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Giant Morgagni Hernia Causing Cardiac Tamponade
CASE REPORT
Case Report
Giant Morgagni Hernia Causing Cardiac Tamponade Tsutomu Matsushita, MD, PhD a,∗ , Peng W. Seah, FRACS a and Jonathon Gani, FRACS b a
Department of Cardiothoracic Surgery, John Hunter Hospital, Lookout Road, New Lambton, NSW 2305, Australia b Department of General Surgery, John Hunter Hospital, Lookout Road, New Lambton, NSW 2305, Australia
A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare. (Heart, Lung and Circulation 2007;16:392–393) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Diaphragmatic hernia; Morgagni; Cardiac tamponade; Surgery; Repair
M
orgagni hernia is a type of diaphragmatic hernia that occurs through the triangular foramen between the muscle fibers of the diaphragm that originate from the xiphisternum and the costal margin and insert on the central tendon of the diaphragm. It is the rarest type of congenital diaphragmatic hernia.1,2 Herniation of abdominal contents is typically caused by an increase in intra-abdominal pressure secondary to trauma, pregnancy, or obesity.3 The majority of Morgagni hernias are right-sided with only rare left-sided occurrences because of the protection provided by the pericardial sac. In this case report, the repair of a giant left-sided Morgagni hernia showing early signs of cardiac tamponade is described.
Case Report A 57-year-old man weighing 120 kg presented to the surgeon’s consultation room with a history of worsening chest pain and shortness of breath for years. He could barely walk more than five steps due to shortness of breath and almost collapsed in the surgeon’s room. He was urgently transferred to our hospital for further investigations and treatment. He had no abdominal symptoms of pain, distension, nausea, vomiting or constipation. His superficial upper limb veins were severely dilated. Computed tomography (CT) scan of the chest was performed (Fig. 1) and he was found to have herniation of his abdominal contents into the anterior mediastinum through a left sided anterior midline defect in the diaphragm. The coronal view Available online 9 March 2007 ∗ Corresponding author. Tel.: +61 2 4921 3000; fax: +61 2 4921 4544. E-mail address: [email protected] (T. Matsushita).
clearly shows the foramen of Morgagni in the diaphragm. The right ventricle of the heart was severely compressed by the herniated contents, which was confirmed on transthoracic echocardiogram. The CT scan also showed a large sliding type hiatal hernia with stomach seen within the posterior mediastinum. At operation, which was performed urgently through a median sternotomy and laparotomy, the anterior mediastinum was entered and a huge hernial sac from the left foramen of Morgagni was identified. This sac extended right up to the sternal notch. It contained the majority of the transverse colon, small intestine and a huge amount of omentum which were adherent to the sac by adhesion. The foramen was enlarged to allow reduction of the contents, and the foramen was repaired with a polypropylene mesh (Prolene meshR , ETHICON, Somerville, New Jersey, USA) patch after the excision of the hernia sac. The hiatal hernia was left intact. He recovered uneventfully.
Discussion Foramen of Morgagni hernias represent only 3% of all surgically treated diaphragmatic hernias. Amongst those patients, 28% have symptoms of upper abdominal discomfort, fullness, bloating, vomiting, and bouts of large bowel obstruction.2 Although there are a few case reports of cardiac compromise due to the diaphragmatic Morgagni hernia in children,4,5 it is very uncommon to have signs of cardiac tamponade in an adult. We chose a median sternotomy rather than an abdominal approach or lateral thoracotomy. Fortunately there was no sign of incarceration or strangulation of abdominal organs. If the patient
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.008
Matsushita et al. Giant Morgagni hernia
393 CASE REPORT
Heart, Lung and Circulation 2007;16:392–393
Figure 1. The computed tomographic scan of the chest with intravenous contrast with axial (A) and coronal (B) reconstruction showed a giant anterior mediastinal mass containing abdominal contents such as small intestines and transverse colon with no signs of obstruction or strangulation. (A): The right ventricle of the heart was compressed by the herniated contents. The CT scan also showed a large sliding type hiatus hernia with stomach seen within the posterior mediastinum. (B): The coronal view clearly showed foramen of Morgagni on the diaphragm.
had developed bowel obstruction, it might have lead to acute expansion of the bowel in the hernia sac and subsequently cause severe cardiac tamponade. Repair of a foramen of Morgagni hernia is indicated immediately after diagnosis because of the risk of incarceration or strangulation of abdominal organs.6 Traditionally transthoracic or transabdominal approach has been used for the reduction and repair of the Morgagni hernia.2,7 The transabdominal approach was favoured when the diagnosis was certain as this approach allows easier reduction of the hernia, especially for bilateral hernias.8 Minimally invasive approaches such as thoracoscopy for the diagnosis of uncertain anterior mediastinal masses6 or laparoscopic surgery to confirm diagnosis and to repair the hernia7 have been reported. Laparoscopic repair is an excellent approach in terms of diagnosis, view of the sac, and reduction of hernia contents into the abdominal cavity. This together with repair of the foramen with or without mesh leads to better recovery from the surgery. We considered the use of laparoscopy, but were concerned about the risk of developing severe cardiac tamponade from the abdominal positive pressure required for laparoscopic surgery. The diagnosis in our case was confirmed preoperatively by CT scans. Plain chest X-ray with posteroanterior and lateral views is still very useful if there are gas-filled loops of bowel within the anterior mediastinal mass. CT scans have improved the reliability of preoperative diagnosis.6 In our case, the coronal reconstruction of the CT images
was useful for detecting the foramen of Morgagni. CT scans also detected the severe compression of the right ventricle. Echocardiogram was good for checking the cardiac status but was not helpful in identifying the anterior mediastinal mass. In conclusion, hernia of Morgagni is a rare condition. The symptoms of this hernia are usually respiratory or gastrointestinal in nature. This hernia can cause cardiac compression leading to symptoms of cardiac tamponade.
References 1. Harrington SW. Clinical manifestations and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenterol 1951;18:243–56. 2. Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461–8. 3. Thomas TV. Subcostosternal diaphragmatic hernia. J Thorac Cardiovasc Surg 1972;63:279–83. 4. Etheridge SP, Ruttenberg HD, Williams RV. An unusual cause of severe cyanosis in infancy. Ann Thorac Surg 2001;71:1016–8. 5. de Fonseca JM, Davies MR, Bolton KD. Congenital hydropericardium associated with the herniation of part of the liver into the pericardial sac. J Pediatr Surg 1987;22:851–3. 6. Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956–9. 7. Loong TP, Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005;81:41–4. 8. Bentley G, Lister J. Retrosternal hernia. Surgery 1965;57:567–75.
Case Report
Giant Morgagni Hernia Causing Cardiac Tamponade Tsutomu Matsushita, MD, PhD a,∗ , Peng W. Seah, FRACS a and Jonathon Gani, FRACS b a
Department of Cardiothoracic Surgery, John Hunter Hospital, Lookout Road, New Lambton, NSW 2305, Australia b Department of General Surgery, John Hunter Hospital, Lookout Road, New Lambton, NSW 2305, Australia
A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare. (Heart, Lung and Circulation 2007;16:392–393) © 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Diaphragmatic hernia; Morgagni; Cardiac tamponade; Surgery; Repair
M
orgagni hernia is a type of diaphragmatic hernia that occurs through the triangular foramen between the muscle fibers of the diaphragm that originate from the xiphisternum and the costal margin and insert on the central tendon of the diaphragm. It is the rarest type of congenital diaphragmatic hernia.1,2 Herniation of abdominal contents is typically caused by an increase in intra-abdominal pressure secondary to trauma, pregnancy, or obesity.3 The majority of Morgagni hernias are right-sided with only rare left-sided occurrences because of the protection provided by the pericardial sac. In this case report, the repair of a giant left-sided Morgagni hernia showing early signs of cardiac tamponade is described.
Case Report A 57-year-old man weighing 120 kg presented to the surgeon’s consultation room with a history of worsening chest pain and shortness of breath for years. He could barely walk more than five steps due to shortness of breath and almost collapsed in the surgeon’s room. He was urgently transferred to our hospital for further investigations and treatment. He had no abdominal symptoms of pain, distension, nausea, vomiting or constipation. His superficial upper limb veins were severely dilated. Computed tomography (CT) scan of the chest was performed (Fig. 1) and he was found to have herniation of his abdominal contents into the anterior mediastinum through a left sided anterior midline defect in the diaphragm. The coronal view Available online 9 March 2007 ∗ Corresponding author. Tel.: +61 2 4921 3000; fax: +61 2 4921 4544. E-mail address: [email protected] (T. Matsushita).
clearly shows the foramen of Morgagni in the diaphragm. The right ventricle of the heart was severely compressed by the herniated contents, which was confirmed on transthoracic echocardiogram. The CT scan also showed a large sliding type hiatal hernia with stomach seen within the posterior mediastinum. At operation, which was performed urgently through a median sternotomy and laparotomy, the anterior mediastinum was entered and a huge hernial sac from the left foramen of Morgagni was identified. This sac extended right up to the sternal notch. It contained the majority of the transverse colon, small intestine and a huge amount of omentum which were adherent to the sac by adhesion. The foramen was enlarged to allow reduction of the contents, and the foramen was repaired with a polypropylene mesh (Prolene meshR , ETHICON, Somerville, New Jersey, USA) patch after the excision of the hernia sac. The hiatal hernia was left intact. He recovered uneventfully.
Discussion Foramen of Morgagni hernias represent only 3% of all surgically treated diaphragmatic hernias. Amongst those patients, 28% have symptoms of upper abdominal discomfort, fullness, bloating, vomiting, and bouts of large bowel obstruction.2 Although there are a few case reports of cardiac compromise due to the diaphragmatic Morgagni hernia in children,4,5 it is very uncommon to have signs of cardiac tamponade in an adult. We chose a median sternotomy rather than an abdominal approach or lateral thoracotomy. Fortunately there was no sign of incarceration or strangulation of abdominal organs. If the patient
© 2006 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2006.10.008
Matsushita et al. Giant Morgagni hernia
393 CASE REPORT
Heart, Lung and Circulation 2007;16:392–393
Figure 1. The computed tomographic scan of the chest with intravenous contrast with axial (A) and coronal (B) reconstruction showed a giant anterior mediastinal mass containing abdominal contents such as small intestines and transverse colon with no signs of obstruction or strangulation. (A): The right ventricle of the heart was compressed by the herniated contents. The CT scan also showed a large sliding type hiatus hernia with stomach seen within the posterior mediastinum. (B): The coronal view clearly showed foramen of Morgagni on the diaphragm.
had developed bowel obstruction, it might have lead to acute expansion of the bowel in the hernia sac and subsequently cause severe cardiac tamponade. Repair of a foramen of Morgagni hernia is indicated immediately after diagnosis because of the risk of incarceration or strangulation of abdominal organs.6 Traditionally transthoracic or transabdominal approach has been used for the reduction and repair of the Morgagni hernia.2,7 The transabdominal approach was favoured when the diagnosis was certain as this approach allows easier reduction of the hernia, especially for bilateral hernias.8 Minimally invasive approaches such as thoracoscopy for the diagnosis of uncertain anterior mediastinal masses6 or laparoscopic surgery to confirm diagnosis and to repair the hernia7 have been reported. Laparoscopic repair is an excellent approach in terms of diagnosis, view of the sac, and reduction of hernia contents into the abdominal cavity. This together with repair of the foramen with or without mesh leads to better recovery from the surgery. We considered the use of laparoscopy, but were concerned about the risk of developing severe cardiac tamponade from the abdominal positive pressure required for laparoscopic surgery. The diagnosis in our case was confirmed preoperatively by CT scans. Plain chest X-ray with posteroanterior and lateral views is still very useful if there are gas-filled loops of bowel within the anterior mediastinal mass. CT scans have improved the reliability of preoperative diagnosis.6 In our case, the coronal reconstruction of the CT images
was useful for detecting the foramen of Morgagni. CT scans also detected the severe compression of the right ventricle. Echocardiogram was good for checking the cardiac status but was not helpful in identifying the anterior mediastinal mass. In conclusion, hernia of Morgagni is a rare condition. The symptoms of this hernia are usually respiratory or gastrointestinal in nature. This hernia can cause cardiac compression leading to symptoms of cardiac tamponade.
References 1. Harrington SW. Clinical manifestations and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenterol 1951;18:243–56. 2. Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461–8. 3. Thomas TV. Subcostosternal diaphragmatic hernia. J Thorac Cardiovasc Surg 1972;63:279–83. 4. Etheridge SP, Ruttenberg HD, Williams RV. An unusual cause of severe cyanosis in infancy. Ann Thorac Surg 2001;71:1016–8. 5. de Fonseca JM, Davies MR, Bolton KD. Congenital hydropericardium associated with the herniation of part of the liver into the pericardial sac. J Pediatr Surg 1987;22:851–3. 6. Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956–9. 7. Loong TP, Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005;81:41–4. 8. Bentley G, Lister J. Retrosternal hernia. Surgery 1965;57:567–75.