The first Morgagni hernia was described by Giovanni Battista Morgagni in the year of 1769, who was an Italian anatomist and who anatomist performed postmorten on the patient of head injury and found herniation of the bowel in the retrosternal region. Congenital failure of fusion of septum Transversum in diaphragm with the costal arches is the rare casue of retrosternal Hernia of Morgagni. The defect in retrosternal hernia mostly occurs at 7
th rib level on the both sides of the xiphoid process. Here the superior epigastric arteries pass. Similar defect can also detected on the left side. The defect on the right side is called Morgagni Hernia and on the left named as Larrey’s Hernia. Most of the presentation is asymptomatic with vague symptoms of indigestion and nonspecific respiratory symptoms. Other differential also include cystic lesion arising from the pleuropericardium, pleural mesothelioma, pericaridal fat pad, tumors arising from the anterior chest wall, thymus, and mediastinum ( 2).
Morgagni Hernia may be associated with some of the inheritable condition like Down syndrome, pentalogy of Cantrell, Noonan syndrome, turner syndrome (
The progressive age can cause the weakness of the diaphragm and the increase in pressure of abdomen during the pregnancy, trauma and obesity may attribute to the Morgagni hernia. Mostly the patient don’t have any symptom and some time the presentation may be breathlessness due to the respiratory compromise and pleural infection (
6). The number of cases of Morgagni hernia may be much more than in the recent literature as most of these are asymptomatic.
Diagnosis require chest X-ray PA view and lateral chest X-ray, besides CECT scan and MRI scan are more specific. Surgical treatment is advised even for the asymptomatic cases as there is risk of either intestinal incarceration, strangulation.
As a matter of fact, our patient was a high risk patient, considering age and general condition, however surgical intervention was indispensable. Open repair of the Morgagni hernia can be established via abdominal and thoracic approach. The minimally access technique using laparoscopy will minimize the postoperative pain and ensure the early mobilization of the patient, also decreasing the morbidity of open surgery.
The transabdominal approach is preferred as it results in easy reduction of the content in case of bilateral hernia. In this situation, the hernial contents are reduced to anatomical position in the abdomen. Sometimes the hernial sac can be dissected followed by excision, and closure of the defect with non-absorbable nylon suture in interrupted fashion. Paris et al. performed the excision of sac by extraperitoneal and preperitoneal subxiphoid approach which allows the dissection of sac from the pleura (
The transthoracic approach which was defined by Chin and Duchesne (
8), provided wide exposure and easy repair. Kilic et al. performed thorocotomies on 16 patients for the repair of Morgagni hernia with no recurrence rates ( 9). Thorocotomy was indicated in nonconclusive cases.
There is still controversy regarding the excision of the sac and also about the use of Prosthetic mesh. Primary suture repair of the defect is depended on suitable quality of tissue. The weak diaphragmatic musculature may lead to some difficulties in repairmen. This is the reason that even if the defect is closed primarily the suture closure should be reinforced with mesh. Composite mesh is preferred of the normal polypropylene mesh.
Kuster et al. in 1992 became the first person to perform the Morgagni hernia repair by laparoscopy. Laparoscopy plays an effective role to confirm diagnosis and repair hernia of Morgagni. The hernia sac was dissected by using laparoscope. Its content was reduced by dissecting around the sac and dividing the adhesions. In this surgery the sac was not removed and closure of defect was done by using non absorbable suture. This was strengthened by placing the Prosthetic mesh over the closure site. This minimal access technique of laparoscopic repair provide the advantage of fast recovery for the patient (
10). The procedure is safe in children who present with this problem that has not been diagnosed on CT scan.
In a review literature 44 patients had Morgagni hernia which was operated upon laparoscopically. Most of the patients had transverse colon as the content up to 80%, followed by omentum (13%), and few cases had small intestine (5%), stomach, round ligament and liver in less than 3% cases.
Excision of the sac provides the advantage of reduction of tissue trauma and decrease in visceral injury. It also decreases the chances of seroma formation as the serous membrane is stripped off. Furthermore the chances of recurrence is also declined in this situation.
Previous studies reported that early reherniation does not occurs in cases where hernia sac was excised in paraesophageal hernia (
11). Retro Xiphoid Sternocostal hiatus defects can be successfully repaired with Laparoscopic technique of herniorraphy ( 11). 3.1. Conclusion
Presentation of adult patient with both Morgagni and Larrey’s hernia is rare and would be asymptomatic for long time. Also the herniation of stomach with large intestine in the sac is rarely encountered. The diagnosis can be confirmed by contrast studies or laparoscopy. The latter one provide both the diagnostic along with therapeutic benefits. Furthermore, minimal access approach gives all the benefits of early recovery, less wound infection, less need of analgesia and early discharge. The visualization is good with the laparoscopic approach. Still further randomized trial is needed to compare the effectiveness of open vs laparoscopic approach.