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Morgagni Hernia: How to approach!
Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
Contents lists available at ScienceDirect
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
Morgagni Hernia: How to approach! Mohamed Elshabrawy Saleh MD, Walid Hassan Mohammed MD * Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 March 2017 Received in revised form 7 May 2017 Accepted 21 May 2017 Available online xxx
Background: Morgagni Hernia (MH) is a retrosternal herniation through inherent diaphragmatic defect manifested by respiratory and/or gastrointestinal symptoms and is repaired through transabdominal or transthoracic approaches. Methods: The study aimed to evaluate thoracic and abdominal approaches in terms of operative and postoperative sequalae. Herein, we included 18 patients with MH operated in the Cardiothoracic Surgery Department at Mansoura University Hospital, Mansoura, Egypt over a period of 7 years. They were divided into two groups. Group I operated via right thoracotomy and Group II operated via paramedian laparotomy. Each group included 9 patients. Results: Twelve males and 6 females with right sided MH were included. The mean operative times in thoracotomy and laparotomy groups were 99.44 ± 13.33 and 85.0 ± 20.92 min respectively but without statistical significance P ¼ 0.100. We recorded one recurrence in the thoracotomy group (group I) and one post-operative incisional hernia in the laparotomy group (group II). Conclusions: MH should be repaired upon diagnosis. The optimal surgical technique should be tailored to the patient characteristics. Still, the abdominal approach was linked to easier feasibility, less operative time and recurrence rates. © 2017 Publishing services by Elsevier B.V. on behalf of The Egyptian Society of Cardiothoracic Surgery. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Morgagni Hernia Laparotomy Thoracotomy Diaphragmatic defect
1. Introduction Foramen of Morgagni Hernia (MH) is defined as an erratic parasternal or a retrosternal hernia attributed to anterior diaphragmatic defect. It was foremost designated by the Italian pathologist and anatomist Giovanni Morgagni in 1769 [1]. MH is a rare disorder in all age clusters particularly in pediatric age group; being still asymptomatic or not sizable. It represents 3e4% of all other diaphragmatic hernias [2]. The mechanism of development of MH is ambiguous. Some authors claim that it is an acquired process through a congenital diaphragmatic defect buttressed by recording of previously normal chest X-ray for such patients [3]. The clinical manifestations of MH are often non-specific including respiratory complaints in the form of dyspnea and chest pain, or gastrointestinal complaints in the form of nausea & vomiting [1]. Repair of MH could be via thoracic, abdominal or minimally invasive techniques [4].
* Corresponding author. Cardiothoracic Surgery department, Mansoura University Hospitals, 60, El Gomhoria Street, Qism 17, Mansoura, 35516, Dakahlia, Egypt. E-mail address: [email protected] (W.H. Mohammed). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. http://dx.doi.org/10.1016/j.jescts.2017.05.008 1110-578X/© 2017 Publishing services by Elsevier B.V. on behalf of The Egyptian Society of Cardio-thoracic Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
2
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
The aim of this study was to determine the superlative approach for this defect per every patient characteristics in terms of feasibleness, operative time, hospital stay, patient satisfaction and post-operative complications on follow up. 2. Patients and methods In this retrospective descriptive single center study, we reported all patients with MH diagnosed and operated upon at the Department of Cardiothoracic Surgery, Mansoura University Hospital, Egypt from January 2006 to January 2013. Being a rare anomaly, only a total of eighteen patients, 12 males (66.7%) and 6 females (33.3%) were encountered. Of these, 12 patients (66.7%) were symptomatic and 6 were accidentally discovered. Routine workup with X-ray and Computed tomography (CT) of the chest was performed preoperatively to all patients. Contrast study in the form of barium follow through was done for 9 patients. Preoperative colon preparation was performed by 24-hours solid food fasting and enema at the night of surgery to ease reduction of contents into the peritoneum. The surgical approach was based on surgeon's preference tailored per every patient preoperative characteristic. Thoracotomy was avoided in patients with respiratory comorbidities where laparotomy was performed. Right posterolateral thoracotomy in the 7th intercostal space was performed for the 9 patients (50%) of Group I. Anterior extension of the wound was needed for better exposure. The sac contained the omentum alone (3 patients), or omentum and colon (6 patients) and it was filling the right cardiophrenic recess and extending for a variable distance into the pleural space. The sac was routinely opened, its edges were held with artery forceps and then the contents were slowly reduced into the abdomen to evade injury of the colon or the omentum. The neck of the sac was closed with transverse mattress nonabsorbable suture, descended into the abdomen. The defect was closed by interrupted single layer heavy polypropylene sutures. Chest tube drainage was left for 24 h. Right paramedian muscle sparing incision was performed in the other half of the patients (Group II). After retraction of the wound edges, it was easy to detect the defect, pull the contents, excise the sac and ligate the neck, and close the defect by interrupted single layer non-absorbable sutures. We fully inflated the lung at the end of the operation with no need for chest tube but only abdominal drain (see Figs. 1 and 2). 3. Results Included were 18 patients (33.3% females) with a mean age of 26.83 ± 17.80 years, ranging from 8 to 54 years old. Of which, 50% were in pediatric age group (Table 1 and Fig. 3). In this study, all patients presented with right sided MH. As regard symptoms, 12 patients were symptomatic in the form of dyspnea (7 patients) and cough (5 patients) with recurrent chest infection (4 patients). Six patients were discovered inadvertently during chest X-ray evaluation for other problems as shown in (Table 1 and Fig. 4).
Table 1 Demographic and Perioperative data of studied group. Parameter
No (%) e Mean ± SD.
Age Sex Male Female Symptoms Dyspnea Cough Recurrent chest infection Asymptomatic Laterality Right Left Approach of surgery: Right thoracotomy Paramedian abdominal incision Contents: Omentum only Omentum and colon Operation time (min) Thoracotomy group Laparotomy group Postoperative complications Incisional hernia Recurrence No complication
26.83 ± 17.80 12 (66.7%) 6 (33.3%) 7 5 4 6
(38.9%) (27.8%) (22.2%) (33.3%)
18 (100%) 0 (0%) 9 (50%) 9 (50%) 9 (50%) 9 (50%) 99.44 ± 13.33 85.0 ± 20.92 1 (5.6%) 1 (5.6%) 16 (88.9%)
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
3
Fig. 1. Anterolateral defect through the diaphragm herniating a sac containing an omentum and colon.
In our series, Chest X-rays showed abnormal findings which ranged from an unidentified opacity in the right cardiophrenic angle to gas filled loops of colon, within the right chest cavity consistent with MH. CT Chest established the diagnosis in 15. In the 9 patients with hernial sac containing colon, it was easy to confirm the diagnoses by contrast studies in the form of barium follow through which revealed colon in the right hemithorax. The mean operative time of the thoracotomy and laparotomy groups was 99.44 ± 13.33 and 85.0 ± 20.92 min respectively, but without statistical significance P ¼ 0.100 (Table 1). The drain was removed after 24 h, and all patients were ready for discharge by 48 h. No patient of either group had early postoperative complications related to the approach itself. In an eight years old male patient, the exposure of the defect was unsatisfactory from the thoracotomy approach; we found some difficulty to suture the far medial end of the defect and tried to avoid the pericardium. This patient presented with recurrence of the hernia after 2 weeks from discharge.
Fig. 2. Post-repair of anterolateral defect through the diaphragm herniating sac containing an omentum and colon.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
4
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
Fig. 3. Gender distribution of studied group.
In a 54-year old very obese female patient, the laparotomy approach was used but with poor exposure. Extension of the incision was needed and we made great effort to retract the wound edges and viscera to expose the defect. At one year of follow up, she developed incisional hernia and CT chest revealed rounded 5 cm opacity at the site of original hernia which might be beginning of recurrence or mostly organized fluid in the non-reduced hernia sac (Fig. 5). 4. Discussion Lack of fusion or muscularization of the pleuroperitoneal membrane anteriorly leads to a defect in the costosternal trigones known as the foramen of Morgagni. A hernia through the right sternocostal hiatus is referred as a MH, whereas a hernia through the left hiatus is called a Larrey hernia [4]. MH is quite erratic. Herein, we discuss our single center experience with 18 patients with a mean age of 26.83 years over a 7-year period. Half of these were in the pediatric age group which was a quite large percentage of cases reported in this age group in a single study. The study involved 12 males and 6 females. Pfannschmid et al. [2] reported MH among age interval of 47e73 years, mean 59.3 years and 4 patients out of 7 patients were females. Gedik et al. [1] reported similar age group to Pfannschmidt et al. [2] (42e71 years) where age ranged from 16 to 68 years (mean age 51.5). Five (31%) patients were males, and 11 (69%) patients were females in the study of Kilic et al. [5]. Berman et al. [6] reported 18 cases with MH over a 20-year period. Coiner and Clagett [7] reported 54 patients with MH in a large series of 1750 patients with diaphragmatic hernia. Also, Kilic et al. [5] collected their data from only 16 patients during a 16 years period. In the literature, right side MH predominates, but still left side MH is present [4]; the percentage of left side MH was 5.9% in Allam et al. [8] & 12.5% in Gedik et al. [1], and it was as high as 28% in Pfannschmidt et al. [2]. But surprisingly we had no left sided MH at all.
Fig. 4. Symptomatology of the studied group.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
5
Fig. 5. Postoperative complications.
Regarding our series, twelve patients had respiratory symptoms. Providentially, none of our patients presented urgently with incarceration of intestine. Mostly, patients with abdominal sequalae were evaluated and operated upon by general surgeons. There is still some controversy regarding the operative technique. Some authors advocate the thoracotomy or laparotomy approach, other surgeons favor the video assisted endoscopic technique. In our series, the abdominal approach was technically easier for repairing even complicated hernias, but 6 cases underwent exploratory thoracotomy due to uncertain diagnosis of MH. It is clear that the exposure of the defect was easier and more targeted through laparotomy; also, it was easier to pull the contents from the abdominal side than to push them from the thoracic side. Laparotomy helps avoiding dissection of adhesions and helps exploration of the abdomen in case of suspected intestinal complications. This explains the relatively longer operative time in the thoracotomy group. In addition, thoracotomy is better avoided in patients with poor respiratory reserve. Long and Kocher [9] recommended the transabdominal approach when the diagnosis was certain as it allowed easier reduction of the hernia, especially for bilateral hernias. Also, abdominal visceral contents could be easily pulled down to their normal location in the abdomen and the sac can then be withdrawn and resected. Some authors like Kilic et al. [5] recommended the trans-thoracic approach as it offered extensive exposure with no complication or recurrence in their patients. On the other hand, Bentley and Lister [10] re-explored one patient by laparotomy as he developed intestinal obstruction after the trans thoracic repair of the defect. Monsivais et al., [11] used single-incision laparoscopic port with adequate reduction of the hernia, excision of the sac, and applying mesh over the diaphragmatic defect from 2 cm incision. One of the drawbacks of our study was that pain score was not used postoperatively, but it is generally known that thoracotomy is more painful than laparotomy. From our experience, we advise to avoid laparotomy in obese patients due to difficult exposure and increased risk of developing incisional hernia. We used muscle sparing paramedian incision. Allam and coworkers [8] used upper midline incision. As we had no patients with preoperative bowel complications, the procedure was straight forward in all patients; the closure of the defect was primary in one layer interrupted non-absorbable suture. No patient required mesh augmentation. In all patients, the drain was removed by the second day and patient was discharged by the third day. We had one patient from Group I with early recurrence in whom we found difficulty in suturing the medial end of the defect and the suture seemed to hold loose tissue. We had only one late postoperative complication in Group II in the form of an abdominal incisional hernia. 5. Conclusions Once diagnosed, MH must be repaired to guard against incarceration of the intestine. The repair of MH could be performed safely and effectively by either thoracic or abdominal approaches. The choice of the surgical approach was based on the individual criteria of the patient but the abdominal one was less time consuming, easier, and the edges of the defect were clear so the recurrence was less likely to occur. However, incisional hernia was a potential complication. References [1] Gedik E, Tuncer MC, Onat S, Avcl A, Tacylldlz I. B: a review of Morgagni and Bochdalek hernias in adults. Folia Morphol 2011;70(1):5e12. [2] Pfannschmidt J, Hoffmann H, Dienemann H. MH in adults: results in 7 patients. Scand J Surg 2004;93:777e81.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
6
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
[3] Eren S, Ciri F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol 2005;54:448e59. [4] Abraham Vijay, Myla Yacob, Verghese Sam, Sudhakar Chandran B. Morgagni-Larrey hernia- a review of 20 cases. Indian J Surg 2012 Oct;74(5):391e5. [5] Kilic D, Nadir A, Doner E, Kavukcu S, Akal M, Ozdemir N, et al. Transthoracic approach in surgical management of MH. Eur J Cardiothorac Surg 2001;20: 1016e9. [6] Berman L, Stringer D, Ein SH, Shandling B. The late-presenting pediatric MH: a benign condition. J Pediatr Surg 1989;24:970e2. [7] Coiner TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461e8. [8] Allam A, Hassanein W, Ramadan B, Saleh A, Karara K, Saleh A. Management of MH, 15 Years' experience. J Egypt Soc Cardiothorac Surg 2012;20:215e9. [9] Long TPF, Kocher H. M: clinical presentation and operative repair of hernia. Postgrad Med J 2005;81:41e4. [10] Bentley G, Lister J. Retrosternal hernia. Surgery 1965;57:567e75. [11] Monsivais S, Sharp NE, Vassaur H, Buckley FP. Single-incision laparoscopic MH repair in an adult. Int J Surg Res Pract 2014;1:1.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
Contents lists available at ScienceDirect
Journal of the Egyptian Society of Cardio-Thoracic Surgery journal homepage: http://www.journals.elsevier.com/journal-ofthe-egyptian-society-of-cardio-thoracic-surgery/
Morgagni Hernia: How to approach! Mohamed Elshabrawy Saleh MD, Walid Hassan Mohammed MD * Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 March 2017 Received in revised form 7 May 2017 Accepted 21 May 2017 Available online xxx
Background: Morgagni Hernia (MH) is a retrosternal herniation through inherent diaphragmatic defect manifested by respiratory and/or gastrointestinal symptoms and is repaired through transabdominal or transthoracic approaches. Methods: The study aimed to evaluate thoracic and abdominal approaches in terms of operative and postoperative sequalae. Herein, we included 18 patients with MH operated in the Cardiothoracic Surgery Department at Mansoura University Hospital, Mansoura, Egypt over a period of 7 years. They were divided into two groups. Group I operated via right thoracotomy and Group II operated via paramedian laparotomy. Each group included 9 patients. Results: Twelve males and 6 females with right sided MH were included. The mean operative times in thoracotomy and laparotomy groups were 99.44 ± 13.33 and 85.0 ± 20.92 min respectively but without statistical significance P ¼ 0.100. We recorded one recurrence in the thoracotomy group (group I) and one post-operative incisional hernia in the laparotomy group (group II). Conclusions: MH should be repaired upon diagnosis. The optimal surgical technique should be tailored to the patient characteristics. Still, the abdominal approach was linked to easier feasibility, less operative time and recurrence rates. © 2017 Publishing services by Elsevier B.V. on behalf of The Egyptian Society of Cardiothoracic Surgery. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
Keywords: Morgagni Hernia Laparotomy Thoracotomy Diaphragmatic defect
1. Introduction Foramen of Morgagni Hernia (MH) is defined as an erratic parasternal or a retrosternal hernia attributed to anterior diaphragmatic defect. It was foremost designated by the Italian pathologist and anatomist Giovanni Morgagni in 1769 [1]. MH is a rare disorder in all age clusters particularly in pediatric age group; being still asymptomatic or not sizable. It represents 3e4% of all other diaphragmatic hernias [2]. The mechanism of development of MH is ambiguous. Some authors claim that it is an acquired process through a congenital diaphragmatic defect buttressed by recording of previously normal chest X-ray for such patients [3]. The clinical manifestations of MH are often non-specific including respiratory complaints in the form of dyspnea and chest pain, or gastrointestinal complaints in the form of nausea & vomiting [1]. Repair of MH could be via thoracic, abdominal or minimally invasive techniques [4].
* Corresponding author. Cardiothoracic Surgery department, Mansoura University Hospitals, 60, El Gomhoria Street, Qism 17, Mansoura, 35516, Dakahlia, Egypt. E-mail address: [email protected] (W.H. Mohammed). Peer review under responsibility of The Egyptian Society of Cardio-thoracic Surgery. http://dx.doi.org/10.1016/j.jescts.2017.05.008 1110-578X/© 2017 Publishing services by Elsevier B.V. on behalf of The Egyptian Society of Cardio-thoracic Surgery. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
2
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
The aim of this study was to determine the superlative approach for this defect per every patient characteristics in terms of feasibleness, operative time, hospital stay, patient satisfaction and post-operative complications on follow up. 2. Patients and methods In this retrospective descriptive single center study, we reported all patients with MH diagnosed and operated upon at the Department of Cardiothoracic Surgery, Mansoura University Hospital, Egypt from January 2006 to January 2013. Being a rare anomaly, only a total of eighteen patients, 12 males (66.7%) and 6 females (33.3%) were encountered. Of these, 12 patients (66.7%) were symptomatic and 6 were accidentally discovered. Routine workup with X-ray and Computed tomography (CT) of the chest was performed preoperatively to all patients. Contrast study in the form of barium follow through was done for 9 patients. Preoperative colon preparation was performed by 24-hours solid food fasting and enema at the night of surgery to ease reduction of contents into the peritoneum. The surgical approach was based on surgeon's preference tailored per every patient preoperative characteristic. Thoracotomy was avoided in patients with respiratory comorbidities where laparotomy was performed. Right posterolateral thoracotomy in the 7th intercostal space was performed for the 9 patients (50%) of Group I. Anterior extension of the wound was needed for better exposure. The sac contained the omentum alone (3 patients), or omentum and colon (6 patients) and it was filling the right cardiophrenic recess and extending for a variable distance into the pleural space. The sac was routinely opened, its edges were held with artery forceps and then the contents were slowly reduced into the abdomen to evade injury of the colon or the omentum. The neck of the sac was closed with transverse mattress nonabsorbable suture, descended into the abdomen. The defect was closed by interrupted single layer heavy polypropylene sutures. Chest tube drainage was left for 24 h. Right paramedian muscle sparing incision was performed in the other half of the patients (Group II). After retraction of the wound edges, it was easy to detect the defect, pull the contents, excise the sac and ligate the neck, and close the defect by interrupted single layer non-absorbable sutures. We fully inflated the lung at the end of the operation with no need for chest tube but only abdominal drain (see Figs. 1 and 2). 3. Results Included were 18 patients (33.3% females) with a mean age of 26.83 ± 17.80 years, ranging from 8 to 54 years old. Of which, 50% were in pediatric age group (Table 1 and Fig. 3). In this study, all patients presented with right sided MH. As regard symptoms, 12 patients were symptomatic in the form of dyspnea (7 patients) and cough (5 patients) with recurrent chest infection (4 patients). Six patients were discovered inadvertently during chest X-ray evaluation for other problems as shown in (Table 1 and Fig. 4).
Table 1 Demographic and Perioperative data of studied group. Parameter
No (%) e Mean ± SD.
Age Sex Male Female Symptoms Dyspnea Cough Recurrent chest infection Asymptomatic Laterality Right Left Approach of surgery: Right thoracotomy Paramedian abdominal incision Contents: Omentum only Omentum and colon Operation time (min) Thoracotomy group Laparotomy group Postoperative complications Incisional hernia Recurrence No complication
26.83 ± 17.80 12 (66.7%) 6 (33.3%) 7 5 4 6
(38.9%) (27.8%) (22.2%) (33.3%)
18 (100%) 0 (0%) 9 (50%) 9 (50%) 9 (50%) 9 (50%) 99.44 ± 13.33 85.0 ± 20.92 1 (5.6%) 1 (5.6%) 16 (88.9%)
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
3
Fig. 1. Anterolateral defect through the diaphragm herniating a sac containing an omentum and colon.
In our series, Chest X-rays showed abnormal findings which ranged from an unidentified opacity in the right cardiophrenic angle to gas filled loops of colon, within the right chest cavity consistent with MH. CT Chest established the diagnosis in 15. In the 9 patients with hernial sac containing colon, it was easy to confirm the diagnoses by contrast studies in the form of barium follow through which revealed colon in the right hemithorax. The mean operative time of the thoracotomy and laparotomy groups was 99.44 ± 13.33 and 85.0 ± 20.92 min respectively, but without statistical significance P ¼ 0.100 (Table 1). The drain was removed after 24 h, and all patients were ready for discharge by 48 h. No patient of either group had early postoperative complications related to the approach itself. In an eight years old male patient, the exposure of the defect was unsatisfactory from the thoracotomy approach; we found some difficulty to suture the far medial end of the defect and tried to avoid the pericardium. This patient presented with recurrence of the hernia after 2 weeks from discharge.
Fig. 2. Post-repair of anterolateral defect through the diaphragm herniating sac containing an omentum and colon.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
4
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
Fig. 3. Gender distribution of studied group.
In a 54-year old very obese female patient, the laparotomy approach was used but with poor exposure. Extension of the incision was needed and we made great effort to retract the wound edges and viscera to expose the defect. At one year of follow up, she developed incisional hernia and CT chest revealed rounded 5 cm opacity at the site of original hernia which might be beginning of recurrence or mostly organized fluid in the non-reduced hernia sac (Fig. 5). 4. Discussion Lack of fusion or muscularization of the pleuroperitoneal membrane anteriorly leads to a defect in the costosternal trigones known as the foramen of Morgagni. A hernia through the right sternocostal hiatus is referred as a MH, whereas a hernia through the left hiatus is called a Larrey hernia [4]. MH is quite erratic. Herein, we discuss our single center experience with 18 patients with a mean age of 26.83 years over a 7-year period. Half of these were in the pediatric age group which was a quite large percentage of cases reported in this age group in a single study. The study involved 12 males and 6 females. Pfannschmid et al. [2] reported MH among age interval of 47e73 years, mean 59.3 years and 4 patients out of 7 patients were females. Gedik et al. [1] reported similar age group to Pfannschmidt et al. [2] (42e71 years) where age ranged from 16 to 68 years (mean age 51.5). Five (31%) patients were males, and 11 (69%) patients were females in the study of Kilic et al. [5]. Berman et al. [6] reported 18 cases with MH over a 20-year period. Coiner and Clagett [7] reported 54 patients with MH in a large series of 1750 patients with diaphragmatic hernia. Also, Kilic et al. [5] collected their data from only 16 patients during a 16 years period. In the literature, right side MH predominates, but still left side MH is present [4]; the percentage of left side MH was 5.9% in Allam et al. [8] & 12.5% in Gedik et al. [1], and it was as high as 28% in Pfannschmidt et al. [2]. But surprisingly we had no left sided MH at all.
Fig. 4. Symptomatology of the studied group.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
M.E. Saleh, W.H. Mohammed / Journal of the Egyptian Society of Cardio-Thoracic Surgery xxx (2017) 1e6
5
Fig. 5. Postoperative complications.
Regarding our series, twelve patients had respiratory symptoms. Providentially, none of our patients presented urgently with incarceration of intestine. Mostly, patients with abdominal sequalae were evaluated and operated upon by general surgeons. There is still some controversy regarding the operative technique. Some authors advocate the thoracotomy or laparotomy approach, other surgeons favor the video assisted endoscopic technique. In our series, the abdominal approach was technically easier for repairing even complicated hernias, but 6 cases underwent exploratory thoracotomy due to uncertain diagnosis of MH. It is clear that the exposure of the defect was easier and more targeted through laparotomy; also, it was easier to pull the contents from the abdominal side than to push them from the thoracic side. Laparotomy helps avoiding dissection of adhesions and helps exploration of the abdomen in case of suspected intestinal complications. This explains the relatively longer operative time in the thoracotomy group. In addition, thoracotomy is better avoided in patients with poor respiratory reserve. Long and Kocher [9] recommended the transabdominal approach when the diagnosis was certain as it allowed easier reduction of the hernia, especially for bilateral hernias. Also, abdominal visceral contents could be easily pulled down to their normal location in the abdomen and the sac can then be withdrawn and resected. Some authors like Kilic et al. [5] recommended the trans-thoracic approach as it offered extensive exposure with no complication or recurrence in their patients. On the other hand, Bentley and Lister [10] re-explored one patient by laparotomy as he developed intestinal obstruction after the trans thoracic repair of the defect. Monsivais et al., [11] used single-incision laparoscopic port with adequate reduction of the hernia, excision of the sac, and applying mesh over the diaphragmatic defect from 2 cm incision. One of the drawbacks of our study was that pain score was not used postoperatively, but it is generally known that thoracotomy is more painful than laparotomy. From our experience, we advise to avoid laparotomy in obese patients due to difficult exposure and increased risk of developing incisional hernia. We used muscle sparing paramedian incision. Allam and coworkers [8] used upper midline incision. As we had no patients with preoperative bowel complications, the procedure was straight forward in all patients; the closure of the defect was primary in one layer interrupted non-absorbable suture. No patient required mesh augmentation. In all patients, the drain was removed by the second day and patient was discharged by the third day. We had one patient from Group I with early recurrence in whom we found difficulty in suturing the medial end of the defect and the suture seemed to hold loose tissue. We had only one late postoperative complication in Group II in the form of an abdominal incisional hernia. 5. Conclusions Once diagnosed, MH must be repaired to guard against incarceration of the intestine. The repair of MH could be performed safely and effectively by either thoracic or abdominal approaches. The choice of the surgical approach was based on the individual criteria of the patient but the abdominal one was less time consuming, easier, and the edges of the defect were clear so the recurrence was less likely to occur. However, incisional hernia was a potential complication. References [1] Gedik E, Tuncer MC, Onat S, Avcl A, Tacylldlz I. B: a review of Morgagni and Bochdalek hernias in adults. Folia Morphol 2011;70(1):5e12. [2] Pfannschmidt J, Hoffmann H, Dienemann H. MH in adults: results in 7 patients. Scand J Surg 2004;93:777e81.
Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008
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Please cite this article in press as: Saleh ME, Mohammed WH, Morgagni Hernia: How to approach!, Journal of the Egyptian Society of Cardio-Thoracic Surgery (2017), http://dx.doi.org/10.1016/j.jescts.2017.05.008