Laparoscopic repair of a rare Morgagni hernia: A case report

Abstract

BACKGROUND

Morgagni hernia is an uncommon variant of congenital diaphragmatic hernia that results from developmental anomalies of the diaphragm. Typically diagnosed in pediatric populations, its occurrence in adults is rare.

CASE SUMMARY

We reported the case of a 71-year-old female who presented with a 1-month history of epigastric discomfort, abdominal bloating, and intermittent cramp-like abdominal pain. Computed tomography (CT) confirmed the presence of a Morgagni-type diaphragmatic hernia, with herniation of the intestinal loops and greater omentum into the thoracic cavity. The patient underwent successful laparoscopic abdominal surgery that, involved reduction of the herniated contents and primary repair of the diaphragmatic defect. Postoperative recovery was uneventful. The patient was discharged on the third day without complications.

CONCLUSION

CT is an effective modality to diagnose Morgagni hernia. Timely surgical management is essential to prevent serious complications such as bowel ischemia or necrosis.

Key Words: Morgagni hernia; Diaphragmatic hernia; Adult Morgagni hernia; Congenital diaphragmatic hernia; Laparoscopic diaphragmatic repair; Mesh reinforcement; Case report

Core Tip: Morgagni hernia is an uncommon variant of congenital diaphragmatic hernia. It occurs due to developmental anomalies of the diaphragm, and its discovery in adults is rare. Morgagni hernia was effectively diagnosed in this patient using computed tomography. Timely surgical management is necessary to prevent serious complications such as bowel ischemia or necrosis.

INTRODUCTION

Morgagni hernia was first described in 1796 by Italian anatomist Giovanni Battista Morgagni. It is a rare form of anterior diaphragmatic hernia arising from a congenital defect in the sternocostal triangle[1]. This hernia results when the anterior diaphragmatic pleura and the sternum or costal cartilages fail to fuse, leading to the formation of a space known as the foramen of Morgagni[2,3]. Intra-abdominal organs such as the greater omentum, colon, small intestine, stomach, and portions of the liver may herniate into the thoracic cavity through this defect[4].

There are four recognized types of congenital diaphragmatic hernias including: Bochdalek hernia (posterolateral defects, accounting for roughly 85%-90% of pediatric cases); Morgagni hernia (anterior parasternal defects); diaphragmatic eventration (diffuse muscular thinning); and central tendon deficiency (rare midline deficiencies) of the diaphragm. It is important to note that structural classifications vary across contemporary surgical literature. Many modern authors distinguish true embryological herniations (Bochdalek and Morgagni) from eventrations or central tendon deficiencies, which represent generalized muscular hypoplasia rather than a localized fascial defect[5]. Morgagni hernias represent approximately 1%-9% of these congenital diaphragmatic hernias. Morgagni hernias may be asymptomatic and discovered incidentally. However, they can also present with nonspecific gastrointestinal or respiratory symptoms. Recent epidemiological reviews indicate that adult presentations account for less than 5% of cases, often remaining entirely asymptomatic or masquerading as vague gastrointestinal or respiratory complaints[1]. Computed tomography (CT) is the standard modality for diagnosis. Surgical repair is generally recommended to prevent complications such as strangulation. However, there are no standardized surgical guidelines because of the rarity of the defect.

Morgagni hernias are predominantly diagnosed in the pediatric population. In this report however we highlight a rare presentation of Morgagni hernia in a 71-year-old female patient who experienced epigastric pain and intermittent cramp-like abdominal discomfort.

CASE PRESENTATION

Chief complaints

A 71-year-old female presented to the Digestive Surgery Department with cramping epigastric pain.

History of present illness

The patient reported that she had experienced mild, intermittently cramping epigastric pain for 1 month prior to presentation.

History of past illness

The patient’s medical history was unremarkable, with no prior systemic illnesses, history of trauma, or tobacco and alcohol use.

Personal and family history

The patient had no underlying disease before this admission. Her family history revealed normal findings.

Physical examination

Upon admission to the hospital, the patient had a body mass index of 26 kg/m² and no comorbidities. She was alert and reported only a mild ache in the epigastric area. The clinical examination indicated minor epigastric discomfort.

Laboratory examinations

Laboratory investigations were comprehensively performed. Complete blood count, serum electrolytes, and liver function tests (alanine aminotransferase, aspartate transaminase, and bilirubin) were all within normal physiological ranges. Serum amylase and lipase levels were also normal, effectively excluding acute pancreatitis.

Given the patient’s age and the location of the discomfort, cardiac biomarkers (Troponin I) and an electrocardiogram were obtained; both were negative for myocardial ischemia or arrhythmia, ruling out acute coronary syndrome or angina-related ailments. Furthermore, an initial chest X-ray was performed, which showed a nonspecific retrosternal opacity in the right cardiophrenic angle, prompting the subsequent diagnostic CT scan.

Imaging examinations

To further investigate the etiology of her symptoms, contrast-enhanced CT of the chest and abdomen was performed. The imaging revealed a defect in the anterior aspect of the right hemidiaphragm through which the transverse colon and omental fat had herniated into the right thoracic cavity (Figure 1).

Figure 1  Computed tomography of the hernia through the right hemidiaphragm (arrows).

FINAL DIAGNOSIS

The findings on the CT were consistent with Morgagni hernia.

TREATMENT

After informed consent the patient was administered general anesthesia. Laparoscopic access was achieved using a four-trocar configuration: A 12-mm umbilical camera port, a 12-mm right-mid-axillary port for mesh insertion, and two 5-mm working ports placed in the right and left hypochondrium. Herniation of the transverse colon and omentum was observed through a diaphragmatic defect measuring approximately 4 cm × 2 cm, confirming the diagnosis of Morgagni hernia (Figure 2).

Figure 2 Intraoperative view of the hernia. A: Transverse colon and omentum herniation through the Morgagni hernia defect; B: Morgagni hernia defect after the release of the colon and omentum in the abdominal cavity.

The defect was repaired with single Prolene 1.0 sutures (Figure 3A). We retracted the circular ligament supporting the liver to facilitate the requisite space for mesh insertion. Dissection of the hernia sac proved technically challenging due to risks of diaphragmatic penetration into the mediastinum and injury to the left pericardium, and the sac was left in situ. Reinforcement was achieved with a 15 cm × 20 cm Parietex™ mesh (Medtronic, Minneapolis, MN, United States) secured by Protack™ fixation devices (Medtronic) (Figure 3B) surrounding the diaphragmatic hernia. There were no complications during the surgery.

Figure 3 Treatment. A: Repair of the defect using single Prolene 10 sutures; B: Reinforcement was achieved with a 15 cm × 20 cm Parietex™ mesh secured in place using Protack™ fixation devices.

OUTCOME AND FOLLOW-UP

The patient experienced mild to moderate discomfort at the trocar insertion sites. She received liquid nourishment on the first postoperative day and solid nourishment on the second postoperative day. She was discharged on the third postoperative day. After 1 week the patient resumed normal activity and mobility. At the 12-month follow-up, CT demonstrated no evidence of hernia recurrence. The patient remained asymptomatic and in good health.

DISCUSSION

Morgagni hernia is the rarest subtype of congenital diaphragmatic hernia. It is most frequently diagnosed in pediatric populations[6]. However, several reports have documented its occurrence in adults[1,4]. Morgagni hernias result from a defect in the anterior diaphragm and manifest on the right side of the sternum in 91% of cases. The hernia in this report was consistent with this frequent presentation. Left-sided manifestation occurs in 5%, and bilateral involvement is observed in the remaining cases (4%). The omentum is the most commonly herniated structure, followed by the colon and small intestine. In left-sided Morgagni hernias the stomach is most frequently involved[7,8].

Adult patients are often asymptomatic or present with nonspecific symptoms, leading to diagnostic challenges[9]. Pediatric patients typically experience respiratory distress, whereas adults frequently exhibit gastrointestinal or respiratory symptoms. Respiratory complaints account for 34% of symptomatic presentations[7]. Pain typically arises when herniated abdominal organs become constricted or incarcerated. Females are typically diagnosed after age 50 while males tend to present earlier[10]. Pregnancy, trauma, obesity, chronic constipation, and persistent coughing are known risk factors; physical exertion may also precipitate symptoms[1]. In elderly patients, the clinical presentation often mimics more common conditions such as gallstone disease, peptic ulcer, or even angina pectoris. Therefore, a high index of suspicion and a thorough diagnostic pathway, including the exclusion of cardiac ailments, are essential.

Morgagni hernias are frequently discovered incidentally on chest radiographs. Radiographic features include an air-fluid level if hollow organs are involved. CT of the chest and abdomen is the preferred diagnostic modality because it provides detailed anatomical details of the hernia and its contents. Diagnosis is often confirmed by identifying a fatty mass or herniated viscera posterior to the sternum[10]. Magnetic resonance imaging can differentiate Morgagni hernia from anterior mediastinal masses in ambiguous cases[11].

Due to the risk of complications such as strangulation, surgical repair is recommended for both symptomatic and asymptomatic patients[9]. Surgical approaches include laparoscopic, open abdominal, and transthoracic techniques[8,12]. Currently, surgical repair is the only definitive treatment for Morgagni hernia. However, no standardized guidelines exist due to the rarity of Morgagni hernias[7]. Open abdominal repair is preferred when strangulation is suspected or when significant adhesions are present, but is associated with severe postoperative incisional pain and prolonged mechanical ventilation risks in older adults. Removal of the hernia sac reduces tension and recurrence, but it is generally avoided due to the risk of mediastinal emphysema[8]. Meanwhile, minimally invasive laparoscopic repair is associated with lower postoperative pain, a low complication rate (critical for geriatric patients), and shorter hospital stays but carries risks of tension pneumomediastinum if the chest cavity is inadvertently entered. It is preferred for uncomplicated cases[8]. Postoperative recurrence is rare, and long-term outcomes are generally favorable.

Repair involves primary suturing, the use of non-absorbable sutures, and mesh reinforcement. The use of mesh depends on the size of the defect and the feasibility of tension-free closure. However, effective repair without mesh is feasible in selected patients[13]. Mesh use should be considered for large defects or in cases with significant muscular loss[14,15]. Mesh reinforcement enhances structural stability, but potential complications include adhesions to thoracic structures and diaphragmatic rupture. These risks have been mitigated by the development of composite-coated mesh materials.

We reported the case of a 71-year-old female who presented with epigastric pain and intermittent cramping. CT indicated herniation of bowel loops and omental fat, and laparoscopic surgery confirmed the presence of a Morgagni hernia. The diaphragmatic defect in the anterior right hemidiaphragm was small (4 cm). According to Sanford et al[7], the average maximum dimension of Morgagni hernias is 7.5 cm. The diaphragmatic defect was closed laparoscopically using sutures and reinforced with an intraperitoneally placed mesh to reduce recurrence risk. Prolene 1.0 monofilament sutures are non-absorbable and ideal for the closure of diaphragmatic anomalies. The hernia sac was left in situ because aggressive dissection posed an unacceptable risk of tearing the mediastinal pleura (causing tension pneumomediastinum) or injuring the left pericardium. We opted to utilize mesh to fortify the diaphragm and diminish the probability of hernia recurrence. We added that mesh reinforcement was indicated despite the small 4 cm × 2 cm size, given the patient’s age (71 years) and body mass index of 26 kg/m², which suggests attenuated diaphragmatic tissue and elevated intra-abdominal pressure. Primary suture repair alone carries a higher recurrence rate in geriatric patients. We acknowledge that while Morgagni hernia repairs are documented, the uniqueness of this case lies in the specific surgical decision-making for a geriatric patient. We have used a non-absorbable monofilament suture with mesh reinforcement to close a 4 cm defect, aiming to prevent recurrence in an elderly patient with potentially weakened diaphragmatic tissue. During the reinforcement phase, we purposely avoided the use of Protack™ fixation devices in the area adjacent to the pericardium. This decision was made to mitigate the risk of accidental cardiac injury or tamponade, a known potential complication when using penetrating fixation near the mediastinum. We recommend that surgeons exercise similar caution in laparoscopic repairs, prioritizing suture fixation or choosing non-penetrating options when working in close proximity to the heart.

CONCLUSION

Morgagni hernia is a rare form of congenital diaphragmatic hernia that is most often diagnosed in pediatric patients but is occasionally observed in adults. Clinical presentation varies widely, ranging from acute respiratory, gastrointestinal, or cardiovascular symptoms to incidental detection in asymptomatic patients. Diagnosis is typically established through CT, which provides detailed visualization of the hernia and its contents. Surgical repair with or without mesh reinforcement remains the definitive treatment and may be approached either transabdominally or transthoracically. Surgical intervention is recommended regardless of symptomatology due to the risk of potential complications. Laparoscopic abdominal repair is a minimally invasive technique that is safe and effective, offering advantages such as reduced postoperative pain, shorter hospital stays, and expedited recovery.

ACKNOWLEDGEMENTS

The author is sincerely grateful to the patient and her family for their cooperation and for providing consent for the publication of this case. He would like to acknowledge the dedicated efforts of the Digestive Surgery Department at Cho Ray Hospital for the management of this patient. He is also grateful to the historical patients and current research staff, particularly nurses, for their support in the resolution of this case.