Morgagni hernia presenting as a right middle lobe compression

Bochdalek Hernia Causing Sigmoid Colon Strangulation in an Elderly Patient

Diaphragmatic hernia with bowel strangulation is a fatal condition requiring a prompt diagnosis. Bochdalek hernia is a common type of diaphragmatic hernia that rarely but occasionally occurs in adults. We herein report a case of Bochdalek hernia causing sigmoid colon strangulation in an elderly patient whose condition was initially misdiagnosed as empyema. The early diagnosis of strangulated bowel stemming from diaphragmatic hernia can be challenging because of its rarity and the nonspecificity of its symptoms. However, tracing the mesenteric arteries on computed tomography can enable a quick diagnosis.

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.

Technical description of laparoscopic Morgagni hernia repair with primary closure and onlay composite mesh placement

INTRODUCTION

Morgagni hernias rarely present in adult life and, thus, little data exist on the optimal method of surgical repair. The laparoscopic approach has grown in popularity since the first reported case in 1992. This article showcases a method for laparoscopic repair of Morgagni hernias using both primary closure and mesh reinforcement.

OPERATIVE APPROACH

There were three obese women who presented in adulthood with cardiopulmonary symptoms; in all cases, the symptoms were attributable to local compressive effects of large Morgagni hernias. All three hernias were repaired laparoscopically, first by approximating the diaphragm to the fascia of the anterior abdominal wall, followed by insertion of a composite mesh, tacked to the diaphragm, to buttress the closure. All patients had excellent outcomes with symptom resolution.

DISCUSSION

This case series describes a method of laparoscopic Morgagni hernia repair using primary closure reinforced with a mesh, with excellent postoperative outcomes. Others have described thoracic or open approaches. The authors feel that the method described herein is likely to reduce recurrence in a patient population who are often overweight or obese and, thus, have a high risk of this complication. Furthermore, we discuss all reported laparoscopic repair cases in the literature and highlight the paucity of evidence on the optimal approach.

Emergency surgery due to diaphragmatic hernia: case series and review

Background

Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.

Methods

From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.

Results

Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.

Conclusion

Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.

Morgagni hernia: A rare case report and review of literature

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

Bilateral Morgagni hernia: operative discovery of appendix lying on superior pulmonary vein

A patient presented having an acute abdomen on a background of a twelve-month history of worsening asthma. Computed tomography showed giant bilateral intrathoracic hernias extending to both thoracic apices. Our case was unusual as the defect was bilateral and left-sided. Surgical repair revealed each hernia sac measuring >20 cm and to contain the entirety of the small bowel and colon (including retroperitoneal bowel). The appendix was discovered adjacent to right superior pulmonary vein. Both sacs were excised and the defects dissected and transfixed in a single stage operation. In the post-operative stage, he developed a 6.3 cm fluid collection anterior to the right atrium and a left-sided pleural effusion. Morgagni hernias can escape detection and be attributed to other diagnoses courtesy of false localising signs on clinical examination and symptoms in the history.