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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 52-54

A rare case of morgagni hernia in an elderly female


Department of General Surgery, Goa Medical College and Hospital, Bambolim, Goa, India

Date of Web Publication26-Nov-2019

Correspondence Address:
Shantata Jayant Kudchadkar
Department of General Surgery, Goa Medical College and Hospital, Bambolim, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_2_19

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  Abstract 


Morgagni hernias (MHs) are rare and constitute about 2% of all diaphragmatic hernias. Although uncommon, it has the potential for considerable morbidity if the diagnosis is missed. We present a case report of a 70-year-old elderly diabetic female, who presented in casualty with breathlessness, acute upper abdominal pain, and vomiting. Chest X-ray and contrast-enhanced computed tomography scan chest and abdomen revealed a right-sided MH with impending ischemia of transverse colon as content. The patient underwent emergency exploratory laparotomy with primary tension-free suture repair of hernia defect after reduction of contents back in the peritoneal cavity, and transverse loop colostomy was fashioned. Postoperative course was uneventful. MHs being rare in occurrence, present a dilemma in diagnosis. A high index of suspicion with radiological assistance is required while assessing elderly patients presenting with respiratory distress to prevent morbidity and mortality.

Keywords: Congenital diaphragmatic hernias, diaphragmatic rent, Larry hernia, Morgagni hernia


How to cite this article:
Chodankar SU, Kudchadkar SJ, Huske G, Amonkar D. A rare case of morgagni hernia in an elderly female. Indian J Colo-Rectal Surg 2018;1:52-4

How to cite this URL:
Chodankar SU, Kudchadkar SJ, Huske G, Amonkar D. A rare case of morgagni hernia in an elderly female. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2019 Dec 12];1:52-4. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/2/52/271748




  Introduction Top


The estimated incidence of congenital diaphragmatic hernias (CDHs) is 1 in 2000–5000 live births, usually found in neonates, and 5%–25% of all reported cases occur in adults.[1],[2] They occur mainly in two locations: foramen of Morgagni and the more common involving foramen of Bochdalek. Herniation through right sternocostal hiatus is called Morgagni hernia (MH) and through left sternocostal hiatus is called Larry hernia.[3] Pulmonary hypertension and pulmonary hypoplasia have been recognized as the two most important factors in the pathophysiology. The severity is largely dependent on these two factors and the presence of associated malformations.[1] Radiological investigations are usually required to confirm the diagnosis, assess the contents, and evaluate the presence of any associated abnormality.


  Case Report Top


A 70-year-old elderly diabetic female presented in casualty with breathlessness, acute upper abdominal pain, and vomiting. There was no history of prior trauma to the chest or abdomen. Her vitals were normal (P – 100/min, blood pressure – 114/70 mmHg, relative risk – 28/min, and SO2 – 90% on room air).

Breath sounds were reduced on the right side of the chest. On abdominal examination, there was tenderness in the right hypochondriac and epigastric region with diminished bowel sounds. Her blood investigations were normal. Chest X-ray done showed dilated bowel loop in the right hemithorax with collapse of the right lung and mild pleural effusion. Contrast-enhanced computed tomography (CT) chest and abdomen was done, which revealed right-sided retrosternal defect measuring approximately 3 cm in size containing proximal portion of transverse colon and part of the omentum. After optimizing the patient, she was taken up for emergency exploratory laparotomy. There was right-sided diaphragmatic hernia [Figure 1] containing dilated proximal transverse colon with impending ischemic change and part of the omentum [Figure 2]. After releasing the adhesions and constriction around the defect, contents were reduced back in the peritoneal cavity. A partial omentectomy was done and in view of impending ischemic change due to excessive proximal dilatation of colon, a transverse loop colostomy was performed. Tension-free repair of diaphragmatic rent was done with interrupted prolene sutures after insertion of intercostal chest tube in the right 5th ICS.
Figure 1: Diaphragmatic rent (3 cm) after reduction of peritoneal contents

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Figure 2: Herniated contents – Transverse colon and part of omentum forming band

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Postoperatively, the patient was kept in intensive care unit for 24 h on a ventilator and then shifted to the ward following extubation.

On postoperative day 4, she was started on full liquid diet, chest X-ray showed good expansion of the right lung, and ICT was removed on postoperative day 5. She was discharged on postoperative day 7 on full diet and advised to continue incentive spirometry. On subsequent 1-month follow-up, she was comfortable and stoma closure was done after 3 months.


  Discussion Top


The etiology of CDH is unknown; however, 2% of cases have been intended to be familial and another 15% of patients have associated chromosomal abnormality. It is common in males with a male-to-female ratio of 1.8:1.[4] The rare anterior defect of the diaphragm, referred as MH, accounts for approximately 2% of all CDH cases and is characterized by herniation through the foramen of Morgagni which is located immediately adjacent and posterior to the xiphoid process of the sternum. It was first described by Giovanni Battista Morgagni, an Italian anatomist and pathologist in 1769.[5]

The human diaphragm is derived from four sources: (a) septum transversum, ventral and pericardial portion; (b) the pleuroperitoneal membrane, lateral portions; (c) dorsal mesentery, medial dorsal component; and (d) striated muscles of diaphragm. The canals normally close by 8th week of gestation. Pathophysiology of CDH involves three major defects: (a) failure of diaphragm to completely close during development, (b) herniation of abdominal contents into the chest, and (c) pulmonary hypoplasia. The defect varies in size, ranging from 1 to 2 cm in diameter to complete agenesis of the hemidiaphragm.[6]

Gastrointestinal symptoms are more common in left-sided hernias whereas respiratory distress predominates in right-sided lesions.[7] Defects occur more frequently on the left side (70%–90%) than on the right side (15%–25%) of the diaphragm, and abdominal contents, including stomach, bowel loops, liver, spleen, or fat tissues, can be displaced into the thoracic cavity. The late-presenting CDHs represent a considerable diagnostic challenge. They can develop complications such as acute intestinal obstruction, incarceration, or strangulation or can present with chronic vague symptoms.

Diagnosis is confirmed using chest X-ray and CT scan thorax and abdomen.[8] Different surgical approaches are described to correct CDH such as open transabdominal, transthoracic, or using laparoscopic/thoracoscopic methods. For smaller defects, primary tension-free repair using nonabsorbable suture material is recommended whereas mesh repair is reserved for larger defects. Timely surgical intervention is usually associated with good outcomes.[9]


  Conclusion Top


CDHs are relatively rare in adults and difficult to diagnose. Therefore, a strong clinical suspicion, a thorough clinical examination, and radiological assistance in the form of chest X-ray and CT scan are essential to clinch the diagnosis. For small defects, primary tension-free suture repair is the treatment of choice, and reinforcement with mesh is reserved for large defects. Prompt surgical repair is mandatory for favorable outcomes and to prevent life-threatening complications and associated mortality.

This case highlights the diagnostic challenge due to its rarity in occurrence and delayed clinical presentation in adults, the importance of early diagnosis, and intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kesieme EB, Kesieme CN. Congenital diaphragmatic hernia: Review of current concept in surgical management. ISRN Surg 2011;2011:974041.  Back to cited text no. 1
    
2.
Singh TC, Singh CG, Lamare KN, Babitha N, Kharnaior A. Congenital diaphragmatic hernia in adult presenting with obstruction: A rare case. Int J Sci Stud 2015;2:142-5.  Back to cited text no. 2
    
3.
Griffiths EA, Ellis A, Mohamed A, Tam E, Ball CS. Surgical treatment of a morgagni hernia causing intermittent gastric outlet obstruction. BMJ Case Rep 2010;2010. pii: bcr0120102608.  Back to cited text no. 3
    
4.
Elhalaby EA, Abo Sikeena MH. Delayed presentation of congenital diaphragmatic hernia. Pediatr Surg Int 2002;18:480-5.  Back to cited text no. 4
    
5.
Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9.  Back to cited text no. 5
    
6.
Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek's hernia in a large adult population. AJR Am J Roentgenol 2001;177:363-6.  Back to cited text no. 6
    
7.
Yap KH, Jones M. Late presentation of congenital diaphragmatic hernia after a diagnostic laparoscopic surgery (a case report). J Cardiothorac Surg 2013;8:8.  Back to cited text no. 7
    
8.
Pironi D, Palazzini G, Arcieri S, Candioli S, Manigrasso A, Panarese A, et al. Laparoscopic diagnosis and treatment of diaphragmatic Morgagni hernia. Case report and review of the literature. Ann Ital Chir 2008;79:29-36.  Back to cited text no. 8
    
9.
Horton JD, Hofmann LJ, Hetz SP. Presentation and management of Morgagni hernias in adults: A review of 298 cases. Surg Endosc 2008;22:1413-20.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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