Laparoscopic repair of Morgagni hernia by artificial pericardium patch in an adult obese patient

Background

Morgagni hernia is a kind of rare congenital diaphragmatic hernia. We reported a case of Morgagni hernia repaired successfully with artificial pericardium patch via the laparoscopic approach.

Methods

The patient was admitted with a 3-month history of postprandial nausea and vomiting, and accompanied by epigastric pain. Computed tomography (CT) scans showed a large anteromedial diaphragmatic hernia. The hernial contents were reduced back into the abdominal cavity and the diaphragmatic defect was repaired with artificial pericardium patch by laparoscopic intracorporeal suture.

Results

We achieved satisfactory intracorporeal repair of this large diaphragmatic defect. The patient had excellent recovery and started on oral diet on the first postoperative day, and then was discharged just two days after operation.

Conclusions

The minimally invasive advantage of laparoscopic approach offers a secure, reliable and satisfactory way to confirm the diagnosis and achieve the repair of non-complicated Morgagni hernia.     

Laparoscopic paraesophageal hernia repair: quality of life outcomes in the elderly

Paraesophageal hernias (PEH) occur when there is herniation of the stomach through a dilated hiatal aperture. These hernias occur more commonly in the elderly, who are often not offered surgery despite the failure of medical treatment to address mechanical symptoms and life‐threatening complications. The aim of this study was to assess the impact of laparoscopic repair of PEH on quality of life in an elderly population. Data were collected prospectively on 35 consecutive patients aged >70 years who had laparoscopic repair of a symptomatic PEH between December 2001 and September 2005. The change in quality of life was assessed using a validated questionnaire, the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), and by patient interviews. Patients were assessed preoperatively, and at 6 weeks, 6 months, 12 months, 1 year, and 2 years postoperatively. Mean patient age was 77 years (range 70–85); mean American Society of Anesthesiologists class was 2.7 (range 1–3). There were 28 women and 7 men. There was one readmission for acute reherniation, which required open revision. Total complication rate was 17.1%. All complications were treated without residual disability. There was no 30‐day mortality, and median hospital stay was 3 days (range 2–14). Completed questionnaires were obtained in 30 of 35 patients (85.7%). There was a significant improvement in quality of life, as measured with QOLRAD, at all postoperative time points (P < 0.001). Laparoscopic PEH repair can be performed with acceptable morbidity in symptomatic patients refractory to conservative treatment and is associated with a significant improvement in quality of life. Our data support elective repair of symptomatic PEH in the elderly, a population who may not always be referred for a surgical opinion.     

A huge Morgagni hernia with compression of the right ventricle

A 21 year old male with no relevant medical history presented to our Institution for further assessments of a right paracardiac mass founded on a chest X-ray. Chest computed tomography revealed a wide median defect of the diaphragm at the level of xiphoid process of the sternum, with the herniation of omental fat tissue in the mediastinum. Cardiac magnetic resonance confirmed the presence of a huge hernia originating from the foramen of Morgagni (sterno-costal hiatus), displacing the heart leftwards and posteriorly and compressing the right ventricle (RV), giving to it a tubular shape.The signal characteristics were typical of fat tissue, with hyperintense signal in T1 and T2 weighted black blood images and homogeneus signal suppression on STIR T2 black blood images. Short axis real time cine images, performed during deep inspiration, showed an early diastolic ventricular septal bounce, with flattening of the interventricular septum during mid-late diastole: they represented signs of diastolic dysfunction of the right ventricle, resembling a sort of “pseudo-constrictive” pathophysiological model. The patient was thus referred to surgical repair of the diaphragmatic defect.     

Simple suture or prosthesis hiatal closure in laparoscopic repair of paraesophageal hernia: a retrospective cohort study

Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1‐year postoperative follow‐up, were included in the study. Pre‐ and postoperative testing included symptom questionnaires, barium esophagogram, pH‐monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty‐eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.     

Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes

SUMMARY.   The choice of the optimal surgical approach for repairing paraesophaeal hernias (PEH) is debated. Our objective is to evaluate the short-term outcomes of primary laparoscopic and open repairs of PEH performed in the Calgary Health Region. A retrospective review of all patients undergoing repair of PEH between October 1999 and February 2005 was performed. The outcome measures evaluated included intra-operative parameters and post-operative variables, mortality rates, recurrence rates and patient satisfaction. A total of 93 patients underwent either a laparoscopic ( n  = 46) or open ( n  = 47) primary PEH repair. The laparoscopic approach was associated with a longer mean operative time (3.1 ± 1.2 hours vs. 2.5 ± 0.7 hours, P  = 0.005) but resulted in a shorter overall hospital stay (5 days [2–16 days] vs. 10 days [5–24 days]; P  < 0.001), and fewer post-operative complications (10/46 [22%] vs. 25/47 [53%] P  = 0.002). Although the follow-up was short (laparoscopic 16 months; open 18 months), a 9% recurrence rate was reported with both approaches. Patient satisfaction using the Gastroesophageal Disease Health-Related Quality Of Life questionnaire was similar in both groups ( P  = 0.861) with most patients reporting excellent outcomes (laparoscopic: 32/36 [89%]; open 27/35 [77%]). Our review suggests that the laparoscopic approach is safe with shorter hospital stay and recovery. Although early follow-up suggests that recurrence rates and patient satisfaction are similar, long-term follow-up is required to determine whether the laparoscopic approach will become the procedure of choice.     

Hiatal hernia and disorders of the spine: a historical perspective

Our understanding of esophageal disease and the foregut has evolved over the past 100 years, especially in recent times. Modern diagnostic technologies and new management paradigms have provided progressive insights into the anatomy, physiology, and normal and abnormal function of the esophagus, as well as improving patient care. Yet, the relationship between the esophagus and its close neighbor, the spine, is rarely discussed and likely underappreciated. Anatomic proximity and intertwined pathophysiology led early investigators to postulate relationships between esophageal disease and spinal abnormalities. More recent studies have illustrated a link between spinal disease and hiatal hernias. Objective radiographic measurements of kyphoscoliosis have correlated with increased hiatal hernia formation. Spinal abnormalities and disease of the esophageal hiatus are becoming more common in our aging population, with each carrying significant risk of morbidity and decreased quality of life. Operative planning and subsequent hiatal hernia repair must be undertaken in the context of these spinal abnormalities. A historical review of past publications related to the subject forms the basis for this publication, thus revealing insight and improving our understanding of the association between spinal abnormalities and hiatal hernias.     

Non-traumatic diaphragmatic hernia of the liver in an adult:a case report

BACKGROUND: Diaphragmatic hernia of the liver is a rare clinical entity, usually found after trauma in adults. This study was undertaken to elucidate a misdiagnosis of non-traumatic diaphragmatic hernia of the liver in an adult. METHOD: The clinical data of one patient with non-traumatic diaphragmatic hernia of the liver was analyzed. RESULTS: A tumor in the right lower thorax was revealed by chest X-ray and computed tomography. Non-traumatic diaphragmatic hernia of the liver was not identified until the operation. Pathological analysis confirmed the finding. The patient recovered well. CONCLUSIONS: Non-traumatic diaphragmatic hernia of the liver in an adult is a rare right-sided diaphragmatic hernia, which can move up into the chest cavity. It should be distinguished from lung cancer. The diagnosis and evaluation of non-traumatic diaphragmatic hernia of the liver can help optimize surgical management.     

腹腔镜下应用补片治疗食管裂孔疝3例

目的:探讨腹腔镜下应用补片修补食管裂孔疝的临床价值.方法:2007-07/2008-05我科行腹腔镜联合补片术治疗食管裂孔疝患者3例. 分析患者手术时间、术中失血量以及术后并发症, 并随访6-12mo.结果:3例患者手术顺利, 无中转开腹或开胸,手术时间分别为155、120、130 min, 术中失血量分别为50、50、70 mL, 3例患者术后第2天排气并进流质饮食, 术后第7天出院, 术后3 mo内3例患者临床症状完全消失, 随访6-12mo, 无复发病例.结论:腹腔镜下应用补片治疗食管裂孔疝临床疗效显著, 值得推广应用.     

Hiatal hernia repair with biologic mesh reinforcement reduces recurrence rate in small hiatal hernias

The utility of mesh reinforcement for small hiatal hernia found especially during antireflux surgery is unknown. Initial reports for the use of biological mesh for crural reinforcement during repair for defects greater than 5 cm have been shown to decrease recurrence rates. This study compares patients with small hiatal hernias who underwent onlay biologic mesh buttress repair versus those with suture cruroplasty alone. This is a single‐institution retrospective review of all patients undergoing repair of hiatal hernia measuring 1–5 cm between 2002 and 2009. The patients were evaluated based on surgical repair: one group undergoing crural reinforcement with onlay biologic mesh and other group with suture cruroplasty only. Seventy patients with hiatal hernia measuring 1–5 cm were identified. Thirty‐eight patients had hernia repair with biologic mesh, and 32 patients had repair with suture cruroplasty only. Recurrence rate at 1 year was 16% (5/32) in patients who had suture cruroplasty only and 0% (0/38) in the group with crural reinforcement with absorbable mesh (statistically significant, P = 0.017). Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1?5 cm with significant recurrence rate and failure of antireflux surgery. Crural reinforcement with absorbable mesh may reduce hiatal hernia recurrence rate in small hiatal hernias.     

Narrative review of management controversies for paraesophageal hernia

ObjectiveTo review management controversies in paraesophageal hernia and options for surgical repair.BackgroundParaesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted.MethodsRecent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes.ConclusionsThe extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the “reverse C” or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.     

Clinical spectrum of paraesophageal herniation

Paraesophageal herniation is a potentially devastating condition of the gastroesophageal hiatus commonly manifesting in patients of advanced age with other significant medical problems. Surgical treatment is generally indicated to avoid catastrophe related to gastric volvulus. The operative approach utilized should be individualized to the patient's pathophysiologic condition rather than attempting to apply a single repair for all patients with this heterogeneous clinical problem.     

Aortic hiatus gastric hernia

Congenital diaphragmatic hernias are a relatively common anomaly that can present with significant respiratory morbidity and mortality. We report on a case of an aortic-hiatal gastric hernia that initially presented with repeated episodes of respiratory distress, which was diagnosed as asthma. The diagnosis of a diaphragmatic hernia was made at 18 months of age. In the operating room, it was noted that it was an aortic hiatal hernia, which was surgically repaired. Subsequently, there has been improvement in daily respiratory symptoms.     

Giant morgagni hernia causing cardiac tamponade

A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare.     

Late presentation of congenital diaphragmatic hernia in patients with cystic fibrosis

Late presentation of congenital diaphragmatic hernia (CDH) is unusual, especially in patients with cystic fibrosis (CF). To our knowledge, cases of CDH in CF patients and the combined effects on lung function have not been previously described. Here we report two cases of late presenting CDH in CF patients and describe effects on lung function. Late presentation of CDH in CF patients can cause gastrointestinal or respiratory symptoms and requires a high index of suspicion as well as proper interpretation of imaging. In patients with CF and CDH, lung function abnormalities could include obstructive, restrictive defects, or combined defects. Pediatr Pulmonol. 2010; 45:403–405. © 2010 Wiley‐Liss, Inc.     

Fetal Intra‐pericardial Morgagni Hernia with effusion affecting one member of a twin gestation

Congenital diaphragmatic hernia (CDH) is a rare type of developmental defect of the diaphragm, occurring in 1 per 2000 pregnancies. Morgagni hernia, in particular, which results from an anterior defect of the diaphragm, is the least common type of CDH (5%). Herniation of the liver into the pericardial space, presenting as a thoracic mass with pericardial effusion, is an extremely rare form of Morgagni hernia. Such reported cases are few and occurred only in singleton pregnancies. To the best of our knowledge, we report the first case of fetal echocardiography and fetal MRI following referral due to large pericardial effusion.     

Physical activity, fitness, and dyspnea perception in children with congenital diaphragmatic hernia

We assessed whether physical activity could influence the performance and perception of dyspnea in children who were operated on for high risk congenital diaphragmatic hernia (CDH). We hypothesized that CDH children with normal activity would have better lung function and exercise performance level when compared to sedentary CDH subjects. We studied 18 children (11 males and 7 females, mean age 6.6 ± 2.6 years) who were surgically corrected. All children underwent physical examination, ECG at rest, and a maximal exercise stress test on a treadmill to measure the duration of exercise, maximal heart rate and blood pressure, maximal oxygen uptake (VO₂ max and VO₂ ml/kg/min). Lung function testing to measure forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV₁), and peak expiratory flow (PEF) was also performed. Following the stress test, the Dalhousie dyspnea and effort scale was shown to children as a pictorial panel with three groups of increasing (from 1 to 7) levels of effort perception, throat discomfort, and chest dyspnea. Children were divided into group A (sedentary) and group B (regular physical participation). There was no difference in CDH severity between the two groups. Group A had a statistically significant lower duration of exercise (P < 0.01), maximal oxygen consumption (VO₂ max P < 0.0001), VO₂ ml/kg/min (P < 0.001), higher throat closing feeling (P < 0.004), chest dyspnea (P < 0.001), and effort perception (P < 0.04) compared to group B. No differences were found in lung function tests. In conclusion, our data may suggest that children with a history of CDH who are active maintain a higher level of performance with less perception of dyspnea and effort. Pediatr. Pulmonol. 2011; 46:1000–1006. © 2011 Wiley‐Liss, Inc.     

Late presentation of Bochdalek hernia: clinical and radiological aspects

Three infants with late presentation of Bochdalek hernia are presented. The presenting symptoms were cough, intermittent vomiting, dyspnea, and cyanosis. Initial diagnoses of isolated paravertebral mass and foreign material aspiration were made in two infants, based on plain chest x-ray findings and history of the patients. Further radiological investigations, such as contrast upper gastrointestinal series or enema, computerized tomography, and magnetic resonance imaging of the chest, suggested the diagnosis of Bochdalek hernia. The hernia was found on the left side in two patients and on the right side in one. At operation, the stomach, small intestine, and spleen were found as herniated organs in one patient, ascending colon in one, and all of the small intestine together with ascending colon in the other. A congenital diaphragmatic defect should be suspected in every child presenting with unusual respiratory or gastrointestinal symptoms and with abnormal chest x-ray findings. The radiological findings vary greatly from one case to another, and even in the same case at different times because of differences in herniated organs and intermittent spontaneous reduction. The possibility of congenital diaphragmatic hernia should be kept in mind to avoid a wrong diagnosis, undue delay in diagnosis, and inappropriate treatment.     

Intestinal obstruction caused by a strangulated Morgagni hernia in an adult patient

A Morgagni hernia is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The reported incidence of congenital diaphragmatic hernias is estimated to be 1 in between 2000 to 5000 births. Morgagni hernias comprise 2% of diaphragmatic hernias. Most Morgagni hernias are found and repaired in children, but 5% are found in adults. They are usually asymptomatic and often found incidentally on chest radiography. Symptoms of these hernias are attributable to the herniated viscera. Morgagni hernias containing bowel may require repair on presentation because of the risk of incarceration. We present a case of an incarcerated and strangulated Morgagni hernia in a 71-year-old woman admitted to our clinic for abdominal pain and symptoms of intestinal obstruction. The diagnosis was made preoperatively by chest radiography, sonography, and computed tomography. Emergent laparotomy was performed, with the herniated transverse colon and omentum reduced into the abdomen. The diaphragmatic defect was repaired, followed by resection of the strangulated omentum. In conclusion, a Morgagni hernia may cause intestinal obstruction. Routine radiographic studies are usually sufficient to arrive at the diagnosis, but a CT scan and sonography may be necessary. Laparotomy is appropriate for the management of symptomatic adult patients with Morgagni hernias, particularly those with findings of intestinal strangulation, with laparoscopic treatment an alternative approach in selected cases.