Ann Thorac Surg 2004;77:1956-1959
© 2004 The Society of Thoracic Surgeons
Original article: general thoracic
Foramen of Morgagni hernia: changes in diagnosis and treatment
Peter C. Minneci, MDa,
Katherine J. Deans, MDa,
Peter Kimb,
Douglas J. Mathisen, MDa,b*
a Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
b Division of General Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
Accepted for publication December 10, 2003.
* Address reprint requests to Dr Mathisen, General Thoracic Surgical Unit, Blake 1570, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
e-mail: dmathisen{at}partners.org
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Abstract
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BACKGROUND: Foramen of Morgagni hernias are uncommon diaphragmatic hernias for which there are limited reported data. The purpose of this study is to report a recent case series of foramen of Morgagni hernias in the context of new diagnostic and treatment modalities.
METHODS: A retrospective chart review was performed over a 15-year period, from 1987 to 2001. Twelve patients who had a foramen of Morgagni hernia repaired at our hospital were identified, and data from these patients were collected.
RESULTS: The average age at treatment was 45 years, with 50% of patients being asymptomatic. Radiographic evaluation included computed tomography scans in two thirds of the patients with a 100% sensitivity for diagnosis. All hernias were right-sided, and the most common contents of the hernias were omentum and colon. The transabdominal route was the preferred surgical approach. Thoracoscopy was used in 2 patients to further characterize a mediastinal mass. Two patients underwent laparoscopic repair. Postoperative complications were infrequent, and there were no recurrences during a 6-month to 10-year follow-up.
CONCLUSIONS: The emergence of highly accurate diagnostic computed tomography scans combined with less invasive surgical techniques utilizing laparoscopy and thoracoscopy has aided in the treatment of foramen of Morgagni hernias over the last 15 years.
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Introduction
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Subcostosternal diaphragmatic hernia is an uncommon form of diaphragmatic hernia. In 1769, Morgagni first described the substernal herniation of abdominal contents into the thoracic cavity based on observations made during autopsy examinations [1]. In 1828, Larrey described a surgical approach to the pericardial cavity through an anterior diaphragmatic defect [2]. The diaphragmatic defect described by both Morgagni and Larrey is a triangular space 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. This potential space is referred to as the foramen of Morgagni or the space of Larrey. The internal mammary artery passes through this space as it becomes the superior epigastric artery with its associated vein and lymphatics [3]. Congenital defects of the diaphragm in the subcostosternal region can result in direct herniation of abdominal contents into the thoracic cavity. The hernias are referred to as foramen of Morgagni hernias, retrosternal hernias, or Larrey's hernias. Herniation of abdominal contents is typically caused by an increase in intraabdominal pressure secondary to trauma, pregnancy, or obesity [4]. The majority of Morgagni hernias are right-sided with only rare left-sided occurrences because of the protection provided by the pericardial sac.
Foramen of Morgagni hernias are rare entities in the general population; therefore, only a few clinical series are reported in the literature. Most large reports were published between 1950 to 1980 [4, 5]. In the past 20 years, new diagnostic modalities such as computed tomography (CT) scans have assisted in the evaluation of surgical diseases. In addition, less invasive surgical techniques have decreased the morbidity associated with thoracic surgery. We report our experience with the management of foramen of Morgagni hernias over the past 15 years, incorporating the use of diagnostic CT scanning and minimally invasive surgical techniques.
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Patients and methods
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We performed a retrospective chart review of patients who underwent surgical repair of foramen of Morgagni hernias at our hospital between 1987 and 2001. Patients were identified by preoperative diagnosis, surgical procedure, or pathologic specimens. Data were collected on patient demographics, presenting symptoms, modes of diagnosis, surgical procedures, and pathologic evaluation.
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Results
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Twelve patients underwent surgical repair of foramen of Morgagni hernias between 1987 and 2001. Table 1
displays the patient characteristics. The average age at diagnosis was 42 years and at treatment, 45 years. There was only 1 pediatric patient. There was a slight male predominance, and 5 of the 12 patients were obese. There was no significant history of trauma in any of our patients.
An asymptomatic diagnosis was made in 6 of the 12 patients. Among the symptomatic patients, presenting symptoms included shortness of breath, food intolerance with postprandial emesis, gastroesophageal reflux, intermittent nausea and vomiting, abdominal cramping and distention, dysphagia, and nonspecific abdominal pain. Of note, 1 patient in the series presented 3 years after asymptomatic diagnosis with acute colonic incarceration and obstruction.
All of the patients in our series had abnormal chest radiographic findings, which ranged from an unidentified density in the right cardiophrenic angle to gas-filled loops of bowel within the right chest cavity consistent with a diagnosis of foramen of Morgagni hernia. One patient had an upper gastrointestinal series performed with results diagnostic of an anterior diaphragmatic hernia containing transverse colon. Two thirds of the patients had CT scans as part of their diagnostic workup, and in all of these cases the preoperative diagnosis of foramen of Morgagni hernia was correctly made.
All hernias were right-sided and had hernia sacs. The most common contents of the hernias were omentum, followed by colon, stomach, and small bowel.
The preoperative diagnosis was a foramen of Morgagni hernia in 10 of the 12 cases and was an anterior mediastinal mass in the other 2 cases. Transabdominal surgical repair was performed in 10 of the 12 cases. In all 10 cases, the repair was carried out through an upper midline incision, followed by reduction of the hernia, and subsequent primary repair of the diaphragmatic defect with interrupted nonabsorbable mattress sutures. Two hernias were repaired laparoscopically using a polypropylene patch and a laparoscopic tacking device. Two patients with the preoperative diagnosis of an anterior mediastinal mass underwent thoracoscopic exploration during which time foramen of Morgagni hernias were diagnosed secondary to the presence of omentum in the mediastinum. In these 2 cases, subsequent hernia repair was performed by the transabdominal approach.
Postoperative complications were infrequent. There was one self-resolving pneumothorax and one incisional hernia requiring operative repair. There were no reported recurrences of foramen of Morgagni hernias based on review of the medical record including reports of all available radiographic studies performed after the operative date including chest radiographs and CT scans.
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Comment
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Foramen of Morgagni hernias account for 3% of all surgically treated diaphragmatic hernias. One of the largest previously published series is from the Mayo Clinic in 1966 in which 50 patients were treated for foramen of Morgagni hernias [5]. They reported that 70% of the patients were female, 90% of the hernias were right sided, and 92% of the hernias had hernia sacs. The most common contents of the hernia were omentum, with 60% containing transverse colon and 12% containing stomach. Only 28% of their patients were symptomatic, and the symptoms included upper abdominal discomfort, fullness, bloating, vomiting, and bouts of large bowel obstruction. The diagnosis was made by chest radiography with or without contrast gastrointestinal studies. Preoperatively, 70% of the cases were diagnosed as foramen of Morgagni hernias and were repaired through a transabdominal approach with interrupted nonabsorbable sutures. The remaining 15 cases had preoperative diagnoses of anterior mediastinal masses and were repaired through a transthoracic approach. Although successful repair can be performed transthoracically, the transabdominal approach was preferred in this series. Our series reports similar findings to the Mayo series, but raises several new issues regarding the diagnosis and the repair of foramen of Morgagni hernias.
The use of the computed tomography as a diagnostic tool in patients with foramen of Morgagni hernias has increased the reliability of preoperative diagnosis. In our series, 83% of patients were correctly diagnosed with foramen of Morgagni hernias preoperatively compared with 70% of the patients in the Mayo Clinic series. Diagnostic CT scans were performed preoperatively in 8 of our patients and correctly identified a foramen of Morgagni hernia in all of them. Computed tomography scans can help to further characterize anterior mediastinal masses that are detected on chest radiographs and aid in preoperative diagnosis and operative planning. A radiographic diagnosis of a Morgagni hernia with CT scan is defined by a large paracardiac fat density with linear densities consistent with omental blood vessels and an abnormally high location of the transverse colon [6]. A CT scan can delineate a cardiophrenic mass from the heart and will identify loops of bowel within the chest [7]. A mass with a density consistent with fat may be all that is detected on CT scan, and leads to a differential diagnosis of a Morgagni hernia containing omentum versus a lipoma or a pericardial fat pad [8]. However, the presence of fine linear or curvilinear densities within the fatty mass radiating from the parasternal aspect of the diaphragm is consistent with the presence of omental blood vessels and is strongly suggestive of a foramen of Morgagni hernia [8]. Figures 1 and 2
are representative CT images of patients with foramen of Morgagni hernias. With CT scans facilitating correct preoperative diagnosis, the surgical repair can be performed through the preferred transabdominal approach and avoid the potentially more morbid transthoracic approach.
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Fig 1. Computed tomography image of a patient with a large foramen of Morgagni hernia containing omental fat and colon. (Image obtained in electronic format from Amersham plc 2003.)
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Fig 2. Computed tomography image of a patient with a foramen of Morgagni hernia containing omental fat. The curvilinear densities within the fatty mass represent omental blood vessels, which distinguish this foramen of Morgagni hernia from a lipoma. (Image obtained in electronic format from Amersham plc 2003.)
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Traditional teaching states that repair of a foramen of Morgagni hernia is indicated immediately after diagnosis because of the risk of incarceration or strangulation of abdominal organs. In our series, 8 of the 12 patients were diagnosed with foramen of Morgagni hernias and were not referred immediately for surgical repair. Although only 1 of our patients developed an acute large bowel obstruction, delays between diagnosis and repair may account for the increased proportion of symptomatic patients seen in our series. The risk of hernia incarceration with gastrointestinal obstruction is not trivial and the surgical repair becomes more complicated as the hernia enlarges or if incarceration occurs. Therefore, we believe that prompt surgical repair is paramount in managing these hernias to avoid unnecessary patient morbidity.
In our series, thoracoscopy was used in 2 cases to further characterize ill-defined anterior mediastinal masses. This minimally invasive approach allowed for a definitive diagnosis to be made without committing the patient to a transthoracic repair. Subsequently, the preferred transabdominal approach to repair the hernia was performed with a minimal overall increase in morbidity. Also in our series, 2 of the patients' hernias were repaired laparoscopically using a polypropylene mesh patch to close the defect. The development of minimally invasive thoracoscopic and laparoscopic techniques have decreased the morbidity of many surgical procedures. These techniques are being applied to more and more surgical procedures as experience with them builds, and they are now being used to treat Morgagni hernias. There are case reports of both thoracoscopic [9] and laparoscopic surgical repair of foramen of Morgagni hernias employing primary closure [10–12] and patch repair [13–15] techniques with successful long-term outcomes. These minimally invasive surgical technologies are being used to both diagnose and repair Morgagni hernias and with more experience, they may replace the more traditional open transabdominal approach as the preferred method of repair.
In conclusion, a foramen of Morgagni hernia is a rare surgical disease. Patients are usually asymptomatic and present with an anterior mediastinal mass on chest radiographs. The preoperative diagnosis of these hernias may be aided by the use of CT scans. Once diagnosed, these hernias should be referred for surgical repair. The transabdominal approach with interrupted nonabsorbable sutures remains the preferred method of repair. However, laparoscopic and thoracoscopic surgical techniques offer innovative approaches to the management of this disease.
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References
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- Morgagni G. Seats and causes of diseases. In: Candell AMaT, ed. London: 1769:205
- Larrey D. De plaies du pericarde et du coeur clinique chirugicale. In: Gubon P, ed. Paris: 1828:284
- LoCicero J., Pom R. Foramen of Morgagni hernia. In: Shields T., ed. General thoracic surgery. Philadelphia: Lippincott Williams & Wilkins, 2000:647-650.
- Thomas T.V. Subcostosternal diaphragmatic hernia. J Thorac Cardiovasc Surg 1972;63:279-283.[Medline]
- Comer T.P., Clagett O.T. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-468.[Medline]
- Fagelman D., Caridi J.G. CT diagnosis of hernia of Morgagni. Gastrointest Radiol 1984;9:153-155.[Medline]
- Yildirim B., Ozaras R., Tahan V., Artis T. Diaphragmatic Morgagni hernia in adulthood: correct preoperative diagnosis is possible with newer imaging techniques. Acta Chir Belg 2000;100:31-33.[Medline]
- Sutro W.H., King S.J. Computed tomography of Morgagni hernia. NY State J Med 1987;87:520-521.
- Hussong R.L., Jr, Landreneau R.J., Cole F.H., Jr Diagnosis and repair of a Morgagni hernia with video-assisted thoracic surgery. Ann Thorac Surg 1997;63:1474-1475.[Abstract/Free Full Text]
- Angrisani L., Lorenzo M., Santoro T., Sodano A., Tesauro B. Hernia of foramen of Morgagni in adult: case report of laparoscopic repair. J Surg Laparosc Surg 2000;4:177-181.
- Greca G., Fisichella P., Greco L., et al. A new simple laparoscopic-extracorporeal technique for the repair of a Morgagni diaphragmatic hernia. Surg Endosc 2001;15:99.
- Orita M., Okino M., Yamashita K., Morita N., Esato K. Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni. Surg Endosc 1997;11:668-670.[Medline]
- Huntington T.R. Laparoscopic transabdominal preperitoneal repair of a hernia of Morgagni. J Laparoendosc Surg 1996;6:131-133.[Medline]
- Vanclooster P., Lefevre A., Nijs S., de Gheldere C. Laparoscopic repair of a Morgagni hernia. Acta Chir Belg 1997;97:84-85.[Medline]
- Rau H.G., Schardey H.M., Lange V. Laparoscopic repair of a Morgagni hernia. Surg Endosc 1994;8:1439-1442.[Medline]
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Abstract
Introduction
