2020 by two authors independently in May 2022. Only articles written in English were included. A total of 180 case reports of laparoscopic Morgagni's hernia repair procedures were found; direct repair was performed in 59 patients, mesh was used in 119 patients, and mesh was not used in 2 patients. The hernia sac was removed in 71 patients, and the defect was closed before mesh placement in 49 patients. Nonabsorbable, dual or biologic mesh was used. The mean operative time was 92.65 min for direct repair and 84.11 min for mesh repair. One recurrence was reported in the direct repair series. The optimal method of repair has not yet been identified. The laparoscopic approach is associated to fewer complications and facilitates a faster recovery than the open approach. Several manoeuvres have been reported to help surgeons, who are not trained in laparoscopic knotting, perform extracorporeal knotting. Mesh should be placed when tension is too high after a direct repair or when primary closure cannot be achieved.

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.

Laparoscopic repair of Morgagni hernia by primary closure with extra-abdominal suture: a case report and review of the literature

We report a case of a Morgagni hernia repaired by primary closure with an extra-abdominal suture. Moreover, we reviewed cases of laparoscopically repaired Morgagni hernia, in which the size of the hernia defect was known, to establish a size criterion for mesh utilization. An 87-year-old woman presented to our hospital with right upper abdominal pain and vomiting. She had no history of abdominal surgery or trauma. Chest radiography and computed tomography (CT) revealed a Morgagni hernia, with the stomach and transverse colon herniated into the right chest cavity. Initially, an endoscopic repair was performed for the herniated stomach due to her age, which was successful. However, she had a recurrence 2 days later, prompting us to perform a semi-emergent laparoscopic surgery. Laparoscopic examination revealed a Morgagni defect, with the omentum, transverse colon, and stomach herniated, with the stomach reduced by pneumoperitoneum. Fortunately, the herniated organs could be easily relocated into the abdomen with no adhesions. The hernia defect measured 6 x 3 cm. We performed primary closure with an extra-abdominal suture. No sac resection was performed. The operation lasted 98 min. Oral intake was initiated on postoperative day 1, and the patient was discharged on postoperative day 3 without complications. Chest radiography and CT scans at 1 month postoperatively showed no recurrence, and the patient remained asymptomatic at the 9-month follow-up examination. According to our review findings, primary closure is an efficient method for small hernia defects (rule of thumb: width, <4 cm; length, <7 cm).

Laparoscopic Repair Following a Delayed Presentation of Traumatic Diaphragmatic Hernia: A Case Report

Traumatic diaphragmatic hernia is a rare condition that occurs after trauma, and some patients have a delayed presentation. A laparoscopic approach is rarely used to repair traumatic diaphragmatic hernias. We encountered a case of asymptomatic diaphragmatic hernia diagnosed after a comprehensive medical examination. A 71-year-old woman was diagnosed with a delayed presentation of traumatic diaphragmatic hernia with prolapse of the greater omentum owing to a traffic injury 20 years ago. Surgery was performed laparoscopically using three ports, and intraoperative respiratory management was performed using a double-lumen tube. The 2.5-cm-diameter hernial orifice was sutured under contralateral one-lung ventilation after the greater omentum was returned to the abdominal cavity. The patient's postoperative course was uneventful, and she was discharged on the third day. Intraoperative strategies such as respiratory management and the laparoscopic approach play a crucial role in ensuring favorable postoperative outcomes. The last follow-up was at six months post-operation, and the patient was doing well.

Successful Laparoscopic Treatment of Morgagni's Hernia in an Elderly Female Presenting as a Hypoxemic Hypercapnic Respiratory Distress

Morgagni's hernia (MH) occurs when the abdominal viscera herniates into the thoracic cavity through a congenital anatomical defect in the diaphragm, termed the foramen of Morgagni. Although it is more frequently detected in childhood, its delayed presentation in adults and the elderly could be easily overlooked due to the non-specificity of its symptoms. Here, we report the case of an elderly female who presented purely with dyspnea and desaturation, necessitating admission to the intensive care unit. Her computed tomography (CT) scan revealed the presence of MH with complete lobar collapse. Laparoscopy was successful in reducing the hernia, and the patient improved with a good prognosis. Surgical treatment for MH is advised for all cases in order to prevent the occurrence of serious complications.

Incidental finding and successful management of Larrey's hernia during laparoscopic cholecystectomy: Case report

INTRODUCTION

Larrey hernias (LH) are birth defects causing abdominal viscera to protrude into the thoracic cavity. With an incidence of 2-4 %, they are exceptional in adults.

CASE PRESENTATION

A 65-year-old female patient was admitted for an elective laparoscopic cholecystectomy. During history intake, besides biliary colic, no additional symptoms were reported. Physical examination yielded normal results. Chest-X ray did not reveal any anomalies. Intraoperatively, an inspection of the diaphragm revealed a 3 cm defect in the left-sided sternocostal triangle, with the omentum protruding through the thorax. After performing cholecystectomy, the content of the LH was cautiously reduced. The hernia sac was not resected, to prevent potential injury to the neighboring anatomical structures. The defect was closed using non-resorbable interrupted sutures. The postoperative course was uneventful. No recurrence was detected during follow-up.

CLINICAL DISCUSSION

LH diagnosis is challenging due to its unspecific symptoms. Only 10 % of patients are asymptomatic. CT imaging establishes a positive diagnosis and identifies acute complications requiring emergency management.

CONCLUSION

Asymptomatic LH cases mandate surgery. Laparoscopic management is safe and efficient. The trans-abdominal approach offers easier access to hernia content. Hernia sac resection is still debatable. The selection of defect closure technique hinges on the quality and elasticity of the tissue, as well as the size of the defect, all under the unwavering banner of the tension-free principle. Literature remains conflicting on mesh use.

Rare Diaphragmatic Hernias in Adults-Experience of a Tertiary Center in Esophageal Surgery and Narrative Review of the Literature

A rare entity of non-hiatal type transdiaphragmatic hernias, which must be clearly differentiated from paraoesophageal hernias, are the phrenic defects that bear the generic name of congenital hernias-Bochdalek hernia and Larey-Morgagni hernia, respectively. The etiological substrate is relatively simple: the presence of preformed anatomical openings, which either do or do not enable transit from the thoracic region to the abdominal region or, most often, vice versa, from the abdomen to the thorax, of various visceral elements (spleen, liver, stomach, colon, pancreas, etc.). Apart from the congenital origin, a somewhat rarer group is described, representing about 1-7% of the total: an acquired variant of the traumatic type, frequently through a contusive type mechanism, which produces diaphragmatic strains/ruptures. Apparently, the symptomatology is heterogeneous, being dependent on the location of the hernia, the dimensions of the defect, which abdominal viscera is involved through the hernial opening, its degree of migration, and whether there are volvulation/ischemia/obstruction phenomena. Often, its clinical appearance is modest, mainly incidental discoveries, the majority being digestive manifestations. Severe digestive complications such as strangulation, volvus, and perforation are rare and are accompanied by severe shock, suddenly appearing after several non-specific digestive prodromes. Diagnosis combines imaging evaluations (plain radiology, contrast, CT) with endoscopic ones. Surgical treatment is recommended regardless of the side on which the diaphragmatic defect is located or the secondary symptoms due to potential complications. The approach options are thoracic, abdominal or combined thoracoabdominal approach, and classic or minimally invasive. Most often, selection of the type of approach should be made taking into account two elements: the size of the defect, assessed by CT, and the presence of major complications. Any hiatal defect that is larger than 5 cm2 (the hiatal hernia surface (HSA)) has a formal recommendation of mesh reinforcement. The recurrence rate is not negligible, and statistical data show that the period of the first postoperative year is prime for recurrence, being directly proportional to the size of the defect. As a result, in patients who were required to use mesh, the recurrence rate is somewhere between 27 and 41% (!), while for cases with primary suture, i.e., with a modest diaphragmatic defect, this is approx. 4%.

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.

A rare case of pseudomyxoma peritonei with Morgagni hernia

Both pseudomyxoma peritonei and Morgagni hernias in adults are rare clinical conditions. A 70-year-old woman who was diagnosed with pseudomyxoma peritonei with Morgagni hernia underwent cytoreductive surgery and primary repair. Pseudomyxoma peritonei causes increased intra-abdominal pressure that may lead to acquired congenital diaphragmatic hernia when there is a local fragility in the diaphragmatic musculature. Parietal peritonectomy of the right diaphragmatic peritoneum can safely remove the hernia sac. The high rate of infections associated with cytoreductive surgery causes hesitation for concurrent mesh repair for Morgagni hernia. This is the first report of pseudomyxoma peritonei with Morgagni hernia. Cytoreductive surgery including parietal peritonectomy of the right diaphragmatic peritoneum plus primary repair of hernial defect was performed safely and successfully, which achieved positive short-term results for patients with pseudomyxoma peritonei-associated Morgagni hernia.

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

Case report: Laparoscopic nissen-sleeve gastrectomy in a young adult with incidental finding of Morgagni-Larrey hernia

Laparoscopic sleeve Gastrectomy (LSG) is the most performed bariatric procedure worldwide but it is associated with an increased incidence of de-novo or recurrent GERD. Recently a new technique consisting in LSG with associated fundoplication has been described. Morgagni-Larrey hernia is very rare and there is a lack of evidences on its correct surgical treatment. There are only rare cases of a MLH incidental diagnosis in patients submitted to bariatric surgery. We present our experience of Morgagni-Larrey Hernia (MLH) incidentally found intraoperatively in a patient with Gastroesophageal Reflux Disease (GERD) with Hiatal Hernia (HH) undergoing a bariatric surgical procedure.

Laparoscopic double mesh repair of a large Morgagni hernia: a video vignette

Morgagni hernia (MH) is a rare congenital diaphragmatic hernia (CDH) that accounts for less than 2% of surgically repaired CDH in adulthood. Even if this condition is often asymptomatic, surgery is advised due to the risk of life-threatening complications such as volvulus or bowel strangulation. Surgery for MH repair can be performed by transthoracic, transabdominal, laparoscopic, or thoracoscopic approaches. Though laparoscopy has recently improved surgical outcomes, the use of prosthetic meshes and the need for reduction of the hernia sac are still the most debated issues. We present the video of a laparoscopic repair of a large MH with the use of a double mesh technique and no resection of the hernia sac.

A Case Report and Literature Review on Incidental Morgagni Hernia in Bariatric Patients: To Repair or Not to Repair?

Morgagni hernia (MH) is a congenital diaphragmatic hernia that is often asymptomatic in adult patients. These defects may be discovered incidentally during the intraoperative period and repaired laparoscopically with tension-free synthetic mesh when surgery is warranted. Presently, there is a dearth of studies addressing incidental MH repair in the setting of concomitant bariatric surgery. As such, there are no clear guidelines as to whether or not asymptomatic hernias found incidentally during bariatric surgery require operative repair. Herein, we present the case of a morbidly obese female patient with an incidental Morgagni defect that was identified during an elective sleeve gastrectomy. We also reviewed the literature to assess the efficacy of concurrent bariatric surgery and hernia repair.

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.

Robotic Morgagni's hernia repair in adults - A single centre experience

BACKGROUND

This study was aimed at reporting the surgical outcomes and evaluating the safety and feasibility of robotic repair of Morgagni's repair in adults.

METHODS

This is a retrospective analysis of seven cases of Morgagni's hernia in adults, managed by robotic method in a tertiary-level thoracic surgery centre over 9 years. A detailed analysis of all perioperative variables including complications was carried out.

RESULTS

A total of seven patients underwent Robotic Morgagni's hernia repair during the study period. Males (71.4%) were predominant in the patient cohort. Median age group was 33 years (range: 28-78 years). All patients were pre-obese with median body mass index of 29.4 (range: 27.5-29.9). All patients underwent robotic-assisted hernia repair with no conversions. Omentum was the most common hernial content (100%). In all cases, the defect was reinforced with a composite mesh. Median operative time was 140 min (range: 120-160). Median hospital stay of 3 days (range: 2-4 days). No post-procedural complications. All the patients had complete resolution of presenting symptoms. No recurrence was noted in the median follow-up period of 32 months (range: 6-78 months).

CONCLUSION

Robotic-assisted surgical repair of Morgagni's hernia in adults is safe, feasible and effective. However, studies with larger sample size and multi-institutional collaboration are recommended for further conclusions.

Non-operative management of a large Morgagni hernia-an alternative approach?

Morgagni's hernia (MH) is a congenital diaphragmatic hernia with a small percentage of cases diagnosed in adulthood. The average age of diagnosis is 57 years, with 61% being female and 10-28% being asymptomatic. It is common practice to complete surgical repair of MH regardless of symptomology or size of the defect despite a paucity of evidence. This paper highlights the potential for non-operative management as a reasonable treatment option in large asymptomatic MH. A female in her 40s was referred following an abnormal spirometry result as a part of a routine pre-employment check. She subsequently had imaging, which showed a large MH with abdominal contents within the thoracic cavity. Following discussion at a multidisciplinary team meeting, it was decided that the risk of perioperative morbidity likely exceeded the risk of strangulation while asymptomatic, and thus surveillance was recommended.

Laparoscopic repair of Morgagni hernia with extra-abdominal sutures and ileocecal resection for colon cancer: a case report

Morgagni hernia is a rare form of diaphragmatic hernia. It is located at the anterior edge of the diaphragm and does not have an anterior rim. It is difficult to achieve a secure closure and maintain the tension of closure with laparoscopic surgery. We have performed laparoscopic resection of colorectal cancer and hernia repair simultaneously. An 89-year-old woman underwent laparoscopic hernia repair and ileocecal resection simultaneously. Regarding hernia repair, we considered that it would be difficult to use a mesh from the viewpoint of infection due to the colectomy. Therefore, we have done the extra-abdominal suture method. After laparoscopic ileocecal resection, a small incision was made in the epigastric region, and Morgagni hernia repair was performed with extra-abdominal sutures. She had no recurrence of either colon cancer or hernia for 22 months post-operatively. The extra-abdominal suture method can provide secure closure of the hernia orifice for Morgagni hernia.

Congenital diaphragmatic hernia in adults: a decade of experience from a single tertiary center

INTRODUCTION

Congenital diaphragmatic hernias (CDHs) in adults remain rare, with limited data on them available. However, CDHs can cause respiratory and gastrointestinal symptoms in adults, even resulting in the strangulation of the bowel when incarcerated. Here, we aimed to analyze surgical outcomes among adult patients. The primary outcome of interest was the complication rate, reoperations and 90-day mortality after laparoscopic and open hernia repair.

METHODS

We identified all adult patients diagnosed with a Morgagni or Bochdalek hernia treated operatively between 2010 and 2019 in a single tertiary care hospital. Data on patient demographics, surgical characteristics, mortality and morbidity were collected.

RESULTS

In total, we identified 37 patients (67.6% female; average age, 57 years). Overall, 78.4% patients underwent minimally invasive operations, while 35.1% underwent emergency operations. A Clavien-Dindo grade II-V complication was experienced by 18.9% of patients. No deaths occurred within 90 days of surgery, and we detected no recurrences in short-term or long-term follow-up. A minimally invasive technique correlated with a shorter hospital stay of 3.6 days versus 6.8 days in the open surgery group (p = .007, t = 3.3, 95% confidence interval = 1.04-5.21).

CONCLUSION

Our findings indicate that the laparoscopic repair of a congenital diaphragmatic hernia is safe and effective, offering short hospital stay and a low amount of complications.

Robotic repair of a giant Larrey-type congenital left-sided diaphragmatic hernia in a young woman. A case report and literature review

Congenital diaphragmatic hernia is a rare condition caused by a malformation in the diaphragm that is usually diagnosed in newborns, infants and children. Sometimes it can be incidentally identified in adults. Once the diagnosis is made, surgery is indicated to avoid the risk of life-threatening complications of herniated viscera. Traditional approaches include laparotomy or thoracotomy or both; in the last decades minimally invasive techniques have proved to be a safe alternative to the open approach but only few cases of robotic hernia repair have been described so far, the most with a combined thoracic-abdomen approach. We report a case of an 18-year-old female presenting with abdominal pain due to a giant left-sided anterior diaphragmatic hernia (Larrey-type) that was repaired using a robotic-assisted laparoscopic approach with mesh placement. The hernia contents included gastric body and fundus, duodenum, jejunum, ileus, cecum, right colon and mesentery; spleen and pancreas were rotated and dislocated anteriorly. The outcome was unremarkable, with no major post-operative complications and no signs of long-term recurrence. The robotic approach seems to be a valid option for the treatment of diaphragmatic hernias, improving post-operative outcome and providing surgeon better visualization, greater precision and enhanced dexterity in a confined space.

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Congenital diaphragmatic hernias are a rare condition that may have a late onset.

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Once the diagnosis is made, surgery is mandatory due to the risk of life-threatening complications.

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Minimally invasive approaches are a safe option for congenital diaphragmatic hernia repair and can improve post-operative outcome.

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Robotic diaphragmatic hernia repair allows better visualization, greater precision and enhanced dexterity in a confined space.

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The use of a mesh is controversial, but in large defects it is recommended to reinforce the primary repair.

Morgagni Hernia Repair in Adults: A Single-Center Experience in Spanish Population

Introduction: Morgagni hernia (MH) is a rare congenital disorder, especially in adults, accounting for 2%-4% of all congenital diaphragmatic hernias. Materials and Methods: Retrospective review of all patients who underwent surgical repair of MH at our center from 1991 to 2022. A descriptive analysis was performed. Results: Eighteen patients presented with MH, of whom 11 (61.11%) were female, with a median age of 67.60 (IQR 50.25-84.50) years old. Six (33.33%) were asymptomatic and 12 (66.67%) presented with symptoms, being dyspnea (4; 33.33%) the most common. On the group of symptomatic patients, the computed tomography scan (8; 66.67%) was the most frequent diagnostic test. Whereas in the asymptomatic group, 5 patients (83.33%) were diagnosed intraoperatively, during surgery for other reasons. MH was mostly located on the right (16; 88.89%). Hernia contents included omentum and colon (10; 55.56%), omentum (5; 27.78%), and stomach (3; 16.67%). All patients underwent surgical repair, needing in 3 cases (16.67%) emergency surgery. Surgical approaches included 10 laparoscopies (55.56%), 7 laparotomies (38.89%), and 1 thoracotomy (5.55%). Repair was generally performed whether by primary closure in 8 patients (44.4%) or by mesh implantation in 10 (55.56%). The median hospital stay was 6 days (IQR 3-10). Three patients presented complications (17.65%): urinary tract infection (1 patient), intra-abdominal collection (1 patient), and the last 1 presented with renal failure and pneumonia. The median follow-up was 74 months (IQR 4.5-130). No recurrence was described. Conclusions: MH is a rare condition in the adult population. In our series most patients presented with symptoms. The gold standard treatment is surgical repair, being the laparoscopic approach the most frequent. The complications rate was relatively low and no recurrence was described in our study.

Two unusual fat-containing mediastinal entities: Pearls and pitfalls in imaging of Morgagni hernia and fat necrosis

This review focuses on 2 fat-containing entities in the mediastinum that may raise a diagnostic challenge: Morgagni's hernia and Epipericardial (mediastinal) fat necrosis. Familiarity with the typical imaging findings of these 2 entities is vital for the radiologist to recognize and accurately characterize unusual mediastinal pathological conditions.

Acquired Morgagni hernia following coronary artery bypass graft (CABG) with successful robotic repair of hernia

INTRODUCTION AND IMPORTANCE

Morgagni hernia is an uncommon type of diaphragmatic hernia and commonly presents as a congenital disease. Acquired Morgagni hernias following open cardiac surgery are exceedingly rare and only reported in the pediatric population.

CASE PRESENTATION

The patient is a 70-year-old female who presented with complaints of shortness of breath and cough one year following a coronary artery bypass graft (CABG). A chest CT scan showed a large Morgagni type diaphragmatic hernia with herniated transverse colon occupying the anterior mediastinum as well as the right hemi-thorax. This hernia was successfully repaired using transabdominal robotic approach with complete resolution of patient's symptoms.

CLINICAL DISCUSSION

This is the first reported case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery. The potential etiologies for this hernia include distal extension of the median sternotomy and involvement of the anterior diaphragm, iatrogenic injury to the attenuated anterior diaphragm during pericardial window creation, or pericardial drain placement. Operative repair is the mainstay of treatment and is usually performed with a transabdominal approach since it is thought to be less challenging and allows for evaluation of the entire abdominal cavity. If primary repair cannot be achieved, then synthetic mesh may be needed to obtain a tension free and durable repair.

CONCLUSION

We present a case of acquired Morgagni type diaphragmatic hernia in an adult following open cardiac surgery that was successfully repaired using a transabdominal robotic approach.

A Deployed Soldier Presenting With Dyspnea and Orthopnea Due to a Morgagni Hernia

Shortness of breath is an important complaint in the austere setting with a broad differential diagnosis. The difficulty of deployed patient movement and lack of diagnostic testing at treatment sites complicates its evaluation. This case highlights a young Soldier presenting with shortness of breath caused by a Morgagni hernia. A 25-year-old deployed male presented with a 1-month history of dyspnea with exertion and right-sided chest tightness. After initial diagnoses of bronchitis, later chest radiographs demonstrated a linear opacity in the right middle lobe (RML). The patient was transferred to a higher level of care where a chest computer tomography scan was consistent with Morgagni hernia. Morgagni hernias can present with a wide variety of clinical complaints, including gastrointestinal symptoms, dyspnea, and chest pain. A lack of familiarity among providers who care for adults and the nonspecific nature of the symptoms frequently cause a diagnostic delay in diagnosis. CXR is helpful in this diagnosis, although this case demonstrates that this hernia may appear similar to RML atelectasis or pneumonia.6 Computed tomography remains the modality of choice to confirm the diagnosis, as well as provide anatomical details and rule out complications. While most experts agree that Morgagni hernias should be surgically repaired, the optimal surgical technique remains uncertain.3 Despite its rarity, Morgagni hernia is important to consider in a broad range of clinical presentations. Its nonspecific symptoms, combined with radiographs that can mimic other disease entities, can lead to a delay in diagnosis, mistreatment, prolonged patient suffering, and complications.

A rare adult morgagni hernia mimicking lobar pneumonia

Morgagni hernia is the rarest form of congenital diaphragmatic hernia and is commonly found either in the first few hours of life or in antenatal period. It is less common in adult and is mostly diagnosed incidentally in an asymptomatic patient. Symptomatic adult cases are even rarer with a wide variety of symptoms. Here we report a patient with a one year history of chronic recurrent cough and dyspnea, who had been misdiagnosed as recurrent pneumonia before being recognized and treated as Morgagni hernia.

Laparoscopic repair of an incarcerated Morgagni Hernia in a COVID-19-positive patient: A video case report

Introduction

Morgagni Hernia (MH) is a type of congenital diaphragmatic hernia (CDH). CDH is a diaphragmatic discontinuity that permits abdominal viscera to herniate into the chest during development. It does not only occur in early childhood but also has been reported in adults. The most prevalent clinical sign of MH is respiratory disorder of all ages.

Case presentation

An elderly woman with a known history of diabetes, ischemic heart disease, hypertension, and constipation presented to us with increased abdominal pain. Besides, her PCR test results were positive for COVID-19. She underwent diagnostic laparoscopy surgery. The incision was closed with an intracorporeal suture, and then dual mesh was fixed to diaphragmatic wall. The postoperative progress was satisfactory two weeks after surgery. Based on a negative PCR test, the patient was discharged from the hospital.

Discussion

The foramina of Morgagni is a defect in the costosternal trigons produced by a lack of anterior pleuroperitoneal membrane muscularization. Although gastrointestinal symptoms and cardiorespiratory discomfort are typically connected with the diagnosis and treatment of MH in youngsters, there are a few middle-aged people who, like our case, develop symptoms suddenly. Albeit a paradigm change in the 21st century deems less invasive laparoscopic surgery to be the treatment of choice, open surgical procedures via a trans-thoracic or trans-abdominal route are still used.

Conclusion

MH is indeed uncommon in adults, but in patients with an acute onset of intestinal obstruction, the possibility of MH should be in mind. It can be fatal if it is misdiagnosed.

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The possibility of Morgagni hernia should be in mind even in elderly patients

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Laparoscopic technique is one of the best approaches to the Morgagni hernia cause all abdominal organs can be evaluated with laparoscopy in a minimally invasive manner.

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The operation can be performed in a COVID-19 positive patient.

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COVID-19 may be a spark of underlying disease manifestations.

[Diagnostics and treatment of morgagni-larrey hernia]

OBJECTIVE

To analyze the peculiarities of diagnosis, surgical treatment and laparoscopic suturing of Morgagni-Larrey hernia.

MATERIAL AND METHODS

Morgagni-Larrey hernias were diagnosed in 20 out of 78 patients (26%) with diaphragmatic hernias. Mean age was 56 years. Nineteen patients had right-sided hernia, 1 patient - left-sided hernia. Abdominal approach was used in all cases.

RESULTS

In 50% of patients, hernias were asymptomatic and found during X-ray examination. Symptoms were shortness of breath (4), cough (3), chest pain (1), epigastric pain (6), stool and gas retention (3), vomiting (1), belching (1). Hernia sac included omentum in all patients, transverse colon in 9 cases and small bowel in 1 patient. CT data completely coincided with intraoperative findings. Intraoperative dimension of hernia was 7.4±1.7 cm. Hernia sac was excised in all cases. Median laparotomy was performed in 10 patients, transrectal incision - in 3 cases. Laparoscopic suturing of hernia orifice with imposing 3-5 extracorporeal transfascial-muscular U-shaped polypropylene sutures was performed in 7 cases. We passed the thread through abdominal wall (two skin incisions up to 2 cm) and diaphragm using a straight needle for suturing the wound from the port EndoClose. Ligatures were tied in subcutaneous fatty tissue. No postoperative complications and recurrent hernias were observed.

CONCLUSION

Morgagni-Larrey hernias occur in adults aged over 50 years as a rule. These hernias are usually right-sided, asymptomatic in 50% of cases and detected during routine X-ray examination. Laparoscopic suturing of hernia orifice using extracorporeal transfascial-muscular sutures with fixation of ligatures in subcutaneous tissue ensures adequate closure of defect.

Comparison of Optical Forceps-Assisted Single-Port Laparoscopic PIRS and Open Surgery in Morgagni Hernia Repair

INTRODUCTION

 This study aimed to compare the results of classical surgery (CS) and optical forceps-assisted single-port laparoscopic percutaneous internal ring suturing (SP-PIRS) repair for the treatment of Morgagni hernia.

MATERIALS AND METHODS

 Patients with Morgagni hernia who were operated on between January 2005 and July 2020 were included in the study. Patients were divided into two groups (CS or SP-PIRS) and compared retrospectively in terms of demographic data, defect size, duration of hospitalization, costs, postoperative complications, and recurrence.

RESULTS

 Thirty-two patients were included in this study. There were no statistically significant differences between the groups in terms of gender, defect size, postoperative complications, and recurrence (p > 0.05). The SP-PIRS group had a shorter operation time (p < 0.01), shorter hospital stay (p = 0.02), and lower cost (p < 0.01) than the CS group. The average follow-up was 24 months, and recurrence was detected in two patients in each group.

CONCLUSION

 SP-PIRS repair is recommended because it is practical to perform and reduces the duration of surgery, hospital stay, and cost. It is superior to other laparoscopic techniques, as there is no need to use additional study forceps, except in extreme cases, and the surgeon can perform the procedure without an assistant to hold the laparoscope.

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.

Surgical technique in the laparoscopic repair of Morgagni hernia in adults. How do we do it?

INTRODUCTION

Adult Morgagni hernias are rare congenital diaphragmatic hernias, which can present with an array of symptoms based on the size and the contents of it. This article focuses primarily on the laparoscopic repair with transfascial suturing.

METHODS

A number of five patients over the course of 10 years were admitted in our clinic, one of them being admitted with emergency symptoms. Four of the patients were treated laparoscopically, one of them requiring conversion to open approach.

RESULTS

The median age was 53 (range 44-71), 80% of the patients being females. Four of the patients received laparoscopic treatment with transfascial suturing, the fifth being converted, but respecting the same technique. The median surgery duration was 110 min, with a median blood loss of 30 ml. Removal of the sac was attempted in two cases. Median hospitalization stay was 3 days, with a median follow-up of 21 months, with no postoperative complications reported.

CONCLUSIONS

Laparoscopic repair with transfascial suturing provides an feasible and efficient repair, compared to the other laparoscopic techniques. Although no postoperative complications were reported, the removal of the sac still remains an controversial issue.

Laparoscopic and single incision laparoscopic repair of Morgagni hernia in adults

Background: In this study, we aimed to compare multiple versus single incision laparoscopic repair of Morgagni hernia in adults and to investigate effectiveness and feasibility of both techniques.

Methods: Between January 2011 and March 2018, a total of 15 patients (5 males, 10 females; median age: 58.6 years; range, 36 to 70 years) who underwent laparoscopic or single-incision laparoscopic repair of Morgagni hernia were retrospectively analyzed. Demographic and clinical characteristics of patients, perioperative data, and treatment outcomes were evaluated.

Results: The median follow-up was 38 (range, 11 to 84) months. Of the patients with Morgagni hernia, 12 were treated with laparoscopic and three were treated with single incision laparoscopic repair technique. Patient satisfaction was excellent for most of the patients in both groups. No recurrence was observed during follow-up.

Conclusion: Morgagni hernia is a very rare type of hernia in adults. Laparoscopic mesh-reinforced primary repair of Morgagni hernia should be one of the first choice in patients, particularly with large hernias that would cause tension on edges of the diaphragm when closed. Single incision laparoscopic repair of Morgagni hernia is also another laparoscopic option with high patient satisfaction.

Intestinal Air in the Mediastinum

CASE PRESENTATION

A 74-year-old man, in excellent physical condition and doing regular intense cycling, was evaluated for transient episodes of thoracic discomfort over a period of several months. His medical history only included a right inguinal hernia, surgically treated, and an abdominal aortic aneurysm measured at 46 mm and treated medically. Physical examination did not reveal much information. The patient did not report gastroesophageal reflux, dysphagia, or history of digestive occlusion. The patient had normal weight and had no trauma history. He had no nicotine or alcohol-dependent behaviors. Vital signs were within normal values. Laboratory test results were normal. Functional status was normal, without anomalies of pulmonary function tests or arterial blood gases. The ECG did not reveal any anomaly.

A novel approach for the treatment of Morgagni hernias: robotic transabdominal preperitoneal diaphragmatic hernia repair

PURPOSE

We introduce a novel approach to the surgical repair of Morgagni hernias (MHs) utilizing the robotic transabdominal preperitoneal repair (rTAPP) approach. Borrowed from our previous and robust experience with rTAPP repairs for hernias of the anterior abdominal wall, this technique boasts the benefits of hernia sac reduction, the use of an uncoated mesh in an extraperitoneal plane, and minimal fixation leading to lower postoperative pain relative to other approaches.

METHODS

To evaluate the effectiveness of this novel approach, five consecutive symptomatic Morgagni hernias (MHs) were repaired with the rTAPP approach. The size of the defect, mesh size, length of stay, follow-up imaging, and follow-up complications were documented for comparison.

RESULTS

The size of the MH defects ranged from 4 × 6 cm to 5 × 10 cm. LOS was an average of 1.2 days. Two out of the five patients underwent concomitant repair of a lower abdominal hernias (one Spigelian hernia, and one indirect inguinal hernia). Outpatient follow-up from surgery ranged anywhere from 6 months to 4 years, with most patients receiving follow-up after 1 year. Four out of the five patients received follow-up CT scans to confirm the absence of hernia recurrence. One patient experienced an incisional hernia from the midline 12-mm port site which was repaired 1 year after.

CONCLUSION

We propose a new technique for a minimally invasive strategy to treat these complex hernias utilizing an rTAPP technique resulting in minimal length of stay and a durable result in long-term follow-up. The benefits of repair, which include minimal postoperative pain, minimal length of stay, and cost-effective prosthetic mesh hidden from the visceral contents, are consistent with the author's experience for rTAPP repairs for hernias of the anterior abdominal wall.

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.

When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review

BACKGROUND

Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair.

METHODS

A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH.

RESULTS

Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected.

CONCLUSIONS

DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries.

A novel technique of robotic preperitoneal approach for Morgagni hernia repair

INTRODUCTION

Morgagni hernia (MH) is a rare, congenital diaphragmatic hernia. We developed a novel robotic-assisted technique to repair MH which enables dissection into the preperitoneal space, facilitating closure of the diaphragmatic defect and placement of a synthetic mesh.

MATERIALS AND SURGICAL TECHNIQUE

Between August 2017 and August 2020, 8 consecutive patients with MH were repaired by robotic-assisted transabdominal preperitoneal (r-TAPP) approach. A preperitoneal plane is developed at the level of the falciform ligament and extended toward the diaphragmatic defect. The pocket is dissected inferior to the defect to allow 3 to 5 cm overlap of synthetic mesh. Excision of the hernia sac followed by closure of defect is performed. A synthetic mesh is deployed in the preperitoneal space with wide overlap. This technique using the robot provides superior optics and ergonomics for dissection while isolating the mesh from underlying viscera and avoiding the need for suturing or tacking of the mesh. Data of patients who underwent r-TAPP were reviewed. Mean operating time was 113 minutes. Mean pain visual analog scale score was 5/2 on post-operative days 1/7. Average hospital stay was 1.8 days. One patient developed superficial cellulitis related to the abdominal drain. There were no procedure-related complications, 30-day readmissions, or hernia recurrences at a mean follow-up of 10 months.

DISCUSSION

A robotic-assisted preperitoneal approach is a novel, safe, and anatomically justified alternative technique for MH repair that may lead to improved post-operative outcomes.

Congenital right diaphragmatic defects: Our institutional experience

BACKGROUND

The descriptive clinical study was conducted to analyse the clinical profile as well as the outcome of congenital right diaphragmatic defects among children including neonates in a tertiary care referral neonatal and paediatric centre in southern Karnataka, India.

MATERIALS AND METHODS

This retrospective and prospective observational clinical study was conducted from January 2005 to August 2019, over a period of 14.7 years in a tertiary care referral neonatal and paediatric centre. Clinical characteristics and risk factors of 33 children including neonates admitted and diagnosed with congenital right diaphragmatic defects were assessed both pre- and postoperatively. Neonates and children with acquired right diaphragmatic hernia defects and the left-sided diaphragmatic defects were not included in this clinical study.

RESULTS

For statistical as well as clinical analysis, 33 study subjects were grouped into four groups, depending on the pre-operative and intraoperative findings as well as on their final diagnosis. Group I comprised right congenital diaphragmatic hernia (RCDH) (n = 18), Group II comprised RCDH with sac (n = 6), the babies with diagnosis of right diaphragmatic eventration were included in Group III (n = 7), whereas babies with other right-sided diaphragmatic hernia defects diagnosis were included in Group IV (n = 2).

CONCLUSION

Right-sided congenital diaphragmatic defects, though rare, do carry excellent survival if referred early and managed in a tertiary care neonatal and paediatric centre as that of left diaphragmatic defects.

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.

Incarcerated Small-Bowel Pericardial Diaphragmatic Hernia After Pericardio-Peritoneal Window Creation: Report of a Rare Case

Patient: Female, 84-year-old

Final Diagnosis: Diaphragmatic hernia • small bowel obstruction

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Three-dimensional reconstruction model in the diagnosis of Morgagni's hernia

Morgagni’s hernia (MH) can be diagnosed by different utilities, but all these methods are not always 100% accurate. Three-dimensional (3D) reconstruction model could be helpful in better understanding the important anatomical structures. We report a case of MH who was once misdiagnosed as diaphragmatic eventration at the other institution and we offered laparoscopic repair according to the 3D reconstruction model. Our case highlights that 3D reconstruction model could be a useful supplementary tool in the diagnosis and preoperative assessment for patients with MH especially when it is confused in diagnosis in clinical practice.