Congenital diaphragmatic hernia

Simultaneous repair of diaphragmatic hernia and ventricular septal defect with postoperative complication in a Down syndrome child

Morgagni hernia (MH) is a rare form of congenital diaphragmatic hernia, typically occurring predominantly on the right side and exhibiting a higher prevalence in females. Usually diagnosed incidentally, MH may coexist with congenital heart defects, chest wall abnormalities and certain genetic syndromes such as Down syndrome. A 4-year-old boy with Down syndrome underwent simultaneous repair of MH and closure of a ventricular septal defect (VSD). A vertical midline sternotomy was performed, and the VSD was repaired using the right atrium approach. Subsequently, MH repair was conducted. Three weeks after the surgery, this patient developed a complete heart block, which lead to the implantation of a VVI pacemaker.

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.

Laparoscopic repair of Morgagni hernia in children

Aim

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

Methods

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

Results

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

Conclusions

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

Delayed traumatic parasternal hernia causes jejunal necrosis: A case report

Diaphragmatic injury is a common clinical condition, and it may be difficult to avoid diaphragmatic hernia if detection and treatment is not timely. Parasternal hernia is mostly congenital. It is relatively rare in adults, and intestinal obstruction as a complication of intrathoracic intestinal herniation occurs only rarely. We treated a patient in whom parasternal hernia occurred 2 years after thoracic injuries. We present the plain radiography and computed tomography findings of this adult patient with acute abdomen symptoms caused by parasternal hernia.

Repair of Morgagni Hernia in Adults with Primary Closure and Mesh Placement: First Robotic Experience

INTRODUCTION

Morgagni hernia (MH) is an uncommon type of diaphragmatic hernia, especially in adults. Laparoscopic or thorascopic approaches have been described in adults. There are few reported cases using the Da Vinci robot in children and no previously described cases in adults. We report our early experience and technique using the robotic approach for MH repair in adults and its potential advantages.

METHOD

Robotic repair of MH was performed in 3 female patients. Four trocars were used to gain access to the abdomen. The hernia contents were reduced, the sac excised, and the defect closed primarily. A 4 × 6 inch bioabsorbable coating mesh was used in 2 patients and a biologic mesh in 1 for reinforcement.

RESULTS

Robotic repair of MH was technically successful in all 3 patients. The average operative time was 199.3 minutes, and difficult hernia exposure in one case caused prolonged surgical time. There were no intraoperative complications. Additional interventions, including a repair of a transverse colon serosal tear during the reduction of hernia contents, occurred in 1 patient. Two of the 3 female patients were discharged on postoperative day 1, whereas the other patient was discharged on postoperative day 3. There were no postoperative complications.

CONCLUSION

Robotic MH repair is an alternative minimally invasive approach for adults that allows for precise sac excision and primary tension-free repair with mesh reinforcement.

Morgagni hernia presenting as gastric outlet obstruction in an elderly male

Morgagni hernia is the rarest of all congenital diaphragmatic hernias, first described in 1769. It is rarely symptomatic and found on routine radiological examinations for other conditions. Gastric outlet obstruction in adults with Morgagni Hernia is exceedingly rare. An 80-year-old man was taken to the operating room with a diagnosis of Morgagni hernia with gastric outlet obstruction. An upper midline laparotomy was performed, and the incarcerated pylorus and antrum of the stomach reduced with primary closure of the defect. Postoperative period was uneventful, and the patient was discharged on the sixth postoperative day. Morgagni hernia is exceedingly rare in adults and may present with gastric outlet obstruction in the emergency room. This clinical entity should be kept in mind while evaluating the patient, and early surgical intervention should be initiated.

Bochdalek hernia in a symptomatic adult

Bochdalek hernias usually present in neonates with respiratory failure, need to be operated early and are associated with a high mortality. We describe an adult patient who came to the emergency department with nonspecific recurrent chest and abdominal pain. A computed tomography scan showed a large posterolateral diaphragmatic defect and an oversized spleen. The hernia was repaired by a thoracoabdominal approach and Gore-Tex patch. Congenital diaphragmatic hernias are rare and are associated with nonspecific symptoms in adults. With suspicious chest or abdominal radiographs, a computed tomography scan is essential to plan an individualized surgical intervention.

Congenital Morgagni's hernia: a national multicenter study

BACKGROUND

Congenital Morgagni's hernia (CMH) is rare and represents less than 5% of all congenital diaphragmatic hernias. This is a national review of our experience with CMH outlining clinical presentation, methods of diagnosis, associated anomalies, treatment, and outcome.

PATIENTS AND METHODS

The medical records of all patients with the diagnosis of CMH treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for age at diagnosis, sex, presenting symptoms, associated anomalies, diagnosis, operative findings, treatment, and outcome.

RESULTS

During a 20-year period (January 1990-December 2010), 53 infants and children with CMH were treated. There were 38 males and 15 females. Their age at diagnosis ranged from 1 month to 9 years (mean 22.2 months). Forty-three (81%) presented with recurrent chest infection. Twenty-two (44.5%) had right CMH, 15 (28.3%) had left-sided hernia and 16 (30.2%) had bilateral hernia. In 7, the diagnosis of bilaterality was made at the time of surgery. Associated anomalies were seen in 38 (71.7%). Twenty-one (39.6%) had congenital heart disease, 8 (15%) had malrotation, and 15 (28.3%) had Down syndrome. All were operated on. Twenty-nine (54.7%) underwent repair via an open approach. The remaining 24 (45.3%) underwent repair using minimal invasive surgery, laparoscopic-assisted hernia repair (19 patients) or totally laparoscopic approach (5 patients). At the time of surgery, the hernia sac content included the colon in 33 (62.3%), part of the left lobe of the liver in 13 (24.5%), the small intestines in 11 (20.75%), the omentum in 5 (9.4%), and the stomach in 4 (7.5%). In 12 (22.6%), the hernia sac was empty. When compared to the open repair, the laparoscopic-assisted approach was associated with a shorter operative time, an earlier commencement of feeds, less requirement for postoperative analgesia, a shorter hospital stay, and better cosmetic appearance. There was no mortality. On follow-up, 2 (7%) of the open surgical group developed recurrence.

CONCLUSIONS

CMH is rare and in the pediatric age group commonly presents with recurrent chest infection and has a high incidence of associated anomalies, commonly congenital heart disease and Down syndrome. We advocate a laparoscopic-assisted approach to repair CMH. This is a simple technique that produces a sound repair, and when compared with the open approach it takes less operative time, requires less analgesia, allows earlier commencement of feeds, is associated with a shorter hospital stay, and has a better cosmetic outcome.

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.

[Intussusception after congenital diaphragmatic hernia repair]

INTRODUCTION

Bowel intussusception is a common complication of abdominal surgery. However, the literature on intussusception after congenital diaphragmatic hernia (CDH) repair is scarce.

CASE REPORT

A 24-month-old female was admitted with vomiting, crying and leukocytosis, with no objective abdominal signs. The chest x-ray showed the presence of bowel in the left hemithorax. Surgical exposure reduced a hernia across a Bochdalek defect, involving part of the left colon and the transverse colon. On the 7th postoperative day, the patient had symptoms of intestinal obstruction with worsening of her general condition. The explorative laparotomy evidenced an ileoileal intussusception, 15 cm from the ileocecal valve, in absence of a leading point.

CONCLUSION

A postoperative intussusception in a similar case could be explained by atony of the herniated bowel, possibly a functional leading point in the postoperative phase, when the peristalsis is reactivated.

Morgagni hernia presenting as obstructive jaundice

Morgagnis hernia is rare in pediatrics, representing 1%-6% of all congenital diaphragmatic hernias (CDH). We report a young boy presented with obstructive jaundice caused by compression of common bile duct (CBD) due to stretching and rotation of second part of duodenum in right-sided Morgagni hernia. Such presentation is rarely reported in literature.

Laparoscopic repair of diaphragmatic Morgagni hernia in children: review of 3 cases

This article retrospectively reviews the laparoscopic repair of Morgagni hernias in 3 children. The surgical procedure was performed by closing the defect using extracorporeal, interrupted, nonabsorbable sutures. Recovery was uneventful in all 3 patients. There were no recurrences and the chest radiograph stayed normal during the postoperative follow-up.

Adult intra-thoracic kidney: a case report of bochdalek hernia

Introduction. Bochdalek hernia is a congenital posterior lateral diaphragmatic defect that allows abdominal viscera to herniate into the thorax. Intrathoracic kidney is a very rare finding representing less than 5% of all renal ectopias with the least frequency of all renal ectopias. Case Presentation. We report a case of a 62-year-old man who had a left thoracic kidney associated with left Bochdalek hernia. Abdominal X-ray and chest X-ray revealed dilated loops of the colon above left hemidiaphragm. Abdominal ultrasound (US) showed the right kidney with many fluid and esophytic cysts; left kidney was unfeasible to study because of the impossibility to find it. Computed Tomography (CT) basal scan demonstrated a left-sided Bochdalek hernia with dilatated colon loops and the left kidney within the pleural space. Magnetic Resonance (MR) confirmed a defect in left hemidiaphragm with herniation of left kidney, omento, spleen and colon flexure, and intrarotation with posterior hilum on sagittal plane. Conclusion. The association of a Bochdalek hernia and an intrathoracic renal ectopia is very rare, that pose many diagnostic and management dilemmas for clinicians. Our patient has been visualized by CT and MR imaging. A high index of suspicion can result in early diagnosis and prompt intervention with reduced morbidity and mortality.

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.

Congenital hernia of Morgagni in infants and children

BACKGROUND

Congenital Morgagni hernia (CMH) is very rare, comprising 3% to 5% of all types of congenital diaphragmatic hernia; and very little is written about it. Commonly, it is diagnosed during childhood but can remain asymptomatic till adulthood. In the pediatric age group, the presentation is usually vague and nonspecific leading to delay in diagnosis.

PATIENTS AND METHODS

The medical records of all patients with the diagnosis of CMH treated at our hospital were retrospectively reviewed for age at diagnosis, sex, presenting symptoms, associated anomalies, diagnosis, operative findings, treatment, and outcome.

RESULTS

During an 18-year period (January 1983 through December 2001), 20 cases with the diagnosis of CMH were treated at our hospital. There were 15 males and 5 females. Their age at time of diagnosis ranged from 28 days to 9 years (mean, 16 months), and most of them (65%) were younger than 1 year. Sixteen of them (80%) presented with recurrent chest infection, which most of them had had since early infancy. In 3 patients, Morgagni hernia was discovered after blunt abdominal trauma in one, after insertion of ventriculoperitoneal shunt in another, and as a result of liver enlargement after splenectomy for beta-thalassemia major in the third. Of the 20 patients, 9 had right-sided Morgagni hernia, 5 had left-sided, and 6 had bilateral hernias. In 4 of those with bilateral hernia, the diagnosis of bilaterality was made at the time of surgery. Associated anomalies were seen in 14 (70%) of our patients. Five (25%) had congenital heart disease, 4 (20%) had malrotation of bowel, and 3 (15%) had Down's syndrome. All our patients were operated on transabdominally (14 upper midline, 5 upper transverse) except for one who had a right thoracotomy. In all 3 was a hernial sac, which was excised, and the defect was repaired using nonabsorbable sutures. The contents of the hernial sac included colon, small intestines, part of the liver, and omentum, with the colon being the most common (80%). There was no mortality, and postoperatively all patients did well. One of our patients required postoperative ventilation for 5 days because of associated lung hypoplasia.

CONCLUSIONS

Congenital Morgagni hernia is very rare. The rarity, as well as the vague and nonspecific presentations, contributes to the delay in diagnosis. Commonly, the presentation in the pediatric age group is that of recurrent chest infection and rarely with gastrointestinal symptoms. Physicians caring for these patients should be aware of this, and a high index of suspicion is recommended to obviate delay in diagnosis with its associated morbidity. We advocate surgical repair even in asymptomatic patients. This is to obviate the risk of strangulation and colonic perforation. We also advocate a transabdominal approach via either an upper midline or an upper transverse incision. This allows easy reduction and inspection of contents, allows access and repair of bilateral hernias, and corrects an associated malrotation if present.

Congenital retrosternal (Morgagni) diaphragmatic hernias in three horses

CASE DESCRIPTION

3 Horses were examined and treated because of sudden onset of signs of abdominal pain.

CLINICAL FINDINGS

All horses had a retrosternal (Morgagni) hernia involving the right side of the diaphragm. In each horse, the large colon was incarcerated in a right muscular defect in the diaphragm with a large hernial sac.

TREATMENT AND OUTCOME

Definitive surgical repair of the hernia was not performed during the initial celiotomy. The hernia was repaired with mesh herniorrhaphy, but without resection of the hernia sac in 2 horses. For 1 horse, conservative management was applied. In the 2 horses treated with surgical correction, no major postoperative complications developed, and all 3 horses have been free of signs of abdominal pain.

CLINICAL RELEVANCE

Horses with retrosternal hernias involving the diaphragm can develop clinical signs of intermittent obstruction of the large colon and chronic colic. In horses, retrosternal diaphragmatic hernias appear to develop exclusively in the right ventral aspect of the diaphragm and could represent an embryologic defect of diaphragm formation. Affected horses can be successfully treated with mesh herniorrhaphy or, in some instances, with conservative management.

Transabdominal approach in the surgical management of Morgagni hernia

PURPOSE

Morgagni hernias are uncommon diaphragmatic hernias that are generally asymptomatic, and so far only limited data have been reported. The objective of this retrospective study was to evaluate the outcome of patients presenting with a complicated Morgagni hernia and who undergo a transabdominal repair.

METHODS

Between September 1999 and October 2005, 11 patients with Morgagni hernia were operated on in our department. Eight of them had acute presentations because of a complicated Morgagni hernia. The patient demographics, presenting symptoms, operative approach, and complications were collected. The postoperative course was evaluated for morbidity and mortality.

RESULTS

The patients' ages ranged from 42 to 85 years (mean 69.4). Two (18.2%) patients were male and nine (81.8%) patients were female. Chest roentgenograms, computed tomography, and contrast meal studies were used as diagnostic utilities. A transabdominal approach was used for all patients. One patient died due to pulmonary failure. The mean follow-up was 2.8 years. There was no recurrence or symptoms regarding the operation in the remaining patients.

CONCLUSION

We recommend the transabdominal approach in patients with Morgagni hernia as it makes it easy to reduce the hernia contents and repair of the hernia sac. Moreover, when complicated with strangulation, incarceration or perforation, a surgical repair through a transabdominal approach is mandatory.

Diaphragmatic hernia: diagnostic approaches with review of the literature

Because surgical repair is indicated for the treatment of diaphragmatic hernia (DH), preoperative imaging of the diaphragmatic defect, hernia content, and associated complications with other organ's pathologies is important. While various techniques can be used on imaging of DHs, selection of the most effective but the least invasive technique will present the most accurate findings about DH, and will facilitate the management of DH. We reviewed the diaphragmatic hernia types associated with our cases, and we discussed the preferred imaging modalities for different DHs with review of the literature. We evaluated the imaging findings of 21 DH cases. They were Morgagni's hernia (n=4), Bochdalek hernia (n=2), iatrogenic DH (n=4), traumatic DH (n=6), and hiatal hernia (n=5). Although its limited findings on DH and indirect findings about the diaphragmatic rupture, plain radiography is firstly preferred technique on DH. We found that ultrasound (US) is a useful tool on DH, on traumatic DH cases especially. Not only it shows diaphragmatic continuity and herniated organs, but also it reveals associated abdominal organ's pathologies. Computed tomography (CT) scan is most effective in many DH cases. It shows the herniated abdominal organs together with complications, such as intestinal strangulation, haemothorax, and rib fractures. We stressed that Multislice CT scan with coronal and sagittal reformatted images is the most effective and useful imaging technique on DH. With high sensitivity for soft tissue, MR imaging may be performed in the selected patients, on the late presenting DH cases or on the cases of the diagnosis still in doubt especially.

Fraternal twins with Morgagni hernias

Fraternal twins with identical left-sided foramen of Morgagni hernias are described. The occurrence of this rare type of congenital diaphragmatic hernia in twins suggests that genetic factors play a role in the formation of this lesion.

Laparoscopic repair of diaphragmatic Morgagni hernia

A novel case of laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 5-year-old boy is reported. The patient had a prompt and complete recovery, with no evidence of recurrence noted at 1 year after surgery. Laparoscopic repair is considered to be a suitable and safe procedure for the treatment of Morgagni hernia.

Mesh Crural Repair of Large Paraesophageal Hiatal Hernias

Surgical repair is indicated in patients with paraesophageal hernias but is associated with a high recurrence rate. Our objective was to assess the safety and efficacy of mesh reinforcement of the crural closure in laparoscopic paraesophageal hernia repair. We conducted a 7-year retrospective review of all patients undergoing laparoscopic paraesophageal hernia repair with or without use of mesh. The main outcome measures were use of mesh, reason for use, age, sex, preoperative symptoms, length of operation, length of hospital stay, postoperative complications, and long-term follow-up conducted by physician interview. Twelve patients were repaired with mesh (Group A) and 12 without (Group B). Age, sex, operating time, length of hospital stay, and postoperative complications were similar in both groups. In Group A two patients required an interposition graft and ten required mesh reinforcement of the crural closure. One Group A patient developed an early recurrence requiring a reoperation, and one Group B patient developed a gastric leak where the fundus was sutured to the crura. The remainder of the patients experienced resolution of their symptoms at 2 weeks follow-up. Long-term follow-up (average 37 months) showed one Group B patient with a recurrence of reflux symptoms, but an upper gastrointestinal study showed no recurrence of hernia. All others remained asymptomatic. We conclude that the use of mesh in laparoscopic repair of large paraesophageal hernias appears safe and may reduce recurrence.

MR imaging of non-CNS fetal abnormalities: a pictorial essay

The recent popularity of prenatal magnetic resonance (MR) imaging has been associated with the development of ultrafast MR imaging techniques such as the single-shot fast spin-echo sequence. However, the majority of previous reports have concerned the fetal central nervous system (CNS) and chest disorders. MR imaging can demonstrate non-CNS fetal anatomy and pathologic conditions clearly. With its excellent tissue contrast, MR imaging provides information that supplements that provided by ultrasonography (US), especially in cases of neck, chest, and gastrointestinal lesions. Because of its large field of view, MR imaging allows evaluation of the relationship between a large lesion and adjacent structures. MR imaging should be considered if the diagnosis of a suspected non-CNS lesion is unclear at fetal US. MR imaging plays an important complementary role to US in cases of non-CNS fetal lesions and will be further accepted for fetal imaging in the future.

Surgical embryology and anatomy of the diaphragm with surgical applications

This article reviews the development, surgical anatomy, and teratology of the diaphragm, and discusses the diagnostic procedures, surgical therapy, and prognosis of congenital disturbances. Special attention is paid to the traumatic rupture of the diaphragm, concerning incidence, cause, diagnosis, prognosis, and surgical repair.

Laparoscopic repair of a Morgagni hernia: report of a case and review of the literature

A case is reported of an 85-year-old woman with subacute intestinal obstruction due to a large Morgagni hernia containing the transverse colon. The repair was carried out laparoscopically without a mesh. The procedure lasted 45 min, and the patient was discharged after 4 days. According to the literature, mini-invasive repair of a Morgagni hernia can be performed easily and without complications. In only few cases was a mesh necessary. The Morgagni hernia must be considered a clear indication for laparoscopic surgery, which should be offered as the first approach to this disease.

Congenital diaphragmatic hernia with ipsilateral eventration: a report of two cases

We report herein the cases of two patients in whom the unusual association of a diaphragmatic hernia with eventration of the diaphragm on the same side were confirmed. Although various recognized patterns of malformations have been described in children with diaphragmatic defects or eventration, to the best of our knowledge, this association has never been reported before. Following our case reports, the literature on this unusual topic is reviewed and a discussion on the possible pathogenesis is presented.

Bochdalek's hernia completely reduced by spontaneous ipsilateral tension pneumothorax

This report describes a premature (29 weeks gestation) infant with a left Bochdalek's diaphragmatic hernia, in whom the development of a spontaneous ipsilateral tension pneumothorax caused complete reduction of the hernia into the abdomen. In the presence of a tension pneumothorax, a diaphragmatic hernia may be masked on a chest radiograph and therefore difficult to diagnose.

Laparoscopic repair of a Morgagni hernia

Laparoscopic repair of a diaphragmatic hernia through the right sternocostal foramen of Morgagni in an obese 42-year-old man is described. The indications for surgery were symptoms of strain-induced dyspnea and tightness in the chest. The technique was carried out by incorporating a marlex mesh into the defect and fixing it in place with hernia staples. The patient had an immediate recovery after repair of the hernia and has remained free of recurrence or complaints 9 months after surgery.

Alveolar epithelial composition and architecture of the late fetal pulmonary acinus: an immunocytochemical and morphometric study in a rat model of pulmonary hypoplasia and congenital diaphragmatic hernia

The aim of the present study was to compare the architecture and alveolar epithelial cell composition of the pulmonary acinus in hypoplastic and normal fetal rat lungs. For this purpose, a rat model of pulmonary hypoplasia in association with congenital diaphragmatic hernia (CDH) induced by Nitrofen (100 mg on day 10 of pregnancy) was studied. Sections (5 microns) from lungs of control and Nitrofen-exposed fetal Sprague Dawley rats with or without CDH aged 18-22 days (vaginal plug on day 1, birth on day 23) were stained with hematoxylin and eosin. To identify developing alveolar epithelial cells, sections were incubated with anti-surfactant protein A (SP-A; rabbit anti-mouse) or preimmunization serum (indirect immunofluorescence). On days 18 and 19, control lungs and exposed lungs from fetuses with and without CDH looked similar (pseudoglandular stage of lung development). The prospective pulmonary acinus consisted of acinar tubules with small round lumens, lined by cuboid, fluorescent type II cells. Morphometric analysis on day 19 showed significantly smaller lung volumes and lung tissue volumes after Nitrofen exposure. On day 20 (canalicular stage), some tubules were slightly dilated and lined by cuboid and thinner fluorescent cells; these dilated tubules were less numerous in lungs from exposed fetuses with CDH. On days 21 and 22 (saccular stage), the saccular lining consisted of cuboid to thin fluorescent cells in exposed lungs from fetuses with and without CDH, and fluorescent (low) cuboid cells interspersed with dark zones (type I cell areas) in control lungs. In the exposed lungs from fetuses with CDH, the lumens of all airspaces were frequently slit-like, and the septa were thicker. These phenomena gave the lungs a primitive, compact aspect. Morphometric analysis on day 22 showed smaller lung volumes and lung tissue volumes, smaller airspace/tissue ratios, smaller epithelial surface areas, and more type II cells per surface area in Nitrofen-exposed lungs than in normal control lungs. The results suggest that Nitrofen-exposed, and thus hypoplastic, fetal rat lungs are retarded with respect to the differentiation of cuboid type II cells into squamous type I cells whether or not CDH is present, and with respect to the development of the future airspaces between days 20 and 22 if CDH is present.

Congenital diaphragmatic hernia: implications for nitrous oxide use in dentistry

The development of diaphragmatic hernias, their associated physical and diagnostic signs and symptoms, and the potential complications with nitrous oxide use are presented with a case report. Depending upon the location and extent of the diaphragmatic defect, portions of the stomach, omentum, liver and/or intestine can occupy a portion of the thoracic cavity. Nitrous oxide's solubility properties allow for rapid expansion of the herniated bowel, resulting in compression of the thoracic organs or strangulation of the herniated abdominal viscera. The presence of a diaphragmatic hernia may necessitate a change in sedation or anesthesia plans to eliminate the use of nitrous oxide during prolonged procedures.

Delayed surgery for congenital diaphragmatic hernia: neurodevelopmental outcome in later childhood

The long term neurodevelopmental outcome was assessed in 23 survivors born with congenital diaphragmatic hernia who had been managed by an elective delay in surgical repair after a period of stabilisation. This cohort was treated in one neonatal surgical unit between 1983 and 1989 by a single team of surgeons and anaesthetists. All children underwent comprehensive neurological, developmental, and anthropometric assessment at a mean age of 56 (range 18-94) months. Two children (9%) had major disability (one with hemiplegia and one with a lower limb monoplegia) and two further children had minor disabilities (one had partial sightedness and squint, the other squint only). The mean developmental quotient (DQ) for the group was 108 (SD 10.8) and none had developmental delay (defined as DQ < 70). Infants who had spent more time in hospital, or had had a longer duration of ventilation, tended to have lower weights and lower occipitofrontal circumference centiles in later childhood. Preoperative stabilisation and delayed surgery for congenital diaphragmatic hernia is not associated with an impaired neurodevelopmental outcome.

Congenital diaphragmatic hernia: Update on regional experience

A consecutive series of 34 patients with congenital diaphragmatic hernia are reported from a tertiary neonatal care unit in the Eastern Province. All the patients presented within the first 24 hours of life with left-sided defect. The overall mortality (56%) and postoperatiVE mortality (44%) are comparable with reports from other centers. The outcome of treatment correlated well with the age on presentation, the size of the defect, and preoperative blood gas results. Our approach to management has been modified lately, in the light of recent experience from other centers. The surgery is delayed until the neonate is stabilized with biochemical values of PaCO2 = 45 torr or less; pH = 7.2 or higher; and PaO2 = 50 torr or more. This management policy did not adversely affect overall survival. The problem encountered with patient transfer and the need for continued improvement in the organization of regionalized care are highlighted.

Unsuspected diaphragmatic hernia: a potential cause of sudden and unexpected death in infancy and early childhood

Congenital diaphragmatic hernias are usually found in neonates who present with respiratory distress. However, a significant number may remain clinically undiagnosed until much later in life. Of interest, the prognosis is felt to be better in this latter group. We describe three previously well patients (aged 2, 4, and 24 months) who suffered unexpected cardiorespiratory arrests due to unsuspected congenital diaphragmatic defects with intestinal herniation. Deaths resulted from cardiovascular and respiratory compromise due to visceral herniation that caused mediastinal and pulmonary compression.

Disorders of the fetal thorax and abdomen

Many disorders of the fetal thorax and abdomen can be evaluated using ultrasound. Even when a definitive diagnosis cannot be made prenatally, sonography can provide valuable clinical information regarding the nature and location of the abnormality, associated anomalies, and the presence of secondary complications. An awareness of these disorders and their sonographic appearance is important to impact upon obstetrical management and overall prognosis.

Pars sternalis diaphragmatic hernia with omphalocele: a report of two cases

A rare type of congenital diaphragmatic hernia occurs in which there is a large opening in the anterior diaphragm between the pericardial and peritoneal cavities without a sac. This hernia is invariably associated with defects in the anterior abdominal wall and with sternal defects. More commonly, it is associated with cardiac anomalies as in the Pentalogy of Cantrell. The etiology of this hernia is undoubtedly different from the more common hernia of Morgangni, which has a sac and few associated anomalies. The etiology may be failure of fusion of the pars sternis area of the septum transversum. Only five other cases have been described.

Meconium peritonitis and pleuritis: a clue to perforation of an incarcerated Bochdalek hernia in a neonate

The case of a neonate presenting with respiratory distress who had an incarcerated Bochdalek hernia with perforation and meconium peritonitis and pleuritis is reported. The patient had an associated jejunal atresia in an incarcerated segment of intestine, which undoubtedly contributed to the obstruction, strangulation, and perforation in the incarcerated hernia. Gastrointestinal complications attributable to the hernia are most unusual in the neonate, and aggressive preoperative resuscitation and stabilization with the earliest possible surgical intervention are imperative features in management.

Congenital left atrial aneurysm in an infant

Congenital left atrial aneurysm, without associated cardiac abnormalities, is a rare defect. We report the case of a large left atrial aneurysm filling almost the entire left hemothorax. This is the first report of this anomaly occurring in an infant less than 1 year of age.