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Symptomatic retrosternal (Morgagni) hernia
Symptomatic Yaacov
Wolloch,
Retrosternal (Morgagni) Hernia
MD, Petah Tiqva, Israel
Michael Gruiiebaum,
MD, Petah Tiqva, Israel
lrena Glanz, MD, Petah Tiqva, Moshe Dintsman,
Israel
MD, Petah Tiqva,
Israel
Morgagni’s hernia is an uncommon finding in adults and rarer still in infants and children. Harrington [I], in a review of 534 cases of all types of diaphragmatic hernia, found only fourteen (2.6 per cent) of the Morgagni variety. In another series, consisting of seventy-seven children with all varieties of diaphragmatic hernia, Snyder and Greaney [Z] found only 1 per cent with Morgagni’s hernia. Its true incidence may, however, be considerably greater than these figures suggest; the reason for its infrequent diagnosis is that some cases are asymptomatic. Chin and Duchesne [3] attribute the low reported incidence of Morgagni’s hernia to the absence of clinical signs and to radiologic misinterpretation of opacities in the cardiophrenic angle, particularly on the right side. We wish to report on three patients with symptomatic Morgagni’s hernia in whom the diagnosis was established during the course of investigation for various complaints and who were operated on in our department. Case Reports Case I. The patient, a twenty-eight year old man whose medical history was noncontributory, began to experience a sensation of pressure in the chest, dyspnea, and cough, particularly after exertion, one year prior to admission. One month prior to admission an irritating
From the Department of Surgery A, Pediatric Radiology Unit, and Department of Diagnostic Radiology, Beilinson Medical Center, Tel Aviv University Medical School, Petah Tiqva, Israel. Reprint requests should be addressed to Dr Wolloch. Department of Surgery A. Beilinson Medical Center, Petah Tiqva, Israel.
Volume 127, May 1974
cough developed, accompanied by pyrexia. Roentgenography of the chest revealed a loop of colon in the retrosternal region obliterating the right cardiophrenic angle (Figure I), which suggested the possibility of a Morgagni type of retrosternal hernia. The diagnosis was confirmed by barium enema study in which a segment of transverse colon was demonstrated in the chest overlying the heart shadow on the right side. (Figure 2.) The dyspnea and precordial distress on exertion were considered to be caused by pressure on intrathoracic structures by the hernial contents, and he was referred to our department for surgical repair of the hernia. Physical examination revealed a man in good general condition. Pulse was 88 per minute and regular; blood pressure was 105/80 mm Hg. Examination of head, neck, heart, and lungs revealed no abnormality; the abdomen was soft and nontender. The liver and spleen were not palpable, and the peristaltic sounds were normal. Laboratory investigation revealed a hemoglobin of 13.8 gm per 100 ml and a white blood cell count of 7,300 per mm:’ with a normal differential count. Blood urea was 27 mg per 100 ml. Results of liver function tests and urinalysis were within normal limits. At laparotomy a large Morgagni’s hernia containing a segment of transverse colon was found. After reduction of colon into the abdominal cavity the hernial opening was closed in two layers without resection of the hernial sac. The postoperative course was uneventful and the patient was discharged on the ninth day after operation. At follow-up examination he was well and no longer complained of dyspnea or pressure in the chest at rest or on exertion. Case II. The patient, a sixty-one year old man, had had a myocardial infarction at age fifty-one and since then had intermittent left-sided chest pain. In the year preceding admission he began to experience a sensation
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figure 1. Case I. Chest x-ray films: A, posteroanterior view; 8, lateral view. Loops of bowel, probably colon, are seen retrosternally and obliterate the right cardiophrenic angle. of precordial pain and pressure in the left side of the chest and shortness of breath unrelated to effort. Serial electrocardiograms, white blood cell counts, and enzyme studies revealed no abnormalities. At the same time he also began to have pain in the left hypochondrium, initially only after eating and subsequently without any relation to meals. No relief was obtained from a variety of treatments. A roentgenogram of the chest, taken because of symptoms of pain and dyspnea in the left side of the chest, revealed herniation of large bowel into the chest. (Figure 3.) Further investigation was undertaken to determine the site and contents of the hernia. On upper gastrointestinal series, barium passed normally through the esophagus; however, the stomach showed abnormal filling, with the antral portion either pulled or displaced upwards, medially and anteriorly. The mucosal pattern was normal. Both the duodenal bulb and the duodenum were seen to be pulled upwards. On barium enema, a segment of the transverse colon and the splenic flexure were found to be in the thorax. (Figure 4.) The herniation occurred through the retrosternal opening of Morgagni. The dyspnea and pressure in the chest were considered to be caused by pressure of the hernial con-
tents on structures in the chest, and the patient was referred to our department for operation. On examination he was found to be in good general condition without signs of cardiac failure. Pulse was 76 per minute and regular; blood pressure was 130/80 mg Hg. Examination of the head, neck, heart, and lungs revealed no abnormality; the abdomen was soft. The liver and spleen were not palpable, and the peristaltic sounds were normal. At laparotomy multiple adhesions were found and released. The transverse colon and splenic flexure were found to be pulled up into the chest cavity through a retrosternal hernial orifice on the left side. The stomach was also found to be pulled up by the gastrocolic ligament. After reduction of the colon into the abdominal cavity a large retrosternal hernia was found on the left side. The sac was excised and the opening closed in two layers. The postoperative course was uneventful and the patient was discharged on the tenth postoperative day. When seen two years later he had had no further symptoms of chest pressure or dyspnea since undergoing repair of the Morgagni hernia, and the abdominal symptoms had also disappeared.
Figure 2. Case I. Barium enema: A, anteroposterior view; 8, lateral view. The midportion of the transverse colon is seen overlying the heart shadow.
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The American Journal of Surgery
Figure 3. Case II. Chest x-ray films: A, posteroanterior view; 6, lateral view. Loops of large bowel are seen overlying the left heart border and located retrosternally. Case III. The patient, a female infant aged one year nine months, was born weighing 1.7 kg after a labor accompanied by asphyxia neonatorum. Since birth she had vomited after relatively small feedings. She also suffered from recurrent infections of the upper respiratory tract. Roentgenograms taken at another hospital revealed herniation of the bowel into the chest cavity, but the vomiting and recurrent respiratory infections were not related to this finding. One week prior to admission to our department a high temperature and cough developed after an episode of vomiting. She was treated with antibiotics at an outside clinic but because the pyrexia did not. subside she was referred to the pediatric department. She was found to be in moderately good general condition and weighed 9.1 kg. The tonsils were enlarged, breath sounds were reduced over the right lung field, and peristaltic sounds were thought to be heard over the right lung base. Heart sounds were regular but tachycardie. The abdomen was soft, and the liver and spleen were not palpable. Laboratory examination revealed a hemoglobin of 10.5 gm per 100 ml and a white blood cell count of 8,100 per mm:] with a normal differential. Roentgenography of the chest showed intestinal loops in the right chest ante-
rior to the cardiac shadow. (Figure .5 I tkxw.;t~ 01’ihis. barium enema and an upper gastrointt+.tinal and small bowel series were performed. A hernia 11f ?hr Morgagni type containing a segment of the transverse. colon (Fig:ure 6) and also a portion of the stomach was seen. Because of the history of recurrent respiratory infections and vomiting and since roentgenography of the esophagus, stomach, and small bowel had shown no other pathologic factor that could explain the vomiting, she was transferred to our department f’or repair of’ the diaphragmatic hernia. At laparotomy, a large Morgagni hernia was found on the left side of’ the sternum. The hernial sac contained a large segmetit clt transverse colon and the left lobe of the liver. The st,omach was also seen to be pulled upwards by the gaslrocc+lic ligament. The colon and left hepatic lobe were withdrawn and the defect in the diaphragm was closed wit,hout excision of the hernial sac. Exploration of the abdomen revealed no other pat.hologic features. The postoperative course was uncomplicated and she was discharged on the ninth day after operation. While in our department she had no vomiting. On follow-up study her condition was found to be good and her mother informed IIS that she had no further vomiting.
Figure 4. Case II. Barium enema: A, anteroposterior view; B, lateral view. Contrast material fills the transverse colon which is located in front and to the left of the heart.
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Figure 5. Case Ill. Chest x-ray films: A, anteropostertor view; 6, lateral view, recumbent position. The heart shadow is displaced to the left by loops of large bowel located retrosternal/y and along the right cardiac border.
Comments Morgagni’s hernia, also known as retrosternal, substernal, parasternal, anterior diaphragmatic, or subcostosternal diaphragmatic hernia, occurs in the anterior segment of the diaphragm behind the sternum where the fibers of the diaphragm are connected to the sternum and costal cartilages. Although the hernia is considered to be a congenital anomaly it is only rarely found in neonates. In time, due to an increase in intra-abdominal pressure the hernia extends through the defect in the diaphragm. The hernia is of the direct type and always has a peritoneal sac. It may be unilateral or bilateral and occurs more commonly on the right side. In a large proportion of patients, the hernia may cause no symptoms and only be discovered incidentally on a routine chest x-ray film or at autopsy. In other patients, pressure exerted by the hernial contents on intrathoracic structures or as a result of incarceration or traction on abdominal organs causes various symptoms related to the respiratory system, heart, or gastrointestinal tract, as occurred in our patients. The organs generally found in this hernia are the transverse colon, the omentum, and, more rarely, the stomach and liver. However, even the cecum, terminal ileum, and ascending colon have been described in Morgagni’s hernia [4]. The clinical signs depend on the size and contents of the hernial sac and the age of the patient. In infants severe respiratory distress may be encountered, whereas in older children the signs tend to be milder and are manifested by recurrent respiratory infections. When the hernial sac contains bowel, various symptoms related to the gastrointestinal tract range from mild abdominal pain to symptoms of acute intestinal obstruction. In a
604
larger proportion of patients, however, segments of colon may be present in the hernial sac over a period of years without producing any clinical symptoms. In older patients, the contents of the sac may be large, and pressure on intrathoracic structures produces symptoms such as dyspnea, coughing, precordial pain, and palpitations. In the majority of cases, the presence of omentum in the hernial sac is unaccompanied by symptoms, and the dense opacity seen at the cardiophrenic angle on chest roentgenography is frequently erroneously interpreted as a chest tumor. Bingham [5] described two children, aged eight months and seven years, with Morgagni’s hernia who showed a deformity of the thoracic cage as evidenced by an anterior bulging of the lower end of the sternum. To our knowledge such an association between Morgagni’s hernia and deformity of the chest wall has not been described by other authors. The physical examination is usually not helpful in patients with Morgagni’s hernia. Peristaltic sounds may occasionally be audible in the chest cavity. The essential investigation by which the diagnosis may be established is roentgenographic examination. The lateral chest x-ray film is of particular value in localizing the suspicious shadow in the anterior aspect of the chest. The differentiation between a diaphragmatic hernia and a tumor of the chest cavity may be facilitated by the introduction of air into the abdominal cavity (pneumoperitoneum). A barium enema or meal may be useful in identifying the structures in the hernial sac. All authors believe that a symptomatic Morgagni’s hernia requires operation regardless of the patient’s age. In patients with asymptomatic Morgagni’s hernia, however, the indications for opera-
The American Journal of Surgery
Figure 6. Case Ill. Barium enema: A, anteroposterior view; B, lateral view. The transverse colon overlies the front and right border of the heart. Both colontc flexures are straightened out. The homogeneous triangular shadow at the lower right lateral border of the “enlarged heart shadow ” is produced by omentum or liver or both in the hernial sac. Upper gastrointestinal barium meat: C, lateral view of the stomach. The antral portion of the stomach is pulled up into the retrosternal region.
tion vary with the age of the patient. Asymptomatic hernia in the adult does not require operation, whereas in children surgical correction is advocated by several authors [5,6]. The rationale for this recommendation is that with the growth of the child and the corresponding increase in the amount of fat in the mesentery and omentum, the chances of intestinal obstruction are greater. Furthermore, recurrent subacute obstruction causes inflammatory changes and adhesions, rendering any subsequent surgical procedure more difficult. The surgical approach may be either transthoracic or transabdominal. Protagonists of the thoracic approach 13) justify this route because of the following advantages: (1) the approach to the hernial sac is direct, facilit,ating the release of adhesions; (2) the defect in the diaphragm is more easily repaired; (3) better exposure is provided by this route. Those who recommend an abdominal approach [2,3,6,7] base their recommendation on the following: (1) this approach permits the surgeon to deal at the same time with other pathologic features that may be encountered in the abdominal of the hernial contents cavity; (2) when reduction into the abdominal cavity is technically impossible, a ventral hernia can be left to be dealt with at a later stage; (3) this approach also allows repair of a bilateral Morgagni’s hernia, which is not possible with a unilateral transthoracic approach. Our three patients underwent operation through the abdominal approach with no technical difficulties. We believe that the approach of choice is the abdominal one provided that a tumor of the thoracic cavity can be excluded. The diaphragmatic defect can be closed in the majority of patients. In
Volume127,May1974
patients with a large defect, the dial”ilriignl may i)e sutured to the posterior rectus sheath and to the chest wall. In patient,s with a huge hernia Ciplastic prosthesis such as a patch of Dacron@ or ‘I’eflon@J may be used to secure closure of the detect in the diaphragm. Summary
Three patients with Morgagni’s hernia are described. The presenting symptoms in the first patient were retrosternal pressure, dyspnea, and cough; in the second, precordial pain and pressure in the left side of the chest; in the third, vomiting and recurrent respirator, infections. Surgical repair via an abdominal approach led to the disappearance of symptoms in all three patients. The low reported incidence of this type of hernia may be due to the fact that asympt.omat.ic cases are not diagnosed, and others may not be diagnosed radiologically because of difficulties in interpreting opacities in the cardiophrenic angle. References 1. Harrington SW: Clinical manifestation and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenferal 18: 243, 1951. 2. Snyder WH Jr, Greaney EM Jr: Congenital diaphragmatic hernia: 77 consecutive cases. Surgery57: 576, 1965. 3. Chin EF, Duchesne ER: Parasternal defect. Thorax 10: 214, 1955. 4. Hunter WR: Herniation through the foramen of Morgagni. Br J Surg 47: 22, 1959. 5. Bingham JAW: Herniation through congenital diaphragmatic defects. Br J Surg47: 1, 1959. 6. Bentley G, Lister J: Retrosternal hernia. Surgery 57: 567, 1965. 7. Boyd DP: Diaphragmatic hernia through the foramen of Morgagni. Surg C/in North Am41: 839, 1961.
605
Wolloch,
Retrosternal (Morgagni) Hernia
MD, Petah Tiqva, Israel
Michael Gruiiebaum,
MD, Petah Tiqva, Israel
lrena Glanz, MD, Petah Tiqva, Moshe Dintsman,
Israel
MD, Petah Tiqva,
Israel
Morgagni’s hernia is an uncommon finding in adults and rarer still in infants and children. Harrington [I], in a review of 534 cases of all types of diaphragmatic hernia, found only fourteen (2.6 per cent) of the Morgagni variety. In another series, consisting of seventy-seven children with all varieties of diaphragmatic hernia, Snyder and Greaney [Z] found only 1 per cent with Morgagni’s hernia. Its true incidence may, however, be considerably greater than these figures suggest; the reason for its infrequent diagnosis is that some cases are asymptomatic. Chin and Duchesne [3] attribute the low reported incidence of Morgagni’s hernia to the absence of clinical signs and to radiologic misinterpretation of opacities in the cardiophrenic angle, particularly on the right side. We wish to report on three patients with symptomatic Morgagni’s hernia in whom the diagnosis was established during the course of investigation for various complaints and who were operated on in our department. Case Reports Case I. The patient, a twenty-eight year old man whose medical history was noncontributory, began to experience a sensation of pressure in the chest, dyspnea, and cough, particularly after exertion, one year prior to admission. One month prior to admission an irritating
From the Department of Surgery A, Pediatric Radiology Unit, and Department of Diagnostic Radiology, Beilinson Medical Center, Tel Aviv University Medical School, Petah Tiqva, Israel. Reprint requests should be addressed to Dr Wolloch. Department of Surgery A. Beilinson Medical Center, Petah Tiqva, Israel.
Volume 127, May 1974
cough developed, accompanied by pyrexia. Roentgenography of the chest revealed a loop of colon in the retrosternal region obliterating the right cardiophrenic angle (Figure I), which suggested the possibility of a Morgagni type of retrosternal hernia. The diagnosis was confirmed by barium enema study in which a segment of transverse colon was demonstrated in the chest overlying the heart shadow on the right side. (Figure 2.) The dyspnea and precordial distress on exertion were considered to be caused by pressure on intrathoracic structures by the hernial contents, and he was referred to our department for surgical repair of the hernia. Physical examination revealed a man in good general condition. Pulse was 88 per minute and regular; blood pressure was 105/80 mm Hg. Examination of head, neck, heart, and lungs revealed no abnormality; the abdomen was soft and nontender. The liver and spleen were not palpable, and the peristaltic sounds were normal. Laboratory investigation revealed a hemoglobin of 13.8 gm per 100 ml and a white blood cell count of 7,300 per mm:’ with a normal differential count. Blood urea was 27 mg per 100 ml. Results of liver function tests and urinalysis were within normal limits. At laparotomy a large Morgagni’s hernia containing a segment of transverse colon was found. After reduction of colon into the abdominal cavity the hernial opening was closed in two layers without resection of the hernial sac. The postoperative course was uneventful and the patient was discharged on the ninth day after operation. At follow-up examination he was well and no longer complained of dyspnea or pressure in the chest at rest or on exertion. Case II. The patient, a sixty-one year old man, had had a myocardial infarction at age fifty-one and since then had intermittent left-sided chest pain. In the year preceding admission he began to experience a sensation
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Wolloch et al
figure 1. Case I. Chest x-ray films: A, posteroanterior view; 8, lateral view. Loops of bowel, probably colon, are seen retrosternally and obliterate the right cardiophrenic angle. of precordial pain and pressure in the left side of the chest and shortness of breath unrelated to effort. Serial electrocardiograms, white blood cell counts, and enzyme studies revealed no abnormalities. At the same time he also began to have pain in the left hypochondrium, initially only after eating and subsequently without any relation to meals. No relief was obtained from a variety of treatments. A roentgenogram of the chest, taken because of symptoms of pain and dyspnea in the left side of the chest, revealed herniation of large bowel into the chest. (Figure 3.) Further investigation was undertaken to determine the site and contents of the hernia. On upper gastrointestinal series, barium passed normally through the esophagus; however, the stomach showed abnormal filling, with the antral portion either pulled or displaced upwards, medially and anteriorly. The mucosal pattern was normal. Both the duodenal bulb and the duodenum were seen to be pulled upwards. On barium enema, a segment of the transverse colon and the splenic flexure were found to be in the thorax. (Figure 4.) The herniation occurred through the retrosternal opening of Morgagni. The dyspnea and pressure in the chest were considered to be caused by pressure of the hernial con-
tents on structures in the chest, and the patient was referred to our department for operation. On examination he was found to be in good general condition without signs of cardiac failure. Pulse was 76 per minute and regular; blood pressure was 130/80 mg Hg. Examination of the head, neck, heart, and lungs revealed no abnormality; the abdomen was soft. The liver and spleen were not palpable, and the peristaltic sounds were normal. At laparotomy multiple adhesions were found and released. The transverse colon and splenic flexure were found to be pulled up into the chest cavity through a retrosternal hernial orifice on the left side. The stomach was also found to be pulled up by the gastrocolic ligament. After reduction of the colon into the abdominal cavity a large retrosternal hernia was found on the left side. The sac was excised and the opening closed in two layers. The postoperative course was uneventful and the patient was discharged on the tenth postoperative day. When seen two years later he had had no further symptoms of chest pressure or dyspnea since undergoing repair of the Morgagni hernia, and the abdominal symptoms had also disappeared.
Figure 2. Case I. Barium enema: A, anteroposterior view; 8, lateral view. The midportion of the transverse colon is seen overlying the heart shadow.
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The American Journal of Surgery
Figure 3. Case II. Chest x-ray films: A, posteroanterior view; 6, lateral view. Loops of large bowel are seen overlying the left heart border and located retrosternally. Case III. The patient, a female infant aged one year nine months, was born weighing 1.7 kg after a labor accompanied by asphyxia neonatorum. Since birth she had vomited after relatively small feedings. She also suffered from recurrent infections of the upper respiratory tract. Roentgenograms taken at another hospital revealed herniation of the bowel into the chest cavity, but the vomiting and recurrent respiratory infections were not related to this finding. One week prior to admission to our department a high temperature and cough developed after an episode of vomiting. She was treated with antibiotics at an outside clinic but because the pyrexia did not. subside she was referred to the pediatric department. She was found to be in moderately good general condition and weighed 9.1 kg. The tonsils were enlarged, breath sounds were reduced over the right lung field, and peristaltic sounds were thought to be heard over the right lung base. Heart sounds were regular but tachycardie. The abdomen was soft, and the liver and spleen were not palpable. Laboratory examination revealed a hemoglobin of 10.5 gm per 100 ml and a white blood cell count of 8,100 per mm:] with a normal differential. Roentgenography of the chest showed intestinal loops in the right chest ante-
rior to the cardiac shadow. (Figure .5 I tkxw.;t~ 01’ihis. barium enema and an upper gastrointt+.tinal and small bowel series were performed. A hernia 11f ?hr Morgagni type containing a segment of the transverse. colon (Fig:ure 6) and also a portion of the stomach was seen. Because of the history of recurrent respiratory infections and vomiting and since roentgenography of the esophagus, stomach, and small bowel had shown no other pathologic factor that could explain the vomiting, she was transferred to our department f’or repair of’ the diaphragmatic hernia. At laparotomy, a large Morgagni hernia was found on the left side of’ the sternum. The hernial sac contained a large segmetit clt transverse colon and the left lobe of the liver. The st,omach was also seen to be pulled upwards by the gaslrocc+lic ligament. The colon and left hepatic lobe were withdrawn and the defect in the diaphragm was closed wit,hout excision of the hernial sac. Exploration of the abdomen revealed no other pat.hologic features. The postoperative course was uncomplicated and she was discharged on the ninth day after operation. While in our department she had no vomiting. On follow-up study her condition was found to be good and her mother informed IIS that she had no further vomiting.
Figure 4. Case II. Barium enema: A, anteroposterior view; B, lateral view. Contrast material fills the transverse colon which is located in front and to the left of the heart.
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May 1974
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Figure 5. Case Ill. Chest x-ray films: A, anteropostertor view; 6, lateral view, recumbent position. The heart shadow is displaced to the left by loops of large bowel located retrosternal/y and along the right cardiac border.
Comments Morgagni’s hernia, also known as retrosternal, substernal, parasternal, anterior diaphragmatic, or subcostosternal diaphragmatic hernia, occurs in the anterior segment of the diaphragm behind the sternum where the fibers of the diaphragm are connected to the sternum and costal cartilages. Although the hernia is considered to be a congenital anomaly it is only rarely found in neonates. In time, due to an increase in intra-abdominal pressure the hernia extends through the defect in the diaphragm. The hernia is of the direct type and always has a peritoneal sac. It may be unilateral or bilateral and occurs more commonly on the right side. In a large proportion of patients, the hernia may cause no symptoms and only be discovered incidentally on a routine chest x-ray film or at autopsy. In other patients, pressure exerted by the hernial contents on intrathoracic structures or as a result of incarceration or traction on abdominal organs causes various symptoms related to the respiratory system, heart, or gastrointestinal tract, as occurred in our patients. The organs generally found in this hernia are the transverse colon, the omentum, and, more rarely, the stomach and liver. However, even the cecum, terminal ileum, and ascending colon have been described in Morgagni’s hernia [4]. The clinical signs depend on the size and contents of the hernial sac and the age of the patient. In infants severe respiratory distress may be encountered, whereas in older children the signs tend to be milder and are manifested by recurrent respiratory infections. When the hernial sac contains bowel, various symptoms related to the gastrointestinal tract range from mild abdominal pain to symptoms of acute intestinal obstruction. In a
604
larger proportion of patients, however, segments of colon may be present in the hernial sac over a period of years without producing any clinical symptoms. In older patients, the contents of the sac may be large, and pressure on intrathoracic structures produces symptoms such as dyspnea, coughing, precordial pain, and palpitations. In the majority of cases, the presence of omentum in the hernial sac is unaccompanied by symptoms, and the dense opacity seen at the cardiophrenic angle on chest roentgenography is frequently erroneously interpreted as a chest tumor. Bingham [5] described two children, aged eight months and seven years, with Morgagni’s hernia who showed a deformity of the thoracic cage as evidenced by an anterior bulging of the lower end of the sternum. To our knowledge such an association between Morgagni’s hernia and deformity of the chest wall has not been described by other authors. The physical examination is usually not helpful in patients with Morgagni’s hernia. Peristaltic sounds may occasionally be audible in the chest cavity. The essential investigation by which the diagnosis may be established is roentgenographic examination. The lateral chest x-ray film is of particular value in localizing the suspicious shadow in the anterior aspect of the chest. The differentiation between a diaphragmatic hernia and a tumor of the chest cavity may be facilitated by the introduction of air into the abdominal cavity (pneumoperitoneum). A barium enema or meal may be useful in identifying the structures in the hernial sac. All authors believe that a symptomatic Morgagni’s hernia requires operation regardless of the patient’s age. In patients with asymptomatic Morgagni’s hernia, however, the indications for opera-
The American Journal of Surgery
Figure 6. Case Ill. Barium enema: A, anteroposterior view; B, lateral view. The transverse colon overlies the front and right border of the heart. Both colontc flexures are straightened out. The homogeneous triangular shadow at the lower right lateral border of the “enlarged heart shadow ” is produced by omentum or liver or both in the hernial sac. Upper gastrointestinal barium meat: C, lateral view of the stomach. The antral portion of the stomach is pulled up into the retrosternal region.
tion vary with the age of the patient. Asymptomatic hernia in the adult does not require operation, whereas in children surgical correction is advocated by several authors [5,6]. The rationale for this recommendation is that with the growth of the child and the corresponding increase in the amount of fat in the mesentery and omentum, the chances of intestinal obstruction are greater. Furthermore, recurrent subacute obstruction causes inflammatory changes and adhesions, rendering any subsequent surgical procedure more difficult. The surgical approach may be either transthoracic or transabdominal. Protagonists of the thoracic approach 13) justify this route because of the following advantages: (1) the approach to the hernial sac is direct, facilit,ating the release of adhesions; (2) the defect in the diaphragm is more easily repaired; (3) better exposure is provided by this route. Those who recommend an abdominal approach [2,3,6,7] base their recommendation on the following: (1) this approach permits the surgeon to deal at the same time with other pathologic features that may be encountered in the abdominal of the hernial contents cavity; (2) when reduction into the abdominal cavity is technically impossible, a ventral hernia can be left to be dealt with at a later stage; (3) this approach also allows repair of a bilateral Morgagni’s hernia, which is not possible with a unilateral transthoracic approach. Our three patients underwent operation through the abdominal approach with no technical difficulties. We believe that the approach of choice is the abdominal one provided that a tumor of the thoracic cavity can be excluded. The diaphragmatic defect can be closed in the majority of patients. In
Volume127,May1974
patients with a large defect, the dial”ilriignl may i)e sutured to the posterior rectus sheath and to the chest wall. In patient,s with a huge hernia Ciplastic prosthesis such as a patch of Dacron@ or ‘I’eflon@J may be used to secure closure of the detect in the diaphragm. Summary
Three patients with Morgagni’s hernia are described. The presenting symptoms in the first patient were retrosternal pressure, dyspnea, and cough; in the second, precordial pain and pressure in the left side of the chest; in the third, vomiting and recurrent respirator, infections. Surgical repair via an abdominal approach led to the disappearance of symptoms in all three patients. The low reported incidence of this type of hernia may be due to the fact that asympt.omat.ic cases are not diagnosed, and others may not be diagnosed radiologically because of difficulties in interpreting opacities in the cardiophrenic angle. References 1. Harrington SW: Clinical manifestation and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenferal 18: 243, 1951. 2. Snyder WH Jr, Greaney EM Jr: Congenital diaphragmatic hernia: 77 consecutive cases. Surgery57: 576, 1965. 3. Chin EF, Duchesne ER: Parasternal defect. Thorax 10: 214, 1955. 4. Hunter WR: Herniation through the foramen of Morgagni. Br J Surg 47: 22, 1959. 5. Bingham JAW: Herniation through congenital diaphragmatic defects. Br J Surg47: 1, 1959. 6. Bentley G, Lister J: Retrosternal hernia. Surgery 57: 567, 1965. 7. Boyd DP: Diaphragmatic hernia through the foramen of Morgagni. Surg C/in North Am41: 839, 1961.
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