Congenital hernia through the foramen of Morgagni (a case report).
This is the case report of a hernia through the foramen of Morgagni, a tare congenital entity; the reported incidence being less than 5% of all the diaphragmatic hernia,.
Mr. H. S., a 62 year old male was treated in a private nursing home for vomiting, which were copious, about one and a half litre, watery, mixed with previously ingested food and painless. He was diagnosed on barium meal study as a case of volvulus of stomach, and was treated conservatively. His symptoms subsided. He had no complaints on admission to this hospital on 12th August 1988. On interrogation, a history of two epigastric swellings since childhood was obtained. The swellings were noticeable but were easily reducible without causing any problems. Presence of left inguinal hernia was also noticed since past few months.
No abnormality was detected on general examination. Systemic examination revealed symmetrical chest with diminished expansion and air entry on the right lower aspect and tympanic percussion note. Upper border of the liver dullness was quite low, just one finger above the costal margin.
Two epigastric partially irreducible hernias and a grossly palpable liver occupying almost two-thirds of right side of abdomen were noticed on abdominal examination. There was an indirect inguinal hernia on the left side.
X-rays of chest and upper half of abdomen showed raised, ill-defined right dome of diaphragm and ptotic liver. Multiple cystic lesions and two fluid levels interposed between the diaphragm and liver. (Chiliaditi's sign) (See [Figure - 1]
Barium meal follow through revealed rotation of stomach along both of its axes. (See [Figure - 2]). Distal jejunal loops and ileum were found to be located in the right upper quadrant. Trendelenburg's position showed the bowel loops occupying right thoracic cavity upto the clavicle. (See [Figure - 3]). Ultrasonogram of the abdomen was normal except for ptotic liver and malpositioned normal kidney. Oesophago-gastro-duodenoscopy showed peculiar shape of stomach. Routine investigations were within normal limits except electrocardiogram which showed anterolateral ischemia and stress test revealed poor effort tolerance and ST depression at peak of exercise.
Patient was operated upon on 23rd August 1988. He was given an oblique position, with right side tilted up by 450. Laparotomy done by midline incision revealed macroscopically normal but descended liver in right lumbar region and, lax falciform ligament. The omentum was adherent to the sac of epigastric hernia and was excised. Almost the complete length of small bowel except proximal jejunum was herniating through the right retrocostosternal diaphragmatic defect. During the reduction of these loops, patient developed transient hypotension. Only partial reduction was possible because of intrathoracic adhesions. Hence a separate right thoracotomy through the bed of 8th rib was performed. (See [Figure - 4]). The bare loops of intestine were adherent to pleura and pericardium. After adhesiolysis the contents were pulled down. The diaphragmatic defect was also found on left side and both the defects were confirmed to be the foramens of Morgagni. Right defect measured 6 cm in diameter and sac was devoid of fundus, whereas left defect was 3 cm deep and 5 cm in diameter at the neck and had no contents. Both the defects were obliterated by interrupted polypropylene No. 1 sutures.
The falciform ligament, lesser omentum, Treitz's ligament were lax. Gall bladder had mesentery. The cecum, ascending colon and right kidney were mobile. Fixation of these organs was considered inadvisable.
Postoperatively patient had persistent tachycardia in spite of satisfactory PO2 on respirator. PCO2 was 47.3 min of Hg in spite of metabolic acidosis. CVP was 3 cm of water, which did not respond to intravenous fluid. Clinically patient had poor air entry, which we thought to be because of hypokalemia (2.4 mEq/L) related to respiratory muscle weakness, which responded to the correction of serum potassium. Swan Ganz hemodynamic monitoring revealed right atrial pressure of 2 man of Hg, pulmonary capillary wedge pressure of 13 min of Hg, very low cardiac output (2.7 Lit/min) and extremely low stroke volume (19.38 ml/beat). Patient was digitalised and put on dobutamine. Subsequently stroke volume improved and patient made uneventful recovery.
Barium meal study on 12th post-operative day did not reveal significant abnormality.
The Morgagni's hernia is more commonly encountered on the right side, as pericardial attachment to the diaphragm is more extensive on the left side. Bilateral defects, as in present case, are quite uncommon. The sac may occasionally be absent,,. The common contents of the hernia of Morgagni are nearby structures like omentum, colon, stomach, liver or small bowel. An expensive herniation as in our case is frequently found in Bochdalek's hernia, but is rare in Morgagni's hernia.
The defect is usually asymptomatic and encountered either later in life, most commonly after the age of 40 or after an increase in intrabdominal pressure, secondary to trauma or obesity. Symptoms are related usually to the obstruction of herniated organ, but secondary volvulus of the stomach, is a rarity as in this case.
The hepatodiaphragmatic interposition of bowel (Chiliaditi's sign/syndrome), is not yet described in association with the diaphragmatic hernia. The factors responsible for the Chiliaditi's sign in the present case, may be associated hepatoptosis, lax falciform ligament, and unusual mobility of otherwise fixed bowel. Barium study was helpful in evaluating the cause of volvulus of stomach, Chiliaditi's sign and establishing the diagnosis of diaphragmatic hernia.
Because of the potential for continuous enlargement with time, repair is usually recommended in this type of diaphragmatic hernia, even if it is asymptomatic.
The authors wish to thank Dr. KL Kapur, the Medical Director, Sir HN Hospital, Mumbai, for allowing publication of this case.