Giant Hernia of Morgagni with Acute Coronary Syndrome: A Rare Case Report and Review of Literature

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.

Approach to a large rare diaphragmatic hernia in a patient undergoing cardiac surgery

Hernia of Morgagni is an unusual congenital defect of the sternal portion of the diaphragm. Its concurrence with cardiac surgical pathology is rarely described in the literature. Notwithstanding, huge hernia of Morgagni have been noted to cause serious peri-operative impediment and complications. We report the case of a 50-year-old gentleman with a massive Morgagni hernia that threatened strangulation during cardiopulmonary bypass. We describe the combined surgical approach undertaken to repair this hernia, with an accompanying review of the literature relating to misadventure and management of similar large hernia coinciding with cardiac surgery.

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.

Morgagni Hernia Repair: A Review

Anteromedial subcostosternal defects, also known as a diaphragmatic hernia of Morgagni (MH), allow potentially life-threatening herniation of the abdominal organs into the thorax. Constituting only a small fraction of all types of congenital diaphragmatic hernias, correct diagnosis of MH is often delayed, owing in large part to nonspecific associated respiratory and gastrointestinal complaints. Once identified, the primary management for both symptomatic and incidentally discovered asymptomatic cases of MH are surgical correction because the herniated contents present increasing risk for strangulation. Various thoracic and abdominal surgical approaches have been described without a clear consensus on preference for operative repair technique. In this article, the literature regarding management of MH within the past decade is reviewed, and an illustrative case of laparoscopic repair of a MH with novel reinforcement using a Falciform ligament onlay flap is presented.

Congenital retrosternal hernias of Morgagni: Manifestation and treatment in children

BACKGROUND

Due to scarcity of congenital diaphragmatic hearnias of Morgagni (CDHM), non-specific clinical presentation in the pediatric age group, we aimed to investigate the incidence, clinical manifestations, anatomical characteristics, and develop diagnostic algorithm and treatment of CDHM in children.

MATERIALS AND METHODS

The patients' records of children with CDHM treated in our hospital during past 20 years were retrospectively reviewed for the age at diagnosis, gender, clinical findings, anatomical features, operative details and outcome.

RESULTS

Since 1995 to 2014 we observed 6 (3 boys, 3 girls) patients with CDHM, that comprise 3.2% of all congenital diaphragmatic hernia cases (n = 185). Age at diagnosis varied from 3 mo. to 10y.o. Failure to thrive was main symptom in 4 patients, followed by recurrent respiratory infections (n = 3), dyspnea (n = 3), and gastrointestinal manifestations: constipation (n = 2), abdominal pain (n = 1). Work-up consisted of plain X-ray for all (n = 6), upper GI (n = 3), barium enema (n = 2), sonography (n = 6) and CT (n = 2). Abdominal approach used in 5 patients, and thoracotomy in one. Herniated contents were: liver lobes (n = 4), transverse colon (n = 3) and greater omentum (n = 1). 5 had right-sided lesion, 1- left-sided. Defect repaired using local tissues. Post-operative course was uneventful; all patients appeared well during follow-up.

CONCLUSION

CDHM is very uncommon anomaly, very occasionally diagnosed at the early age. Failure to thrive and recurrent respiratory infections are most frequent clinical manifestations. In suspected CDHM we advocate the following work-up: plain chest and abdominal X-ray, contrast study (upper GI series or barium enema), ultrasonographic screen and CT scan. Surgical repair via abdominal approach, using local tissues and hernia sac removal is preferred.