MORGAGANI HERNIA IN ELDERLY

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Khushbu    on Aug 21, 2012 Says :

good set of information provided regarding Morgagnis Hernia.
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Slide 1 : MORGAGNI’S HERNIA Presented by – Dr Vipan Kumar, Resident Gen Surgery, AHRR
Slide 2 : Patient Presentation A 80 yr old patient, k/c/o Coronary artery disease and Cerebro Vascular Disease, admitted under GE medicine. Presented with c/o Heart burn – 10 days Post meal vomiting – 2 days Upper central abdomen pain – 2 days H/o obstipation – 1 day No c/o haematemesis, malena, jaundice
Slide 3 : On Physical Examination Vitals- Stable Abdomen- Mild epigastric fullness with tenderness but no signs of peritonism No palpable liver, spleen or lump. No free fluid in the peritoneum. Bowel sounds present. Respiratory system- Reduced air entry in the rt basal region and B/L occasional crepts.
Slide 4 : Investigations Showed Routine Blood tests – WNL Liver and renal function tests – WNL USG abdomen – Dilated stomach and pylorus with abrupt cut off at the junction of pylorus with D1. PFT showed moderate restriction. ECHO showed early diastolic dysfunction.
Slide 5 : UGI endoscopy - showed stasis oesophagitis, food residue in the stomach, scope could not be negotiated beyond pylorus.
Slide 6 : IMAGING
Slide 7 : Radiograph chest PA view
Slide 8 : CECT Abdomen
Slide 9 :
Slide 10 :
Slide 11 :
Slide 12 : Impression Large defect in the Rt dome of diaphragm anterior to liver (foramen of Morgagni) Herniation of distal body, antrum and pylorus into the thoracic cavity causing GOO Transverse colon and omentum lying inside the Rt hemithorax
Slide 13 : Plan Patient was Referred to us on 01/09/11. Planned for surgical treatment next day after PAC workup. Considering advanced age (80yrs), comorbidities and the post operative morbidity due to big abdominal incision; patient considered for laparoscopic reduction of contents and mesh repair of Morgagni’s hernia.
Slide 14 : Per operative findings There was a large Morgagni’s hernia anterior to right lobe of liver, defect measuring 10 x 8 cms in size. Distal part of stomach, transverse colon and omentum were found herniating through the defect.
Slide 15 : Surgery performed Laparoscopic reduction of all the contents of hernial defect into abdomen. Margins of hernial defect dissected and defined. A 15x12 cms dual mesh (Prolene+ PTFE) placed over the hernial defect and secured to the margins with 5 mm and 10 mm tackers as well as 2-0 intracorporeal silk sutures.
Slide 16 : Post - op Post op was uneventful, obstruction was relieved. Patient was started on oral diet on 1st POD. Patient was discharged on 2nd POD.
Slide 17 :
Slide 18 : No muscle in the human body, apart from the heart muscle, is more associated with life than the diaphragm. --HUGO DEVLIEGER
Slide 19 : Morgagni’s hernia Foramen of morgagni : Space between attachments of the diaphragm to the xiphoid process and the seventh costal cartilage. Incidence of CDH is 1 in 2000-5000 births. Morgagni’s hernia comprises 2-3% of all CDH 90% of this occur on the right side - enhancement of diaphragm on left side by pericardium & heart.
Slide 20 : Though congenital, rarely diagnosed in early years of life Adults with this usually remain asymptomatic. Some may present with cough, dyspnoea, retrosternal pain. The hernia commonly contains omental fat. In adults it is associated with obesity, trauma, weight lifting or any other condition causing raised intraabdominal pressure. Diagnosis is usually incidental on CXR
Slide 21 : History……… Lazarus Riverius , (1679)- First description of congenital diaphragmatic hernia. Giovani Battista Morgagni, Italian anatomist (1761) - Earliest clear description of hiatal hernia. The bowel, stomach, omentum or even the liver can herniate into the chest through a congenital retrosternal defect where the diaphragm joins the costal arch, as first described by Larrey, Napolean’s chief surgeon. Aue(1902) - First successful repair of diaphragmatic hernia (report published in 1920)
Slide 22 : Gosche et al. detailed four theories in the literature regarding the mechanisms that may contribute to CDH using a teratogenic model. Malformation of the diaphragm is linked to abnormal development of the adjacent lung. Malformation of the diaphragm is the result of abnormal muscle innervation by the phrenic nerve. Improper myotube formation causes CDH. Failure of the pleuroperitoneal canals to close.
Slide 23 : Complications Respiratory distress Lung hypoplasia Gastric Volvulus / GOO Colonic obstruction
Slide 24 : Treatment Surgical repair offers the best treatment. Subcostal incision can be used in the neonates and a midline incision for adults. Minimally invasive approaches are currently being explored via video assisted thoracoscopic and laparoscopic means. Laparoscopy provides an excellent route for both diagnosis and repair of Morgagni's hernia. Primary repair should be attempted first, however prosthetic material such as PTFE can be used.
Slide 25 : Differentials….. Chilaiditi syndrome SOL of the anterior mediastinum pleuro-pericardial cysts, pleural mesothelioma pericardial fat cushion, mediastinal lipoma diaphragmatic tumors or cysts and thymoma.
Slide 26 : Highlights of this presentation Unusual presentation of bowel obstruction within Morgagni’s hernia in an elderly patient. Oldest patient reported in literature is 84 yr old patient who underwent laparoscopic repair is by Vinard et al. (Our patient being the 2nd oldest – 80yrs old)
Slide 27 : Incidentally detected asymptomatic diaphragmatic hernias wait & watch or treat electively?? Morgagni hernia often remains silent The majority of symptomatic cases present acutely with potentially life threatening complications
Slide 28 : Thank You

 


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