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| CASE REPORTS |
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| Year : 2023 | Volume
: 6
| Issue : 1 | Page : 44-47 |
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Morgagni hernia presenting as constipation in the postsurgical patient: A case report
Thomas Cartwright1, Patherica Charoenmins1, Cole Nelson1, Josiah Faustino1, Shaan Jamil Akhtar2
1 College of Medicine, Kansas City University, Kansas City, USA
2 Department of Surgery, United Surgical Associates of Kansas City, Independence, Missouri, USA
| Date of Submission | 27-Oct-2022 |
| Date of Decision | 18-Dec-2022 |
| Date of Acceptance | 20-Dec-2022 |
| Date of Web Publication | 30-Mar-2023 |
Correspondence Address:
Thomas Cartwright
College of Medicine, Kansas City University, 1750 Independence Ave, Kansas City, MO 64106
USA
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijawhs.ijawhs_51_22
In this case report, we discuss an 83-year-old woman who presented to the emergency department with complaints of constipation and progressive abdominal pain 2 days after a right total knee arthroplasty. Chest X-ray indicated a possible hiatal hernia, but computed tomography revealed a Morgagni hernia with a portion of the transverse colon and omentum in the thoracic cavity, resulting in a large bowel obstruction. The more common presenting symptoms associated with Morgagni hernia, dyspnea, and chest pain were not present. Surgical management was pursued with a transabdominal approach, the bowel was successfully reduced and the defect was closed using sutures. This case provides an interesting insight into the many potential presentations and clinical signs of the rare Morgagni hernia. Keywords: Case report, constipation, large bowel obstruction, Morgagni hernia, transverse colon
How to cite this article:
Cartwright T, Charoenmins P, Nelson C, Faustino J, Akhtar SJ. Morgagni hernia presenting as constipation in the postsurgical patient: A case report. Int J Abdom Wall Hernia Surg 2023;6:44-7 |
How to cite this URL:
Cartwright T, Charoenmins P, Nelson C, Faustino J, Akhtar SJ. Morgagni hernia presenting as constipation in the postsurgical patient: A case report. Int J Abdom Wall Hernia Surg [serial online] 2023 [cited 2023 Jun 9];6:44-7. Available from: http://www.herniasurgeryjournal.org/text.asp?2023/6/1/44/372938 |
| Background | |  |
Morgagni hernia (MH), first described by Giovanni Morgagni in 1769, is the least common form of congenital diaphragmatic hernia (CDH), accounting for approximately 3% of cases.[1] These hernias result from a defect in the anteromedial and substernal part of the diaphragm which allows abdominal contents (colon, small intestine, and omentum) to enter the thoracic cavity. Diagnosis is common during fetal to early life, with diagnosis later in life being exceedingly rare.[2] MHs are most commonly right sided with the greater omentum and transverse colon the most common structures to herniate.[3],[4]
| Case Report | | |
An 83-year-old woman former smoker with a history of hypertension, hyperlipidemia, coronary artery disease, chronic kidney disease stage 3, and peripheral artery disease presented to the emergency department (ED) via emergency medical services with a complaint of progressively worsening abdominal pain. Prior to arrival in the ED, she was an inpatient at a local orthopedic institute post-total right knee arthroplasty. The patient was complaining of constipation and abdominal pain to the institute’s nursing staff postop day 0 and was given two Fleet enemas with no improvement. The abdominal pain progressively worsened over the next 24 h, and on postop day 2 institute staff called emergency medical services. Upon arrival at the ED, the patient complained of a sharp, non-radiating pain rated 6/10 to the upper abdomen. Review of systems endorsed nausea but no vomiting, fever, chest pain, or dyspnea. Vital signs were normal. Physical examination of the abdomen showed a rigid, distended abdomen with diffuse tenderness and hypoactive bowel sounds. She was awake and oriented but in apparent distress from the abdominal pain; the rest of the physical exam was within normal limits. Labs (complete blood count with differential and complete metabolic panel) were drawn and were noncontributory except for a mildly decreased hemoglobin, albumin, and calcium. Chest X-ray (CXR) showed possible atelectasis and what was initially believed to be a large hiatal hernia [Figure 1]. Surgery was consulted and a computed tomography (CT) of the abdomen and pelvis without contrast was performed. The CT showed a distended proximal colon [Figure 2] measuring 8 cm in maximum diameter with a large quantity of retained stool up to a sharp transition point at the transverse colon, indicating a large bowel obstruction (LBO). A paracentral diaphragmatic hernia [Figure 3] and [Figure 4] that contained fat and the midportion of the transverse colon was present, creating the LBO. The hernia defect measured 4.5 cm × 3.5 cm, whereas the hernia sac measured 10.5 cm × 7.5 cm × 8.0 cm. A nasogastric tube was placed for decompression and surgical correction was pursued.  | Figure 2: CT scan (coronal) showing distended colon, diaphragm defect, and herniated bowel
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 | Figure 3: CT scan (transverse) showing herniation of bowel into thoracic cavity
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 | Figure 4: CT scan (sagittal) showing anteromedial bowel herniation through diaphragm
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Consent was obtained and the patient was transported to the OR. Owing to size of the hernia and undetermined viability of the intestine, a transabdominal laparotomy approach was chosen. An upper midline incision was made in order to access the intra-abdominal cavity. The herniation was located and successfully reduced with traction. Evaluation of the colon showed no evidence of ischemia or necrosis. The diaphragmatic defect was loosely repaired with 2-0 PDS sutures in an interrupted fashion to minimize risk of seroma formation. The surgical course was uncomplicated with the patient tolerating the procedure well. She was subsequentially transferred to the PACU in stable condition. Two weeks later she was seen at an outpatient clinic for postop follow-up and appeared to have recovered well from both surgeries.
| Discussion | | |
With MHs comprising approximately 3% of cases, the already rare discovery of an MH is furthered by the unlikely diagnosis in one’s eight decades of life. In this 83-year-old woman, constipation was a possible side effect of the opiates she was receiving for pain control after her right total knee arthroplasty. This case was interesting due to the events preceding the final diagnosis and the patient’s presentation. Simply stated, the side-effect of constipation in an elderly receiving opiates is a common occurrence; however, the subsequent discovery of an MH is not. Owing to lack of prior imaging, it is unknown whether the bowel herniated earlier in life and remained asymptomatic until presentation, or herniated as a result of reduced bowel motility due to opiates. We speculate that there was some degree of herniation present before her knee surgery. Regardless, this particular case shows the necessity of both a broad differential diagnosis and early definitive imaging in elderly patients presenting with constipation and abdominal pain. The CXR, while read appropriately, turned out to be misleading and the CT was needed for accurate diagnosis and treatment plan. Prompt identification and diagnosis of MH is important to avoid strangulation and ischemia of herniated bowel contents. Chest or abdominal radiographs can help identify the hernia, but computed tomography is the most accurate diagnostic modality to help elucidate the hernial sac contents.
The preferred surgical approach toward MHs remains unclear, with both trans-thoracic and trans-abdominal approaches described. Pfannschmidt et al.[5] concluded that a trans-thoracic approach was preferred for right-sided hernias for better visualization of the diaphragmatic foramen and pericardial and pleural adhesions although our search of the literature showed most surgeons tend toward an abdominal approach, likely due to the preponderance of general surgeons performing repairs and their familiarity with this approach. In our patient, a trans-abdominal approach with exploratory laparotomy was chosen due to unknown integrity of the herniated bowel and possible need for bowel resection. This approach gave more flexibility to address any complications that may have arisen during the surgery. Fortunately, the transverse colon showed no signs of ischemia or damage and was easily reduced with gentle traction.
Repair of the diaphragmatic defect is another area that lacks clear agreement. After reduction of the bowel and omentum, it was noted that there was still hernia sac present in the thoracic cavity. On the basis of this and the size of the defect, it was decided that placement of mesh was not appropriate, fearing the possibility of a seroma formation. Loose closure with interrupted sutures was performed to reduce risk of future herination. Although this route has a higher possible risk of recurrence compared to a mesh repair, given the patients age and condition, overall recurrence risk was presumed to be low.
The decision for primary closure with suture or repair with mesh is based on the presentation of the patients defect and surgeon comfort. The goal for a diaphragmatic repair is a tension free closure. In retrospective reviews, more surgeons than not elected for a mesh repair based on size of the diaphragmatic defect and the inability for primary closure to provide a tension free repair; smaller defects (≤4 cm) were generally repaired with suture and larger defects (≥5 cm) with mesh.[6],[7],[8],[9] Although mesh is a good option in larger defects, it is not without its own risks that any mesh-based repair has. Additionally, tack fixation is not recommended when the defect is near the pericardium as the tacks can potentially cause cardiac damage[10] and some argue that tack fixation should be avoided altogether[9] thus indicating use of suture to affix the mesh. Despite that suture-only repair might not be feasible in larger defects, it should remain a first-line consideration due to simplicity[6],[11] as historically recurrence rate is exceedingly low.[1] At follow-up in the outpatient clinic the patient was given an option for a second surgery to fully close the defect, but she declined. All things considered, the surgery went along the best course possible and ended with a positive outcome.
| Conclusion | | |
MH is the least common type of hernia and the finding in an 83-year-old patient adds to the rarity. The clinical presentation leading to discovery can vary in a multitude of ways. Chest pain, dyspnea, abdominal pain[4],[12] and constipation, the latter two as we saw in this case, are more common. Regardless of the presentation, this case highlights the importance of maintaining a broad differential diagnosis and of pursuing early imaging in the patient who presents with progressive abdominal pain and constipation. Currently, the best management of MH lacks accord, but a review of the literature seems to indicate that the transabdominal approach is preferred to the thoracic. Laparoscopy versus laparotomy is left to the clinical indications and surgeon preference, with some reporting use of robotics with possible improvements in patient outcomes.[13],[14] Surgical reduction, in any form, is the definitive treatment for MH.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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