MORGAGNI HERNIA IN ADULTS: RESULTS IN 7 PATIENTS

Scandinavian Journal of Surgery 93: 77 81, 2004 MORGAGNI HERNIA IN ADULTS: RESULTS IN 7 PATIENTS J. Pfannschmidt, H. Hoffmann, H. Dienemann Department of Thoracic Surgery, Thoraxklinik Heidelberg, University of Heidelberg, Heidelberg, Germany ABSTRACT Objective: Morgagni s hernia is a relatively uncommon diaphragmatic hernia with a potential for considerable morbidity, if the diagnosis is delayed or missed. This review of cases of Morgagni s hernia was undertaken in order to emphasize methods of diagnosis and treatment. Methods: From 1992 through 2002, seven patients with Morgagni s hernia (5 right, 2left) were surgically treated at our hospital. We investigated the patients preoperatively including chest roentgenogram, chest CT scan, and contrast studies of the upper gastrointestinal tract. Operative repair was accomplished with the transabdominal or transthoracic approach. Basic spirometric tests had been carried out on patients presented for elective surgery. Results: The majority of patients experienced dyspnea and two patients presented with acute abdomen due to peritonitis. Diagnosis for Morgagni s hernia was made preoperatively in all but one patient. In cases with uncertain diagnosis or peritonitis, a transabdominal approach was preferred. One patient had died of septic multi-organ failure in the early postoperative course. Following elective repair of Morgagni s hernia, improvement in basic spirometric values was seen. Conclusions: We conclude that repair for Morgagni s hernia can be performed safely and effectively by using different surgical approaches. The risk of progression and incarceration makes clinical awareness, early diagnosis, and surgical treatment warranted. Improvement in lung function can be expected postoperatively. Key words: Morgagni hernia; surgery; treatment INTRODUCTION The Morgagni foramen is a triangular space located between the muscle fibers from the xiphisternum and the costal margin fibers that insert on the central tendon. Correspondence: J. Pfannschmidt, M.D. Department of Surgery Thoraxklinik Heidelberg Amalienstr. 5 D-69126 Heidelberg, Germany Email: joachim.pfannschmidt@ thoraxklinik-heidelberg.de Hernias through the foramen of Morgagni are uncommon at any age, but less common in the child than in the adult. The percentage of Morgagni s hernia (MH) among all diaphragmatic defects is 3 to 4% (1, 2). Different surgical techniques for repair of diaphragmatic hernias are under discussion. Some recent publications have demonstrated the technical feasibility of video-assisted endoscopic surgery for MH (3 5). We initiated the current report to evaluate the results of transthoracic and transabdominal repair in a small series of seven patients. Our aim is to discuss the clinical presentation and management of these rare cases in adults based on published experience.

78 J. Pfannschmidt, H. Hoffmann, H. Dienemann A Fig. 1. (A) Posteroanterior chest X-ray in a 57-year-old woman with Morgagni s hernia, shows a round right pericardiophrenic density. (B) Lateral chest radiograph localizes the opacity to the retrosternal area. B Fig. 2. Axial computed tomographic scan showing a right retrosternal hernia containing omentum in the anterior cardiophrenic angle. PATIENTS AND METHODS A retrospective analysis of all patients with MH, diagnosed and treated at our institution from 1992 to 2002, was carried out. Seven patients, three males and four females, (age range 47 73 years, mean 59.3 years) were surgically treated. For each patient, the clinical presentation, diagnostic tools, and treatment were analyzed and the surgical outcome was reviewed. Clinical symptoms included dyspnea, chronic cough, thoracic pain, and recurrent chest infections. Two patients presented with local peritonitis and incarceration. In one patient prolonged weaning from the respirator after abdominal surgery was conspicuous. Basic spirometric studies were carried out, preoperatively and postoperatively, in four patients. Postoperative measurements were performed between 3 and 21 months after operation. Obesity with a body mass index over 30 was observed in four of the seven patients. Diagnosis for MH was confirmed preoperatively in six patients. Preoperative chest X- ray and ultrasound of the abdomen, which showed obvious pericardiophrenic solid abnormalities, were carried out on all patients (Fig. 1A, B). In five patients chest CT scans then revealed the diagnosis of MH (Fig. 2). Five patients had a contrast study of the upper gastrointestinal tract which finally confirmed the diagnosis in two of those patients. In one patient a colon contrast enema was used to establish the diagnosis of MH. Despite the use of CT scan, ultrasound of the abdomen and contrast study of the upper gastrointestinal tract, the diagnosis of MH was missed preoperatively in one patient. This patient had undergone laparotomy for acute abdomen. Table 1 summarizes the clinical data of the seven patients. The selection of the surgical approach was based on the site and size of the hernia, and the general condition of the patient, e.g. peritonitis. The principles of repair were much

Morgagni hernia: results 79 TABLE 1 Clinical features and management of patients with Morgagni s hernia. Patient Age Sex BMI Site Symptoms Content of Operative Hospital ICU stay Outcome no. (y) hernia sac treatment stay (d) (d) 1 67 F 33 Right Dyspnea, chest Omentum, Thoracotomy, 11 2 Alive pain, cough colon primary closure 2 48 F 35 Right Dyspnea, Omentum, Thoracotomy, 14 1 Alive recurrent chest colon Marlex patch infection plasty 3 47 F 37 Right Recurrent Omentum Thoracotomy, 27 2 Alive chest infection, Vicryl patch dyspnea plasty 4 57 F 25 Right Cough, chest Omentum Thoracotomy, 12 1 Alive pain, dyspnea incarceration primary closure 5 49 M 22 Left Peritonitis Stomach, Laparotomy, 22 6 Alive omentum, primary closure incarceration 6 71 M 23 Right Peritonitis Omentum, Laparotomy, 10 6 Died of colon, primary closure pneumonia incarceration 7 73 M 31 Left Respiratory Omentum, Thoracotomy, 43 41 Alive failure colon, Marlex patch incarceration plasty BMI = To calculate body mass index (BMI), body weight (kg) divided by the height (m) squared. TABLE 2 Changes in pulmonary functio. FEV 1 Patient no. Preop Postop % Change Preop Postop % Change 1 1.56 1.6 0 2.5 2.16 2.23 3.1 2 2.46 3.3 25.5 3.16 4.00 210.0 3 2.09 0 1.93 8.3 2.70 2.92 7.5 4 1.23 1.6 23.1 1.99 2.08 4.3 FEV 1 = forced expiratory volume in 1 second FVC = forced vital capacity FVC the same. All adhesions were taken down by blunt and sharp dissection. The hernia sac was introduced into the peritoneal cavity. After resection of the hernia sac, their margins were identified for repair. In small defects, tension-free closure was preferred with non-absorbable mattress sutures, if technically feasible. For closure of larger defects, synthetic material was used. RESULTS There was one postoperative death on the 6 Th postoperative day due to septic multi-organ failure after pneumonia. This patient came on admission with a left-sided empyema necessitates. Incision and tube thoracostomy were carried out as initial treatment. During the next four days the patient developed peritonitis due to an incarcerated MH. Emergency laparotomy with repair of a right-sided MH with incarceration of the large bowel, was performed. One patient developed a minor wound infection at the thoracotomy incision. Exploration of the content of the hernial sac revealed omentum, colon, and the gastric fundus and corpus. Omental resection was carried out in four patients, colon resection in one, and gastric resection in one patient. Incarceration of intestine was found in four patients; in two patients gangrenous intestine was resected. A polypropylene (Marlex ) mesh was used in two, a polyglactin (Vicryl ) mesh in one patient. Primary closure was carried out in four patients. Apart from one early postoperative death, all of our patients performed well in the postoperative course. None of the three patients without incarceration needed postoperative ventilator therapy; they were discharged from the intensive care unit (ICU) on the first and second postoperative day. Of the four patients who presented with incarceration of the MH, one received respirator therapy for 27 days. Due to persistent sputum and pneumonia, these four patients were kept in ICU between 1 and 41 days. In four patients who presented for elective operation, pulmonary function tests were carried out pre- and

80 J. Pfannschmidt, H. Hoffmann, H. Dienemann postoperatively. Table 2 shows the comparison of pre- and postoperative forced expiratory volume in 1 second (FEV 1 ) and forced vital capacity (FVC). Improvement in basic spirometric values could be demonstrated. DISCUSSION The vast majority of diaphragmatic hernias occuring in adults are either chronic hiatal hernias or hernias presenting acutely due to traumatic disruption of the diaphragm. Of all types of congenital diaphragmatic hernias, Morgagni s hernia is relatively rare. Comer and Clagett (1) reported 54 patients with MH in a series of 1750 patients with diaphragmatic hernia. Similarly, Berman et al. (6) reported on 18 cases with MH over a period of 20 years. Recently, Kilic et al. (7) collected their data of 16 patients during a 16 year period. Reports of MH in identical twins (8) raised the question of an inherited defect. Associated anomalities, e.g. congenital heart disease (6), and Down s syndrome, are known in children (9, 10). Obesity as well as a history of trauma have been reported as precipitating factors in diaphragmatic hernia (11, 12). In our series four patients were assessed with a body mass index over 30. The heart and pericardium reinforces the foramen on the left. For these anatomic reasons, right-sided MH occurs more commonly (90 %), and bilateral hernias are also seen (1). In our series five of the seven patients presented with right-sided hernia. Beside different locations, where the Bochdalek hernia is located posterolaterally as a result from incomplete formation of the diaphragm, the presentation of a hernia sac also differentiates MH from Bochdalek hernia. A hernia sac was present in all of our patients. Comer and Clagett (1) most often found the hernia sac containing transverse colon, omentum, liver, and, less frequently, small bowel or stomach. In our series the hernial sac contained colon and omentum in four patients, omentum in two, and omentum with gastric fundus and corpus in one patient. The clinical presentation of MH can be variable. The rarity of MH, the variability, and the non-specifity of symptoms contribute to difficulties in establishing the diagnosis. Respiratory complaints with dyspnea and/or cough were presented in five of our seven patients. Due to incarceration, peritonitis developed in two patients, leading to hospital admission. Symptoms and signs frequently reported in the literature are repeated chest infections and/or chronic, non-specific gastrointestinal complaints. The diagnosis of MH is based on chest X-rays, chest CT scans, and contrast radiography of the gastrointestinal tract. Diagnosis can be difficult or delayed if the hernia sac is empty or contains solid parts, like omentum or liver. In all of our patients chest X-rays showed abnormal findings. However, normal chest X-rays do not preclude the diagnosis of MH (6, 13). Chest computerized tomography established the diagnosis in five of our patients. Magnetic resonance imaging can provide similar information and can help in differential diagnosis (14, 15), but was not employed in our series. The treatment of MH is carried out by surgical means. If MH is diagnosed, surgical repair should be performed in elective conditions to obviate the risk for intestinal incarceration. Acute respiratory distress, intestinal obstruction and perforation may develop and are indications for urgent surgical intervention. There is still some controversy regarding the operative technique (16). Some authors advocate the transthoracic (1, 7) or transabdominal approach (2, 6, 17), others the video-assisted endoscopic technique (3, 4, 18, 19). The abdominal approach is regarded as being technically more easy for repairing even complicated, and bilateral hernias. Inspection of the entire abdominal cavity is strongly recommended in all cases with peritonitis. In obese patients the transthoracic route may provide a better access to the hernial sac. We performed the transabdominal approach in cases with uncertain diagnosis or peritonitis. In all elective cases of our series, thoracotomy was preferred on right sided hernias, because of a better visualization of the diaphragmatic foramen and pericardial and pleural adhesions. Recently several authors (5, 20 22) have reported that MH can be resected safely by video-assisted endoscopic surgery. Different endoscopic techniques have been used for hernia repair (19 22). The defect can be closed by direct suturing. For improved security, the hernia can also be reconstructed using a non-absorbable mesh (PTFE, Polypropylene). Fixing the mesh in place intracorporal suture placement and hernia staples were used. Although the approach is challenging, endoscopic surgery entails less postoperative pain and a shorter hospital stay (21). With the advent of endoscopic surgery, repairs using laparoscopy or video-assisted thoracic surgery (VATS) have been described as equally safe and effective for non-complicated MH. On the other hand, there are still some concerns regarding rates of recurrence and complications, i.e. using the diathermy for dissection endoscopically (21, 23). Following elective repair of MH, we were able to demonstrate an improvement in basic spirometric values. Improvement of regional ventilation/perfusion mismatch (24, 25), as well as the re-establishment of normal diaphragmatic contour (26), may improve spirometric abnormalities in diaphragmatic hernia s. In conclusion, the repair of MH can be performed safely and effectively by different surgical approaches. The choice of the surgical procedure is based on individual criteria of the patient. 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