Download 1 Abstract Introduction: Several cases of Morgagni hernia have

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Abstract
Introduction: Several cases of Morgagni hernia have recently been treated with laparoscopic mesh repair, which
is reported to have fewer complications and to be less invasive. Here we describe a case of a laparoscopic
Morgagni hernia repair treated with mesh that progressed to heart failure due to pericardial effusion 2 months
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after hospital discharge.
Case Presentation: A 78-year-old woman was incidentally found to have a Morgagni hernia during a routine
R and an
chest X-ray. The laparoscopic Morgagni hernia repair was performed using Composix mesh ○
R EMS Stapler. The Composix mesh○
R was gently attached to the surface of the diaphragm using
ENDOPATH○
R EMS Stapler. She was discharged from the hospital on the 7th postoperative day without
the ENDOPATH○
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any adverse events. However, 2 months later, she developed dyspnea due to heart failure secondary to a
pericardial effusion. Pericardial drainage was performed during her hospitalization, and she was discharged 7
days later. No recurrence of either the pericardial effusion or the Morgagni hernia has been detected since the
pericardial drainage
Conclusion: Clinicians may need to be aware of the risk of pericardial effusion in these cases, even if there has
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been no damage to the diaphragm or epicardium.
Keywords: Morgagni hernia, laparoscopic repair, postoperative complications, pericardial effusion, heart failure
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Introduction
Morgagni hernia is a relatively rare condition that accounts for only 1%–3% of total diaphragmatic hernia
cases.1 There are few postoperative complications associated with surgical interventions for this condition;
however, laparoscopic mesh repair has been recognized as a standard treatment.2,3 Here we report a case of a
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R ; C.R. Bard, Inc. USA) and a hernia
Morgagni hernia that was repaired using hernia mesh (Composix mesh○
R EMS Stapler; Ethicon, OH, USA) that developed cardiac tamponade due to a
stapler (ENDOPATH ○
pericardial effusion two months after the surgery.
Case report
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A 78-year-old woman was incidentally found to have an abnormal shadow in the inferior right thorax on a
routine chest x-ray. She was diagnosed with a Morgagni hernia based on a thoraco-abdominal computed
tomography (CT) scan. The examination findings included a height of 148 cm, weight of 43 kg, body mass
index (BMI) of 19.6 kg/m2, blood pressure of 126/74 mmHg, heart rate of 64 bpm, SatO2 of 98%, no dyspnea,
normal respiratory sounds, no pulmonary adventitious sounds, and a flat, soft, non-tender abdomen. She also
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had hypertension and hyperlipidemia, which were treated with medication, and no surgical history. The blood
biochemistry examinations on admission revealed no abnormal findings. The frontal view of the chest x-ray
revealed a round tumor shadow with a silhouette sign and a clinically clear margin at the central right lower lobe
of the lung (Fig. 1a). On the chest and abdominal CTs, a defect in the diaphragm was observed in the area that
was just posterolateral to the sternum, (Fig. 1b, c). Omentum was herniated through the defect into the right
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thoracic cavity. Based on the diagnosis of an asymptomatic Morgagni hernia, a hernia repair was planned.
Operative findings: Under general anesthesia, the patient was placed in the lithotomy position, and a 12-mm
camera port was inserted. A pneumoperitoneum was established using 6 mmHg of low insufflation pressure.
Then, 12-mm working ports were inserted below the subcostal arch at the right and left midclavicular lines
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while the operator stood between the patient’s legs. Posterior to the sternum, the surgeons visualized a 5 cm x 3
cm hernial orifice in which omentum was incarcerated (Fig. 2a). The adhesion of the omentum and the hernia
sac was not severe, and the omentum could be reduced into the abdominal cavity without any difficulty (Fig. 2b).
R was attached to the hernia orifice using a hernia stapler,
While avoiding the beating heart, the Composix mesh○
while placing the staples at 20-mm intervals (Fig. 2c). The operative time was 55 minutes with minimal blood
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loss.
Postoperative course: On the first postoperative day, the patient started eating meals. She was discharged from
the hospital on the seventh postoperative day. However, two months later, she developed dyspnea and returned
to the hospital. A chest x-ray revealed an enlarged heart shadow with a cardio-thoracic ratio (CTR) of 65% (Fig.
3a). The chest CT revealed retained pericardial fluid in the pericardium (Fig. 3b), and on the chest 3D-CT, the
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location of the hernia staples was identified. Upon evaluation of the staples used to repair to the diaphragm from
the abdominal side, the surgeons located 4-5 staples near the bottom of the heart; however, they remained inside
the diaphragm. Therefore, there were no staples that penetrated directly into the pericardial space and the heart
(Fig. 3c, d). The patient was admitted to the Department of Cardiovascular Medicine and underwent pericardial
drainage on the same day. A total of 500 mL of serous pericardial effusion was obtained and evaluated; the
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pleural fluid culture, Amplicor Mycobacterium tuberculosis testing, and pathological examination of the biopsy
specimen were all normal. The enlargement of the heart and dyspnea improved after the pericardial drainage.
The patient was discharged on the seventh day after admission. At five years after surgery, there has been no
hernia recurrence or cardiac effusion.
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Discussion
Morgagni hernia was first described by Giovanni Battista Morgagni in 1769.1, 2 The foramen of Morgagni is
located just posterolateral to the sternum. This hernia is caused by a congenital defect of the so-called
sternocostal triangle during the fusion of the septum transversum of the diaphragm and the costal arches. The
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herniated organs generally consist of omentum, transverse colon, small bowel, and, rarely, the stomach.2, 3
Reports have noted that only one-third of these patients are symptomatic.4 For these patients, the spectrum of
symptoms mainly occurs when there is a hollow viscus in the hernia sac; this symptoms include persistent
cough, dyspnea, exercise intolerance, syncope, chest pain, abdominal discomfort, fullness, anxiety attacks,
vomiting, and symptoms of bowel occlusion.5,6 In 70% of cases, the diagnosis is made on incidental radiological
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investigations.7 Anterior-posterior and lateral chest X-rays often show a mass in the right substernal
cardiophrenic angle.7, 8 A CT scan is also a useful diagnostic method, since a retrosternal soft-tissue density
mass and bowel loops within the chest can be seen on a CT scan.5, 9 Furthermore, magnetic resonance imaging is
the best diagnostic modality when mediastinal tumors are being considered in the differential diagnosis.8,10,11
Even if diagnosed incidentally, Morgagni hernias should be surgically repaired because they may cause
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incarceration, and surgical treatment significantly reduces the possibility of the symptoms that were mentioned
above.12
The conventional 15- to 20-cm midline incision has long been the standard approach for Morgagni hernia
repair.12,13 However, wound problems, postoperative pain, and cosmesis issues may often be major concerns for
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these patients.
Laparoscopic repair of the Morgagni hernia was first described in the literature in 1992,14 and was performed in
patients without a previous history of abdominal surgery.12 Horton reviewed 298 cases of
Morgagni hernias
and reported that the advantages of laparoscopic repair were less postoperative pain, shorter hospital stays, and
fewer complications.15,16 These complications, which occurred in 17% of laparotomies, in 6% of thoracotomies,
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in 5% of laparoscopies, and in 0% of thoracoscopies, included pneumonia, arrhythmias, pneumothorax, wound
infections, and pleural effusions except of pericardial effusion. Complications occurred in only two cases, and
there was no recurrence of the hernia after the laparoscopic surgery.16 Pericardial effusion may reflect the
primary diseases of pericardium or may be secondary to any disease. The most frequent causes of pericardial
effusions are malignancy (13%–53%), tuberculosis or other infections (7%–41%), idiopathic (3%–48%), or
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thyroid disease (2%–24%) in East Asia, the United States, and Western Europe. Both penetrating and
non-penetrating trauma, in which the frequent rate is <15%, are also well-recognized causes of pericardial
effusions. The chief iatrogenic causes are pacemakers and cardiac catheterization. Pericardial effusion can also
be seen as a complication of cardiac surgery and esophagectomy, although mediastinal or pericardial drainage
can help prevent a pericardial effusion.
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The present case is the first report of a pericardial effusion after a laparoscopic mesh repair of a Morgagni hernia
R and a hernia stapler. The intraabdominal pressure was set relatively low at 6 mmHg,
using Composix mesh○
and a 4-mm-high stapler was used to avoid injury to the vessels of the pericardium and diaphragm. In her case,
there were no penetrating staples from the diaphragm on the chest 3D-CT during the pericardial effusion (Fig.
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3c, d). A laparoscopic mesh repair allows us to perform tension-free, fast, and effective operations. However,
there have been few papers describing the techniques for manipulating a hernia stapler. In their report, Durak et
al. did not recommend the use of tacking devices in these cases because of the potential of injury to deep
structures.12
Even if the fixed staples did not penetrate the diaphragm, a thin female patient, as in this case, has a higher risk
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of developing a pericardial effusion due to a thin diaphragm. Compared with laparotomy, laparoscopic surgery
has fewer complications, earlier recovery, and less invasiveness. Therefore, this procedure appears to be a
standard therapy for Morgagni hernia repairs2. Nevertheless, there may still be a risk of pericardial effusion, as
seen in the present case. In conclusion, we have described a case of dyspnea due to heart failure caused by a
R and a hernia
pericardial effusion after laparoscopic hernia repair for a Morgagni hernia using Composix mesh○
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stapler. Although laparoscopic surgery using mesh may be considered to be a standard treatment for Morgagni
hernias, care should be taken to prevent pericardial effusion.
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References
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2002 Jun;12(3):161-165.
2. Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: changes in diagnosis and
treatment. Ann Thorac Surg. 2004 Jun;77(6):1956-1959.
3. Marin-Blazquez AA, Candel MF, Parra PA, Mendez M, Rodenas J, Rojas MJ. Morgagni hernia: repair with a
mesh using laparoscopic surgery. Hernia. 2004 Feb;8(1):70-72.
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4. de Vogelaere K, de Backer A, Delvaux G. Laparoscopic repair of diaphragmatic Morgagni hernia. J
Laparoendosc Adv Surg Tech A. 2002 Dec;12(6):457-460.
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hernia: report of three cases. Surg Today. 2002;32(10):902-905.
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Surg. 1996 Apr;6(2):131-133.
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9. Anthes TB, Thoongsuwan N, Karmy-Jones R. Morgagni hernia: CT findings. Curr Probl Diagn Radiol. 2003
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May-Jun;32(3):135-136.
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the foramen of morgagni. Surg Endosc. 1997 Jun;11(6):668-670.
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Surg Today. 1996;26(6):446-448.
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2007 Jun;11(3):265-270.
13. Wolloch Y, Grunebaum M, Glanz I, Dintsman M. Symptomatic retrosternal (Morgagni) hernia. Am J Surg.
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14. Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: laparoscopic repair
case report. J Laparoendosc Surg. 1992 Apr;2(2):93-100.
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Figure legends
Fig. 1: Chest x-ray: (frontal view) A round tumor shadow with a silhouette sign and clinically clear margin on
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the central right lower lobe of the lung (a).
Chest and abdominal CT: In the area just posterolateral to the sternum, there is a defect in the diaphragm (b).
The omentum has herniated through the defect into the right thoracic cavity (c).
Fig. 2: Posterior to the sternum, a 5 cm x 3 cm hernia orifice is detected, which contains incarcerated omentum
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(a). The hernia orifice (5 cm  3 cm) following the reduction of the incarcerated omentum into the abdominal
cavity (b). Composix mesh® is attached to the hernia orifice with staples at 20-mm intervals (c).
Fig. 3: Chest X-ray shows an enlarged heart shadow with a cardio-thoracic ratio (CTR) of 65% (a). Chest CT
shows retention of fluid (pericardial fluid) in the pericardium (b).
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The chest 3D-CT shows that 4 or 5 of the staples attached to the diaphragm from the abdominal cavity side
remain in contact with the inferior surface of the heart (), but the staples are within the diaphragm and did not
directly penetrate into the pericardial space or the heart (c, d).