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Eur J Cardiothorac Surg 2001;20:1016-1019
© 2001 Elsevier Science NL

Transthoracic approach in surgical management of Morgagni hernia

Dalokay Kiliç, Aydin Nadir, Egemen Döner, evket Kavukçu, Murat Akal, Nezih Özdemir, Hadi Akay, lker Ökten

Department of Thoracic Surgery, Ankara University, School of Medicine, 06100 Sihhiye, Ankara, Turkey

Received 16 February 2001; received in revised form 7 May 2001; accepted 19 July 2001.

Corresponding author. Tel.: +90-312-3103333 ext. 3110; fax: +90-312-3106371
e-mail: dalokay7{at}hotmail.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: Morgagni hernia is an uncommon type of diaphragmatic hernias. Numerous approaches have been described and, particularly the significance of laparatomy has been emphasized as an operative technique. We present our experience on patients with Morgagni hernia operated on via transthoracic approach in our department. Materials and methods: Between January 1986 and March 2000, 16 patients with Morgagni hernia were operated in our department. Their ages ranged from 16 to 68 years (mean 51.5). Five (31.25%) patients were male, and 11 (68.75%) patients were female. Chest roentgenograms, thorax CT, barium enema roentgenographic studies were used as diagnostic utilities. Right posterolateral thoracotomy was performed in all patients. Results: Hernia sac was present in all cases. Exploration revealed omentum in hernia sac in eight patients (50%), colon and omentum in seven patients (44%), only colon in one patient (%6). Postoperative course was uneventful. The mean follow-up was 5.7 years. There was no recurrence or symptoms related to the operation. Conclusions: We advocate transthoracic approach for surgical exposure as it provides wide exposure and easy repair of the hernia sac in Morgagni hernia.

Key Words: Morgagni hernia • Diaphragmatic hernia • Surgery • Thoracotomy

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Morgagni hernia is a congenital herniation of the abdominal contents through the retrosternal defect into the thoracic cavity. It was first described by Giovanni Morgagni in 1761. It is the most uncommon type of diaphragmatic hernias and comprises 3% of diaphragmatic hernias [1,2]. Thus, the clinical experience is limited.

Surgical approach is of particular importance as the hernia sac occurs retrosternally, at a distinctive localization between thorax and abdomen. Hence, various surgical procedures ranging from laparatomy to thoracoscopy have been recommended for the repair of Morgagni hernia.

We assessed the feasibility of transthoracic approach as a surgical procedure in patients with Morgagni hernia in a series of 16 patients operated in our department.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
2.1. Patients and clinical findings
Between January 1986 and March 2000, 16 patients with Morgagni hernia were operated in bn-i Sina hospital of Ankara University. Their ages ranged from 16 to 68 years (mean age 51.5). Five (31%) patients were male, and 11 (69%) patients were female. None of the patients had a remarkable history. On physical examination seven patients were obese. Dyspnea was the most common symptom (75%) followed by chest pain (33%), and retrosternal pain (25%). Two (12%) patients were asymptomatic. On physical examination, percussion and auscultation of the thorax revealed areas of tympanism and bowel sounds in seven patients. Laboratory data were within the normal limits in all patients, whereas two patients with diabetes mellitus showed elevated levels of plasma glucose concentration. Chest X-rays, Thorax CT (computerized tomography) and barium enema were used as diagnostic utilities. Preoperative radiological diagnosis was Morgagni hernia in eight (50%) patients (Fig. 1), whereas radiologic findings were interpreted as intrathoracic lipoma in four (25%), and intrathoracic mass in four (25%) (Table 1). Colonic segments and omentum were visible in thoracic cavity in eight patients (Fig. 2).

View larger version (118K): [in this window] [in a new window]   Fig. 1. Computed tomography of the chest showing a pericardial homogenous fatty mass diagnosed as Morgagnia hernia.

View larger version (112K): [in this window] [in a new window]   Fig. 2. Computed tomograpy of the chest showing colonic segments.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Hernia sac was present in all cases. Exploration revealed omentum in eight patients (50%), colon and omentum in hernia sac in seven patients (44%), only colon in one patient (6%). In five patients, omental resection was performed because of the unreduced omentum. In the remainder, abdominal contents and omentum could have been reduced back to the abdominal cavity. Primary repair was done in 14 patients. Primary repair could not have been performed in two patients showing huge defects in the diaphragm. Synthetic materials, such as polypropylene and polytetrafluoroethylene mesh, were used in these patients.

All patients showed an uneventful postoperative course with no recurrence and morbidity related to operative procedure. Mean follow-up was 5.7 years (11 months to 15 years).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Morgagni hernia so-called substernocostal diaphragmatic hernia is rarely encountered entity and we are aware of few reports on this issue [1–4]. Comer and Clagett described only 54 (3%) patients with Morgagni hernia in the largest series ever reported to date, comprising 1750 patients with diaphragmatic hernia [1]. Similarly, Harrington described only 14 patients in a total of 534 patients [4]. We collected the data charts of 16 patients with Morgagni hernia operated in our department during a 16 years period.

Morgagni hernia occurs as congenital, acquired and mixed forms. Defect in development or fusion of the diaphragmatic muscle in embriologic life promotes the hernia sac. Increased intraabdominal pressure resulting from obesity and trauma are precipitating factors. Seven patients were obese in our series. It is frequently associated with a hernia sac, but also may occur without a sac. A well-formed hernia sac formed by peritoneum differentiates the Morgagni hernia from a Bochdalek hernia [5]. All our cases had a hernia sac.

Most of the cases are asymptomatic and diagnosed on routine chest X-rays, but they may occasionally be symptomatic, whereas symptomatic cases accounted a greater percentage in our series. Unless indicated, as it has a potential risk of visceral strangulation [1–3], surgical repair should be performed in elective conditions. In addition, acute respiratory distress secondary to a Morgagni hernia may be an urgent surgical indication [6].

Morgagni hernia often develops in the right hemithorax but also can be seen bilaterally and rarely on the left side [1] The presented series do not include either a left-sided or a bilateral defects.

Chest X-rays, barium enema, CT, MRI are used in the diagnosis. Differential diagnosis should be made between pleuropericardial cyts, lipomas, liposarcoma, mesothelioma, pericardial fat mass, diaphragmatic cyts and tumours, thymoma, anterior chest wall tumours [1,7,8]. Preoperatively, eight patients were diagnosed as Morgagni hernia and the remainder had undergone operation for intrathoracic mass in four and lipoma in four patients. Correct diagnosis of Morgagni hernia was established preoperatively by CT in the recent years. Thus, MRI studies were not necessary in this group of patients and MRI was not available in our hospital previously.

Morgagni hernia usually contains transverse colon, omentum, liver and sometimes small bowel or stomach [1]. In seven patients the hernial sac contained colon and omentum, in one case hernia contained colon only, in eight cases hernia contained omentum only (Table 1). No complications were observed postoperatively. In their long term follow up no complaints and radiologic abnormality were detected.

Both transabdominal and transthoracic approaches are recommended in the surgical repair of Morgagni hernia. Transabdominal repair of Morgagni hernia has been used by numerous authors with favorable results [1,2,4] Abdominal approach may be preferred, particularly in cases with bilateral and complicated hernia sac. An abdomino-mediastinal approach including an upper midline laparatomy with extended lower median sternotomy may be utilized for a hernia sac occupying both sides of the anterior mediastinum as described by Moghissi [3]. Similarly, Paris and Tarazona performed a subxiphoid approach as it allowed freeing of the pleural adhesions to the sac [2]. Recently, videoassisted endoscopic surgery has been claimed as a safe and effective method to fix a Morgagni hernia [9,10]. Comer and Clagett proposed that a transthoracic surgery was preferable to a transabdominal approach, particularly in cases with indeterminate, anterior pericardial masses [1]. They published favorable results with thoracotomy in patients without preoperative diagnosis. Consistently, we obtained satisfactory results with posterolateral thoracotomy in a total of sixteen patients and we had no preoperative diagnosis of Morgagni hernia in half of these cases. Transthoracic route provides easy repair of the diaphragmatic defect, and pericardial adhesions can be easily released as both subcostal margin and the edge of the diaphragmatic foramen are accessible [11,12]. Chin and Duchesne suggest that intraabdominal approach may be difficult in obese patients and intrathoracic sac may remain where a cyst could later develop[12]. Seven patients were obese in the presented series.

In conclusion, we may recommend transthoracic approach, in patients with Morgagnia hernia as it provides sufficient exposure, easy repair of the hernia sac and an acceptable morbidity when compared with transabdominal approach. Moreover, transthoracic approach facilitates the release of pericardial adhesions, of which uncontrolled dissection may result in catastrophic results.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

1. Comer T.P., Clagett O.T. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-468.[Medline]
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3. Moghissi K. Operation for repair of obstructed substernocostal (Morgagni) hernia. Thorax 1981;36:392-394.[Abstract/Free Full Text]
4. Harrington S.W. Clinical manifestions and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenterol 1951;18:243-256.[Medline]
5. Kelly K.A., Bassett D.L. An anatomic reappraisal of the hernia of Morgagni. Surgery 1964;55:495-499.[Medline]
6. Wong N.A., Dayan C.M., Virjee J., Heaton K.W. Acute respiratory distress secondary to Morgagni diaphragmatic herniation in an adult. Postgrad Med J 1995;71:39-41.[Abstract/Free Full Text]
7. Gossios K.J., Tatsis C.K., Lykori A., Constantopoulos S.H. Omental herniation through the foramen of Morgagni. Diagnosis with chest computed tomography. Chest 1991;100:1469-1470.[Abstract/Free Full Text]
8. Kamiya N., Yokoji K., Miyazawa N., Hishinuma S., Ogata Y., Katayama N. Morgagni hernia diagnosed by MRI. Surg Today 1996;26:446-448.[Medline]
9. Hussong R.L., Landreneau R.J., Cole F.H. Diagnosis and repair of a Morgagni hernia with video-assisted thoracic surgery. Ann Thorac Surg 1997;63:1474-1475.[Abstract/Free Full Text]
10. Becmeur F., Chevailer K.I., Frey G., Sauvage P. Laparascopic treatment of a diaphragmatic hernia through the foramen of Morgagni in children. A case report and review of eleven cases reported in the adult literature. Ann Chir 1998;52:1060-1063.[Medline]
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12. Chin E.F., Duchesne E.R. Parasternal defect. Thorax 1955;10:214-219.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Murat Akal Nezih Özdemir Hadi Akay Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kiliç, D. Articles by Ökten, I. Search for Related Content PubMed PubMed Citation Articles by Kiliç, D. Articles by Ökten, I. Related Collections Diaphragm