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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic repair of Morgagni hernia with composite mesh in an elderly woman: Report of a case Masahito Ikarashi,1 Minoru Matsuda,1 Isao Murayama,2 Masashi Fujii1 & Tadatoshi Takayama1 1 Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan 2 Department of Surgery, Sonoda Daiichi Hospital, Tokyo, Japan
Keywords Composite mesh; laparoscopic repair; Morgagni hernia Correspondence Masahito Ikarashi, Department of Digestive Surgery, Nihon University School of Medicine, 1-8-13 Kandasurugadai, Chiyoda-ku, 101-8309 Japan. Tel: +81 3 3293 1711 Fax: +81 3 3292 2880 Email: [email protected]
Abstract A 78-year-old woman was admitted to another hospital with vomiting. Chest X-ray showed an abnormal shadow in the lower right lung field, and CT indicated a Morgagni hernia containing the stomach and transverse colon. The patient was transferred to our hospital and underwent laparoscopic surgery. After the hernia contents were repositioned into the abdominal cavity, we repaired the hernia orifice with a prosthetic mesh to achieve a tension-free repair. There were no complications after the surgery, and there has been no recurrence. The patient has remained free of clinical symptoms since 10 months after the surgery. Laparoscopic repair with a prosthetic mesh for Morgagni hernia is a simple and safety procedure for elderly patients.
Received 16 July 2014; revised 10 September 2014; accepted 24 October 2014 DOI:10.1111/ases.12161
Introduction Morgagni hernia (MH) is a rare type of congenital diaphragmatic hernia that was first reported by Giovanni Morgagni in 1769. An MH involves an abdominal organ escaping through a triangular space behind the sternum into the right thoracic cavity. Various symptoms occur in MH, including pulmonary, gastrointestinal, and cardiovascular symptoms, but 28% of patients have been found to be asymptomatic (1). Surgery should be considered for MH because of the risks of incarceration, strangulation, and pulmonary complication. Laparoscopic surgery has been increasingly employed for MH in recent years because it offers a better postoperative course, fewer complications, and a shorter postoperative stay than open procedures. Herein, we report our experience with a safe and easy laparoscopic repair using a composite mesh in an elderly woman. We also include a review of the literature.
Case Presentation A 78-year-old woman underwent an orthopedic operation in another hospital and thereafter complained of
216
vomiting every 3 days. Chest X-ray showed an abnormal shadow in the lower right lung field. CT revealed the MH findings (Figure 1). The hernia contents were the stomach and transverse colon, but neither had been strangulated or incarcerated. The patient was transferred to our hospital for elective surgery. Preoperative examination revealed a mild pulmonary disorder (%vital capacity, 71.8; forced expiratory volume in 1%, 59.26) and right-side hemiplegia caused by past right thalamic hemorrhage. We chose laparoscopic surgery for the procedure because of its minimal invasiveness. The patient was placed in the supine position, and the operating surgeon was positioned on her left side. A 12-mm trocar was placed below the umbilicus by Hasson’s technique, and pneumoperitoneum was maintained at 10 mmHg. We used a 10-mm flexible scope. One 5-mm trocar was placed at the right hypochondrium and another in the upper right quadrant; a 12-mm trocar was then inserted in the upper left quadrant. The operating table was placed in a slightly head-up position. The operative findings indicated that the transverse colon was adhered to the hernia sac without incarceration (Figure 2). After adhesiolysis, the colon was
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Morgagni hernia in an elderly woman
M Ikarashi et al.
Figure 3 Full-thickness transabdominal suture for reinforcement.
Figure 1 Barium enema shows the transverse colon incarceration into the right chest (arrows indicate the hernia orifice).
Figure 4 CT shows the accumulation of gases and liquids in the hernia sac on postoperative day 7.
Figure 2 The transverse colon and omentum were adhered to the hernia sac.
repositioned into the abdominal cavity. The hernia sac was large and severely adhered to the thoracic cavity. Because we believed there were some risks of complication, a hernia sac excision was not performed. The hernia orifice was approximately 8 × 5 cm, so we considered the primary suture to be difficult. Therefore, we repaired the hernia orifice with a prosthetic mesh (Bard Composix mesh®, Bard, Murray Hill, USA) to achieve a tension-free repair. Bard Composix mesh is made of low-profile polypropylene; expanded polytetrafluoroethylene is bonded to the abdominal side to prevent adhesions. The mesh was fixed to the diaphragm with a hernia stapler
(AbsorbaTack™, Covidien, Mansfield, USA). The mesh had at least a 2-cm overlap margin around the orifice’s entire circumference. Finally, two full-thickness transabdominal sutures were added at the anterior abdominal wall for reinforcement (Figure 3). The operative time was 53 min, and there was little blood loss. After surgery, the patient’s chief complaint disappeared, and no complications were observed. She was transferred to rehabilitation on postoperative day 26. CT demonstrated an accumulation of gases and liquids in the hernia sac on postoperative day 7 (Figure 4), but 10 months after surgery, the hernia sac was completely collapsed on chest X-ray and CT findings. Since then, she has had no recurrence or clinical symptoms.
Discussion Congenital diaphragmatic hernia occurs in 1/2000 to 1/5000 of live births. MH is rare and accounts for 2%–3%
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
217
Morgagni hernia in an elderly woman
M Ikarashi et al.
of congenital diaphragmatic hernias (2,3). Because of its congenital nature, MH is often considered to be a pediatric condition (1). Some cases have been associated with Down syndrome or other congenital anomalies in children (4). There have also been many reports and reviews of adult MH. Surgical treatment is required for MH because of the risk of incarceration of the abdominal organs (5). Kuster et al. reported the first laparoscopic repair in 1992 (6), and recently, reports of laparoscopic surgery have increased. We searched the English-language literature using PubMed and Google to find reports of laparoscopic repair for adult MH. Keywords used were “Morgagni hernia,” “hernia of Morgagni,” “foramen of Morgagni,” “retrosternal hernia,” “laparoscopy,” and “adult.” The literature collected was reported between December 2006 and January 2014, as Horton et al. reported a review of 298 adult MH cases that occurred from 1951 to November 2006 (1). In their review, 62% of patients were women. Most patients (72%) presented with herniarelated symptoms, and pulmonary complaints were the most common (36%). Thoracotomy was done in 49%, and the laparoscopic approach was used in 17%. Laparoscopic surgery achieved a lower complication rate (5%) and the shortest hospital stay (3 days). In our search, we found 38 case reports with 56 patients. Subjects include 21 men and 28 women; sex was not specified in 7 cases. The average age was 54 years old (range, 18–89 years). Pulmonary, gastrointestinal, and cardiovascular symptoms were observed in 18, 26 and 4 patients, respectively, and 5 patients were asymptomatic. Diagnostic methods were mainly chest X-ray (n = 38) and CT (n = 42). Hernia contents were transverse colon (n = 32), stomach (n = 18), omentum (n = 25), and small intestine (n = 12). Simple closure of the hernia orifice was performed in 24 patients, and 37 cases employed tension-free methods using a prosthetic mesh. Simple closure was selected for small hernia orifices, and tension-free repair was often selected for large orifices (20–30 cm2) (7). In our case, the hernia orifice was about 40 cm2, and we believed that tension-free repair was required for safe, easy, and secure surgery. The reports in our search indicated that the hernia sac was excised in 11 cases and not excised in 27 cases; 18 cases did not provide information on hernia sac excision. In laparoscopic surgery, dissection of hernia contents is relatively easy, but resection of the hernia sac is difficult because surgeons are unable to observe the thoracic cavity. Therefore, hernia sac excision involves a risk of pneumomediastinum and pneumothorax. Horton et al. reported that the hernia sac was excised in only 31% of
218
laparoscopic procedures (1). Loong and Kocher also reported similar results (5). Several reports have indicated that liquid remaining in the hernia sac remained for more than a year after surgery (8,9). However, there was no report of complications caused by a residual hernia sac. Our case also showed fluid in the hernia sac on postoperative day 7, but 10 months later, it disappeared. Regardless, it remains controversial whether the hernia sac should be excised in laparoscopic surgery. We believe that it is necessary to judge based on the adhesion of the sac and the general condition of patient. Further evaluation is required, but laparoscopic repair with a prosthetic mesh for MH is likely to become a first-line procedure.
Acknowledgment The authors have no conflicts of interest to declare. T.T was mainly supported by a Grant-in-Aid for Scientific Research (A) 24249068 from the Ministry of Education, Culture, Sports, Science and Technology, Japan.
References 1. Horton JD, Hofmann LJ, Hetz SP. Presentation and management of Morgagni hernias in adults: A review of 298 cases. Surg Endosc 2008; 22: 1413–1420. 2. Harrington SW. Clinical manifestations and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenterol 1951; 18: 243–256. 3. Comer TP & Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966; 52: 461– 468. 4. Jetley NK, Al-Assiri AH, Al-Helal AS et al. Down’s syndrome as a factor in the diagnosis, management, and outcome in patients of Morgagni hernia. J Pediatr Surg 2011; 46: 636– 639. 5. Loong TP & Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005; 81: 41–44. 6. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: Laparoscopic repair case report. J Laparoendosc Surg 1992; 2: 93–100. 7. Palanivelu C, Rangarajan M, Rajapandian S et al. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: A retrospective study. Surg Endosc 2009; 23: 978–985. 8. Contini S, Dalla VR, Bonati L et al. Laparoscopic repair of a Morgagni hernia: Report of a case and review of the literature. J Laparoendosc Adv Surg Tech A 1999; 9: 93–99. 9. Matsui H, Itano O, Igarashi N et al. Laparoscopic compositemesh repair of an adult Morgagni. Dig Endosc 2007; 9: 185– 188.
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Laparoscopic repair of Morgagni hernia with composite mesh in an elderly woman: Report of a case Masahito Ikarashi,1 Minoru Matsuda,1 Isao Murayama,2 Masashi Fujii1 & Tadatoshi Takayama1 1 Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan 2 Department of Surgery, Sonoda Daiichi Hospital, Tokyo, Japan
Keywords Composite mesh; laparoscopic repair; Morgagni hernia Correspondence Masahito Ikarashi, Department of Digestive Surgery, Nihon University School of Medicine, 1-8-13 Kandasurugadai, Chiyoda-ku, 101-8309 Japan. Tel: +81 3 3293 1711 Fax: +81 3 3292 2880 Email: [email protected]
Abstract A 78-year-old woman was admitted to another hospital with vomiting. Chest X-ray showed an abnormal shadow in the lower right lung field, and CT indicated a Morgagni hernia containing the stomach and transverse colon. The patient was transferred to our hospital and underwent laparoscopic surgery. After the hernia contents were repositioned into the abdominal cavity, we repaired the hernia orifice with a prosthetic mesh to achieve a tension-free repair. There were no complications after the surgery, and there has been no recurrence. The patient has remained free of clinical symptoms since 10 months after the surgery. Laparoscopic repair with a prosthetic mesh for Morgagni hernia is a simple and safety procedure for elderly patients.
Received 16 July 2014; revised 10 September 2014; accepted 24 October 2014 DOI:10.1111/ases.12161
Introduction Morgagni hernia (MH) is a rare type of congenital diaphragmatic hernia that was first reported by Giovanni Morgagni in 1769. An MH involves an abdominal organ escaping through a triangular space behind the sternum into the right thoracic cavity. Various symptoms occur in MH, including pulmonary, gastrointestinal, and cardiovascular symptoms, but 28% of patients have been found to be asymptomatic (1). Surgery should be considered for MH because of the risks of incarceration, strangulation, and pulmonary complication. Laparoscopic surgery has been increasingly employed for MH in recent years because it offers a better postoperative course, fewer complications, and a shorter postoperative stay than open procedures. Herein, we report our experience with a safe and easy laparoscopic repair using a composite mesh in an elderly woman. We also include a review of the literature.
Case Presentation A 78-year-old woman underwent an orthopedic operation in another hospital and thereafter complained of
216
vomiting every 3 days. Chest X-ray showed an abnormal shadow in the lower right lung field. CT revealed the MH findings (Figure 1). The hernia contents were the stomach and transverse colon, but neither had been strangulated or incarcerated. The patient was transferred to our hospital for elective surgery. Preoperative examination revealed a mild pulmonary disorder (%vital capacity, 71.8; forced expiratory volume in 1%, 59.26) and right-side hemiplegia caused by past right thalamic hemorrhage. We chose laparoscopic surgery for the procedure because of its minimal invasiveness. The patient was placed in the supine position, and the operating surgeon was positioned on her left side. A 12-mm trocar was placed below the umbilicus by Hasson’s technique, and pneumoperitoneum was maintained at 10 mmHg. We used a 10-mm flexible scope. One 5-mm trocar was placed at the right hypochondrium and another in the upper right quadrant; a 12-mm trocar was then inserted in the upper left quadrant. The operating table was placed in a slightly head-up position. The operative findings indicated that the transverse colon was adhered to the hernia sac without incarceration (Figure 2). After adhesiolysis, the colon was
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
Morgagni hernia in an elderly woman
M Ikarashi et al.
Figure 3 Full-thickness transabdominal suture for reinforcement.
Figure 1 Barium enema shows the transverse colon incarceration into the right chest (arrows indicate the hernia orifice).
Figure 4 CT shows the accumulation of gases and liquids in the hernia sac on postoperative day 7.
Figure 2 The transverse colon and omentum were adhered to the hernia sac.
repositioned into the abdominal cavity. The hernia sac was large and severely adhered to the thoracic cavity. Because we believed there were some risks of complication, a hernia sac excision was not performed. The hernia orifice was approximately 8 × 5 cm, so we considered the primary suture to be difficult. Therefore, we repaired the hernia orifice with a prosthetic mesh (Bard Composix mesh®, Bard, Murray Hill, USA) to achieve a tension-free repair. Bard Composix mesh is made of low-profile polypropylene; expanded polytetrafluoroethylene is bonded to the abdominal side to prevent adhesions. The mesh was fixed to the diaphragm with a hernia stapler
(AbsorbaTack™, Covidien, Mansfield, USA). The mesh had at least a 2-cm overlap margin around the orifice’s entire circumference. Finally, two full-thickness transabdominal sutures were added at the anterior abdominal wall for reinforcement (Figure 3). The operative time was 53 min, and there was little blood loss. After surgery, the patient’s chief complaint disappeared, and no complications were observed. She was transferred to rehabilitation on postoperative day 26. CT demonstrated an accumulation of gases and liquids in the hernia sac on postoperative day 7 (Figure 4), but 10 months after surgery, the hernia sac was completely collapsed on chest X-ray and CT findings. Since then, she has had no recurrence or clinical symptoms.
Discussion Congenital diaphragmatic hernia occurs in 1/2000 to 1/5000 of live births. MH is rare and accounts for 2%–3%
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
217
Morgagni hernia in an elderly woman
M Ikarashi et al.
of congenital diaphragmatic hernias (2,3). Because of its congenital nature, MH is often considered to be a pediatric condition (1). Some cases have been associated with Down syndrome or other congenital anomalies in children (4). There have also been many reports and reviews of adult MH. Surgical treatment is required for MH because of the risk of incarceration of the abdominal organs (5). Kuster et al. reported the first laparoscopic repair in 1992 (6), and recently, reports of laparoscopic surgery have increased. We searched the English-language literature using PubMed and Google to find reports of laparoscopic repair for adult MH. Keywords used were “Morgagni hernia,” “hernia of Morgagni,” “foramen of Morgagni,” “retrosternal hernia,” “laparoscopy,” and “adult.” The literature collected was reported between December 2006 and January 2014, as Horton et al. reported a review of 298 adult MH cases that occurred from 1951 to November 2006 (1). In their review, 62% of patients were women. Most patients (72%) presented with herniarelated symptoms, and pulmonary complaints were the most common (36%). Thoracotomy was done in 49%, and the laparoscopic approach was used in 17%. Laparoscopic surgery achieved a lower complication rate (5%) and the shortest hospital stay (3 days). In our search, we found 38 case reports with 56 patients. Subjects include 21 men and 28 women; sex was not specified in 7 cases. The average age was 54 years old (range, 18–89 years). Pulmonary, gastrointestinal, and cardiovascular symptoms were observed in 18, 26 and 4 patients, respectively, and 5 patients were asymptomatic. Diagnostic methods were mainly chest X-ray (n = 38) and CT (n = 42). Hernia contents were transverse colon (n = 32), stomach (n = 18), omentum (n = 25), and small intestine (n = 12). Simple closure of the hernia orifice was performed in 24 patients, and 37 cases employed tension-free methods using a prosthetic mesh. Simple closure was selected for small hernia orifices, and tension-free repair was often selected for large orifices (20–30 cm2) (7). In our case, the hernia orifice was about 40 cm2, and we believed that tension-free repair was required for safe, easy, and secure surgery. The reports in our search indicated that the hernia sac was excised in 11 cases and not excised in 27 cases; 18 cases did not provide information on hernia sac excision. In laparoscopic surgery, dissection of hernia contents is relatively easy, but resection of the hernia sac is difficult because surgeons are unable to observe the thoracic cavity. Therefore, hernia sac excision involves a risk of pneumomediastinum and pneumothorax. Horton et al. reported that the hernia sac was excised in only 31% of
218
laparoscopic procedures (1). Loong and Kocher also reported similar results (5). Several reports have indicated that liquid remaining in the hernia sac remained for more than a year after surgery (8,9). However, there was no report of complications caused by a residual hernia sac. Our case also showed fluid in the hernia sac on postoperative day 7, but 10 months later, it disappeared. Regardless, it remains controversial whether the hernia sac should be excised in laparoscopic surgery. We believe that it is necessary to judge based on the adhesion of the sac and the general condition of patient. Further evaluation is required, but laparoscopic repair with a prosthetic mesh for MH is likely to become a first-line procedure.
Acknowledgment The authors have no conflicts of interest to declare. T.T was mainly supported by a Grant-in-Aid for Scientific Research (A) 24249068 from the Ministry of Education, Culture, Sports, Science and Technology, Japan.
References 1. Horton JD, Hofmann LJ, Hetz SP. Presentation and management of Morgagni hernias in adults: A review of 298 cases. Surg Endosc 2008; 22: 1413–1420. 2. Harrington SW. Clinical manifestations and surgical treatment of congenital types of diaphragmatic hernia. Rev Gastroenterol 1951; 18: 243–256. 3. Comer TP & Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966; 52: 461– 468. 4. Jetley NK, Al-Assiri AH, Al-Helal AS et al. Down’s syndrome as a factor in the diagnosis, management, and outcome in patients of Morgagni hernia. J Pediatr Surg 2011; 46: 636– 639. 5. Loong TP & Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005; 81: 41–44. 6. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: Laparoscopic repair case report. J Laparoendosc Surg 1992; 2: 93–100. 7. Palanivelu C, Rangarajan M, Rajapandian S et al. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: A retrospective study. Surg Endosc 2009; 23: 978–985. 8. Contini S, Dalla VR, Bonati L et al. Laparoscopic repair of a Morgagni hernia: Report of a case and review of the literature. J Laparoendosc Adv Surg Tech A 1999; 9: 93–99. 9. Matsui H, Itano O, Igarashi N et al. Laparoscopic compositemesh repair of an adult Morgagni. Dig Endosc 2007; 9: 185– 188.
Asian J Endosc Surg 8 (2015) 216–218 © 2015 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.
