Midline Subcostosternal Hernia

Transcription

1 Midline Subcostosternal Hernia Thomas J. Tarnay, M.D., and Bernard Zimmermann, M.D. T e usual hernia of Morgagni occupies a paramedian position with protrusion through the space of Larrey. Our experience with a patient having a large, continuous, bilateral defect prompted a review of the literature and report of the case. A 3weekold male infant was admitted to the hospital with a failure to gain weight. Other than somewhat labored and rapid breathing, there was no history of periods of cyanosis or respiratory difficulties even during feeding. In contrast to his siblings the baby was quieter, rarely cried, and exhibited less spontaneous activity. Physical examination revealed a small, thin, welldeveloped, somewhat undernourished infant with a respiratory rate of 40 and a pulse of 120. The thorax appeared flared at the base, and there were scattered rales in the left lung field but no borborygmi were heard. The abdomen presented a scaphoid appearance. Laboratory studies were within normal limits. Posteroanterior and lateral xrays of the chest demonstrated an abnormal midline density with widening of the mediastinal shadows. A gasfilled loop protruded into the right hemithorax. Barium examination identified the structure as transverse colon. There was no evidence of esophageal hiatus hernia and no evidence of malrotation. The caecum was located in its normal right lower quadrant position (Fig. 1). During surgical exploration through a bilateral subcostal incision the herniated colon reduced itself spontaneously. The right lobe and the major portion of the left lobe of the liver were found in the hernia space. There were no adhesions. The liver was easily reduced. A sac separated it from the pleural and pericardial cavities. The defect was a wide V originating symmetrically and bilaterally at the ends of the eighth and ninth ribs and extending to an apex dorsally 5 to 7 mm. immediately anterior to the inferior vena cava (Fig. 2). An attempt to expand the lung after the hernial contents had been reduced failed to obliterate the hernial cavity. Chest tubes were inserted bilaterally into this contiguous space to promote its collapse during the postoperative period. Without dissection of the sac, the rim of diaphragm was easily approximated to the anterior chest wall with interrupted mattress sutures of 20 silk despite the proximity of the apex of the defect to the vena cava. The round ligament was found to be redundant, and the midportion was amputated to prevent a volvulus. The infant was treated with intestinal intubation and intravenous fluids. On the third postoperative day, oral feeding supplemented the parenteral fluids, and after the fourth day his oral intake was adequate for complete maintenance. The chest tubes were removed on the fourth postoperative day, and the patient was discharged on the twelfth day. At this time there was still some density in the anterior mediastinum suggestive of some remaining fluid in the hernial sac. From the Department of Surgery, West Virginia University Medical School, Morgantown, W.Va. Accepted for publication June 14, VOL. 2, NO. 6, NOV.,

2 TARNAY AND ZIMMERMANN FIG. 1. Preoperative posteroanterior and lateral chest xrays demonstrating bariumcontaining colon in the thorax. FIG. 2. The anatomical defect. The infant was noted to have developed a mild pectus excavatum, and it was thought that this may have resulted from the surgical repair, the greatest tension being at the midline. Six weeks after surgical intervention he was eating well, was vigorous, and behaved like a normal infant in every fashion. The slight pectus excavatum was still present; the normal rotund appearance of an infant s abdomen had replaced the preoperative scaphoid appearznce. Xrays of the chest showed diminution in the residual mediastinal density. 834 THE ANNALS OF THORACIC SURGERY

3 CASE REPORT: Subcostosternal Hernia CASES IN THE LITERATURE Fifteen unequivocal instances of midline retrosternal hernias have been encountered in the literature. In the total group of 16 (including ours), all but 4 were in adults (Table 1). Three were in infants, and 1 was in a child 7 years of age. There were 9 males and 7 females. Symptoms varied from no complaints to intestinal obstruction. The defects were of varying size, but in only 1 was the extent of the lesion in any way comparable to that in our own patient. A ldayold infant reported by Casey and Hidden in 1944 had a large ovoid communication surrounding the vena cava such that the vessel ran through the opening. The lateral margins, however, did not extend to the ninth ribs, but there was a communication with the pericardial cavity. The greater portion of the space was located to the right of the midline. In all cases where the information was available a sac was present. With one exception the contents of the hernias included colon. The exception was a paradoxical herniation with a portion of lung protruding into the abdomen. There were many patients with omentum and several with stomach in the cavity. The liver was present in the sac only in the infants and children. For surgical repair, the chest cavity was entered in only 1 patient where the sternum was split below the fourth interspace. The other explorations were performed through the abdomen. A definitive repair was accomplished in 12 patients. There were no reported recurrences. In some the sac was left in situ; in others it was excised. DISCUSSION A midline subcostosternal hernial defect is a separate variant of the category loosely termed as hernia of Morgagni. The exact incidence is hard to define due to the lack of such a subdivision in the past. The parasternal defects and bilateral parasternal defects appear to be considerably more frequent in occurrence than the midline gap. A sac always exists, and as such these hernias seldom become symptomatic at an early age. The most common viscus incarcerated is and thus it follows that the most common symptoms are those relative to partial or complete bowel obstruction. Malrotation and chest wall deformity, especially pectus carinatum, are the most frequently associated anomalies. The occurrence of a postoperative pectus excavatum clue to a rather snug anteroposterior repair suggests that the short substernal ligament theory of funnel chest etiology may have some merit. Diagnosis can frequently be made on routine chest film and details delineated by the use of radiopaque contrast media. Surgical repair through the abdomen is the treatment of choice. VOI.. 2, NO. 6, NOV.,

4 TABLE 1. COLLECTED CASES OF MIDLINE SUBCOSTOSTERNAL HERNIAS Reference Symptoms Other & Year Age Sex & Findings Defect Sac Contents Anomalies Operation Followup :Kilner [91 30 M Postprandial 3 finger Yes Lung herniated epigastric pain; breadths, into abd. external symmetrical swelling Exploration; No symptoms no repair 6 mo. later :FunkBrentano [61 70 F Intestinal S1. asym 10 cm. loop Exploration Probably died obstruction metric to colon at surgery R; epigastric vessels lateral to defect; 4 cm. diam :Dunhill [51 29 M 5 yr. history 4 in. wide sl. Yes Terminal Malrotation Sternal split Good result 4 epigastric asymmetric ileum to below wk. postop. discomfort to R midtransverse fourth with spon relieved by colon interspace taneous passing flatus completion rotation falciform ments by compartments sion into 2 None finding Postmortem :Harrington [81 34 M Belching: chest 10 cm. diam. Yes Omentum, pain asymmetric transverse to R colon R. rectus incision; oversewn with fascia lata strips to rectus musc.; chest tubes; sac in situ

5 :Casey [PI lday :Landiver [lo1 50 F :Parrella [ M :Denisart [41 39 M :Picard [ F :Guastavino [71 63 F Pain R lower chest: copious sputum; pos. Casoni skin test Cough; fatigability; occ. pain lower chest; borborygmi chest Discovered routine chest film Dysphagia; anorexia; vomiting 2 yr. epigastric pain with vomiting and sympt. obstruction Large; comm. with pericardium; extended behind vena cava; asymmetric to R Ovoid: 7 cm. max. diam. 3% X 3 in. Large oval defect Diameter 5franc piece (1% ) Size not stated colon omentum Transverse omentum R and transverse stomach Yes Stomach, omentum Umbilical None hernia Died 4 hr. after delivery Simple suture Flap of trans Good versus abd. swung to fill defect Side toside Good Abd. approach; simple suture Midline abd. incision: transverse : sac not excised

6 TABLE 1 (Continued) Reference Symptoms Other & Year Age Sex & Findings Defect Sac Contents Anomalies Operation Followup :Craighead [51 54 M Asymptomatic; found routine chest film :Bingham [I Bingham :Bingham :Tarnay [present report1 7 F 8mo. M 72 F 6wk. M Pectus carinatum; occ. abd. pain No symptoms 2 attacks subacute obstruction Poor weight gain Narrow defect Broad defect Broad defect 15 cm. triangular symmetrical defect: out to vena cava omentum, portion stomach left lobe liver Transverse colon stomach liver Part sac excised; sutured to to ant. chest wall Sidetoside through abd. Chest Suture to deformity rectus through abd. Excision sac, suture rim to rectus Abd. bilat. subcostal incision; suture defect to ant. chest wall Good 6 mo.

7 CASE REPORT: Subcostosternal Hernia SUMMARY A case of midline subcostosternal hernia is reported. Fifteen additional cases taken from the literature are tabulated. REFERENCES 1. Bingham, J. A. Herniation through congenital diaphragmatic defects. Brit. J. Surg. 47:1, Casey, A. E., and Hidden, E. H. Nondevelopment of septum transversum with congenital absence of anterocentral portion of the diaphragm and of the suspensory ligament of the liver and presence of an elongated ductus venosus and a pericardioperitoneal foramen. Arch. Path. 38:370, Craighead, C. C., and Strug, L. H. Diaphragmatic deficiency in the retrocostoxyphoid area. Surgery 44: 1062, Denisart, P. De la variete retrocostoxiphoidienne de hernie de diaphragmatique. J. Chir. (Paris) 67:407, Dunhill, T. Diaphragmatic hernia. Brit. J. Surg. 22:475, FunckBrentano, P., Megnin, J., and Allard, P. Hernia diaphragmatique mediosternale. Ann. Anat. Path. 10:401, Guastavino, G. N., and Meeroff, M. Hernia diafragmatica subcostosternal. Prensa Med. Argent. 42:371, Harrington, S. W. Subcostosternal diaphragmatic hernias. Surg. Gynec. Obstet. 73:601, Kilner, J. N. Prolapse of the lung through a deficiency in the anterior part of the diaphragm. Lancet 2:1247, Landivar, A. F., Brea, M. S., Santas, A. A,, and Martinez, J. L. Hernia diafragmatica subcostosternal: A propisito de 3 observaciones. Bol. SOC. Cir. B. Air. 31:984, Parrella, G. S., and Hurwitz, A. Repair of anterior subcostosternal hernia of the diaphragm (hernia of Morgagni) using a flap of transversalis fascia. Arch. Surg. 59:1327, Picard, R., Corniere, J., and Hardy, M. Su un cas de hernie diaphragmatique anterieure. Arch. Mal. Appar. Dig. 41:100, von Greyerz, W. On hernia diaphragmatica retrosternalis. Acta Radiol. 18:428, VOL. 2, NO. 6, NOV.,