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Ann Thorac Surg 1997;63:1474-1475
© 1997 The Society of Thoracic Surgeons

Case Report

Diagnosis and Repair of a Morgagni Hernia With Video-Assisted Thoracic Surgery

Richard L. Hussong, Jr, MD, Rodney J. Landreneau, MD, F. Hammond Cole, Jr, MD

Department of Surgery, The University of Tennessee-Memphis Center for the Health Sciences, Methodist Hospitals of Memphis, Memphis, Tennessee

Accepted for publication December 12, 1996.


   Abstract
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Introduction
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Foramen of Morgagni hernias have traditionally been repaired by either an abdominal or a transthoracic approach. We describe a case in which a Morgagni hernia that presented as a gradually enlarging right anterior pericardiophrenic mass was both diagnosed and repaired using video-assisted thoracic surgery. The procedure went without incident, and the patient had an uneventful postoperative course. The video-assisted thoracic surgical repair can be a safe and effective way to fix a Morgagni hernia.


   Introduction
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 Introduction
Comment
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Morgagni hernias are rare congenital herniations through the retrosternal diaphragm that account for 3% of all surgically repaired diaphragmatic hernias [1]. Usually asymptomatic, they are discovered incidentally on routine chest roentgenograms as slowly enlarging, right-sided cardiophrenic angle masses [1, 2]. Repair is indicated because of the risk of visceral strangulation [1]. We report a case in which we diagnosed and repaired a Morgagni hernia using video-assisted thoracic surgery (VATS).

The patient is a 56-year-old woman referred for an asymptomatic right cardiophrenic angle mass that had steadily increased in size on serial chest roentgenograms from 1991 to 1995 (Figs 1, 2GoGo). A computed tomogram of the chest revealed the mass to have a density consistent with fat and to be in the retrosternal position (Fig 3Go). Because of the progressive increase in the size of the mass, the patient was prepared for VATS exploration of the right chest and possible thoracotomy.



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  		Fig 1. . Anteroposterior chest roentgenogram showing the right cardiophrenic angle density as it appeared in 1991.

 


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  		Fig 2. . Preoperative anteroposterior chest roentgenogram demonstrating the increase in the size of the hernia by 1995.

 


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  		Fig 3. . Preoperative computed tomogram of the chest showing the homogeneous fatty mass in its retrosternal and pericardial location.

 
At operation the patient underwent general endobronchial anesthesia using a double-lumen tube. The camera was inserted through a 15-mm flexible port placed in the sixth intercostal space. A fatty mass measuring 9 x 7 x 2.5 cm was found in the cardiophrenic angle. Two additional working ports were placed for the insertion of dissecting instruments, which were used to free the mass from surrounding structures. Dissection revealed a hernia sac protruding through a 2-cm retrosternal diaphragmatic defect. The sac was entered and found to be free of viscera and adhesions, so it was divided with a stapling instrument and left to retract below the diaphragm (Fig 4Go). The diaphragmatic defect was corrected by reapproximating the diaphragmatic edge to the retrosternal tissue using several interrupted sutures, which were tied extracorporally through the ports. A 20F chest tube was positioned in the apex via one of the operative ports, and the two remaining port incisions were closed in the usual fashion.



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  		Fig 4. . View from the thoracoscope showing the fatty contents of the hernia sac after it was entered. The heart is in the lower left, and the diaphragm is in the lower right corner.

 
The patient had an uneventful postoperative course except for a mild ileus. Her chest tube was removed on postoperative day 3, and she was discharged home the following day. One year later she is doing well without any radiographic evidence of recurrence.


   Comment
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 Introduction
 Comment
References
 
Conventionally the Morgagni hernia has been repaired through a celiotomy or a thoracotomy, with celiotomy preferred when the hernia is diagnosed preoperatively [1]. If encountered through a thoracotomy, they may be repaired transthoracically [1].

With the advent of endoscopic surgery, repairs using the laparoscope have been described and praised as equally safe and effective but less morbid than the open technique [2–6]. Recently VATS repair of a Bochdalek hernia has been described [7]. In another report a Morgagni hernia was repaired using VATS but only after the addition of a minithoracotomy incision.

Video-assisted thoracic surgery offers several advantages when compared with thoracotomy. First, it is less morbid than open thoracotomy or celiotomy, especially when the procedure is being performed for diagnostic purposes. The controlled pneumothorax employed avoids the risk of tension pneumothorax and pneumomediastinum, which may complicate laparoscopy [2, 3]. We cannot advocate this approach as a preferred method of repair until it has been proved efficacious. However, we do believe this case demonstrates that a safe repair can be performed, especially when VATS has been employed to diagnose a right pericardiophrenic angle mass and a Morgagni hernia is encountered.


   Footnotes
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Address reprint requests to Dr Cole, 1325 Eastmoreland Dr, Suite 310, Memphis, TN 38104.


   References
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 Introduction
 Comment
 References
 

  1. Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461–8.[Medline]
  2. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair case report. J Laparoendosc Surg 1992;2:93–100.[Medline]
  3. Campos LI, Sipes EK. Brief clinical report: laparoscopic repair of diaphragmatic hernia. J Laparoendosc Surg 1991;1:369–73.[Medline]
  4. Newman L, Eubanks S, Bridges WM, Lucas G. Laparoscopic diagnosis and treatment of Morgagni hernia. Surg Laparosc Endosc 1995;5:27–31.[Medline]
  5. Smith J, Ghani A. Morgagni hernia: incidental repair during laparoscopic cholecystectomy. J Laparoendosc Surg 1995;5:123–5.[Medline]
  6. Akamine S, Kawahara K, Nakamura A, et al. Successful utilization of a video-assisted thoracic approach to repair Morgagni's hernia: report of a case. Jpn J Surg 1995;25:654–6.
  7. Silen ML, Canvasser DA, Kurkchubasche AG, Andrus CH, Naunheim KS. Video-assisted thoracic surgical repair of a foramen of Bochdalek hernia. Ann Thorac Surg 1995;60:448–50.[Abstract/Free Full Text]



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This Article
Right arrow Abstract Freely available
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Right arrow Email this article to a friend
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Rodney J. Landreneau
F. Hammond Cole, Jr
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Right arrow Articles by Hussong, R. L.
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Right arrow PubMed Citation
Right arrow Articles by Hussong, R. L., Jr
Right arrow Articles by Cole, F. H., Jr

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