What is Morgagni Hernia?
Morgagni hernia is a condition first noted in 1761 by Giovanni Battista Morgagni, the pioneer of analyzing diseases through studying body structures. The diaphragm is a thin, dome-shaped muscle that divides the chest and belly areas. The Morgagni hernia is one of the most uncommon types of a condition called congenital diaphragmatic hernia (CDH), making up only 2% to 5% of these cases. This form of hernia occurs due to a fault in the front part of the diaphragm, located behind the breastbone.
Other types of diaphragmatic hernias include the Bochdalek, hiatal, and paraesophageal hernias. A Bochdalek hernia is caused by a defect in the back part of the diaphragm. A hiatal hernia results from a defect where the food pipe passes through the diaphragm, while a paraesophageal hernia has a defect next to this area.
Interestingly, Morgagni hernias often show fewer symptoms because they’re less likely to lead to underdeveloped lungs. This often means these defects are discovered later than usual.
What Causes Morgagni Hernia?
Morgagni hernias often found in infants or young children are frequently linked to other inborn conditions, with 34% to 50% of cases having such connections. The most commonly associated conditions are heart defects (found in 25-60% of cases) and Down syndrome (found in 15%-71% of cases). Other associated conditions can include malrotation, abnormal formation of the anus and rectum, omphalocele (a birth defect where organs stick out from the belly), skeletal anomalies, and Cantrell’s pentalogy (a rare condition that involves multiple defects in the front of the body).
The cause of an increased recurrence rate of hernia repair in individuals with Down syndrome could be related to improper movement of muscle-forming cells during development, due to increased adhesion or ‘stickiness’ of cells in these patients.
In contrast to patients with a Bochdalek hernia, another type of diaphragmatic hernia that usually shows symptoms shortly after birth because of underdeveloped lungs, up to half of the patients with Morgagni hernias may not show any symptoms when they are diagnosed. On the other hand, patients who are less than 2 years old are more likely to show symptoms at the time of diagnosis. Sometimes, the condition might not be diagnosed until adulthood, when imaging tests of the chest are done for unrelated reasons.
Morgagni hernias are mostly found on the right side of the diaphragm, as the left side is held up with supportive tissues surrounding the heart. Up to 91% of Morgagni hernias are found on the right side, 5% on the left side, and 4% on both sides.
Risk Factors and Frequency for Morgagni Hernia
Morgagni hernias are quite rare, occurring between 1 in 2000 and 1 in 5000 live births. However, the precise frequency of this condition is not known. When looking at all congenital diaphragmatic hernia (CDH) cases, Morgagni hernias account for 2% to 5% of them.
Signs and Symptoms of Morgagni Hernia
A Morgagni hernia often develops later in life than a Bochdalek hernia, and patients commonly experience respiratory and upper digestive system symptoms. Surprisingly, up to half of patients may not show any symptoms when first examined, and the hernia might be discovered while looking for an unrelated issue. In children, respiratory problems such as shortness of breath or fast breathing, as well as recurring lung infections, are the most common symptoms. Sometimes, they may also have issues with feeding, fail to gain weight as they should, and cough or choke when feeding.
Adults, on the other hand, might experience chest or retrosternal pain, which often gets better when standing, along with shortness of breath, burping, indigestion, or abdominal cramps. Factors such as injuries, obesity, pregnancy, persistent constipation, or constant coughing can trigger these symptoms by increasing pressure in the abdomen, which leads to the herniation of the tissue lining the abdominal cavity and intestine through the hernia defect. During physical examination, if the intestine is present in the hernia, doctors may hear the sounds of bowel movement when they listen to the patient’s chest.
Additionally, it’s important to keep an eye out for severe complications like strangulation of the hernia or twisting of the intestine (volvulus), which might present symptoms such as sharp pain when pressure is released, fast heart rate, persistent vomiting, and blood in the rectal examination. Patients showing these symptoms must receive immediate medical attention including fluid resuscitation, diagnosis, evaluation of the intestine with possible resection, and fixing the hernia defect.
Testing for Morgagni Hernia
The main way doctors confirm a diagnosis is through medical imaging, specifically using two types of chest X-rays; one from the front (anteroposterior) and one from the side (lateral). For a condition where the bowel pushes into an abnormal area, a chest X-ray will show a light shadow near the heart that appears behind the breastbone in side view X-rays. Chest X-rays alone can diagnose this condition about 71% of the time, especially when the bowel is seen in the chest. A rounded shadow is often found near where the heart and diaphragm (the muscle that helps us breathe) meet on the right side when tissues or solid organs push through a hole or weak spot.
More detailed imaging may be used to help confirm the diagnosis. This could be a chest CT scan (a type of X-ray that takes detailed pictures of the inside of the body), a swallow study (where you swallow a special liquid that shows up on X-rays to examine the throat and esophagus), or a barium enema (a type of X-ray of the large intestine). A CT scan is often the next step because it’s quick to do and can correctly identify the problem every time. The CT scan might show a mass of fat density behind the breastbone if the fatty tissue or an air-filled organ like the bowel has pushed through. A swallow study might be done if the doctor suspects a hiatal hernia (when part of the stomach pushes up through the diaphragm into the chest). A barium enema is also a possible choice, where upward bending of the middle part of the large intestine can identify if the colon has herniated into the defect.
Treatment Options for Morgagni Hernia
When it comes to managing CDH, the starting ventilator settings usually aim for low pressure and rapid breath rate to make sure that carbon dioxide levels in the body are at the right levels.
All Morgagni Hernias, a rare type of diaphragmatic hernia, should be treated due to the risk of organs getting trapped. However, doctors are still discussing the best approach and method for treatment. The hernia can be approached either from the stomach side or through the chest. If it is approached through the chest, a cut is made between the sixth ribs. This allows for a clear view of the defect on the right side, easier separation of the hernia sac from surrounding structures such as the heart sac, and a potentially safer reduction of organs like the liver back to their proper position.
The hernia sac may or may not be removed. After that, the hernia defect is closed using either silk or polypropylene sutures. However, the chest approach has some downsides, including the risk of missing a defect on both sides due to limited visibility, a higher chance of needing breathing support after the surgery, and the risk of chest wall deformation in children if performed before they grow significantly.
The abdominal approach may be performed either through a large cut in the abdomen (open laparotomy) or with a minimally invasive laparoscopic technique, which uses small cuts and a special camera. The advantages of the abdominal technique include the ability to identity and repair defects on both sides and evaluate and repair other conditions within the abdomen at the same time. The open laparotomy is typically reserved for emergency repairs, and for patients who cannot tolerate laparoscopy, have severe abnormal curvature of the spine, or extensive adhesions, or require extensive bowel resection due to a trapped hernia.
The hernia contents are pushed back to their proper location, and there is a debate whether the hernia sac should be cut off or included into the sutures. However, the main repair should not be under too much tension. It is suggested that a mesh should be placed for hernias larger than a specific size. The defect is repaired using non-absorbable sutures in a way that incorporates the costal margins. The minimally invasive approach has a quicker recovery time and faster return to normal activities and eating with no difference in complication rates, while providing more space for dissection and better visualization.
Georgacopulo was the first to report a successful laparoscopic Morgagni hernia repair in a child in 1997. With the laparoscopic approach, the patient is placed in reverse Trendelenburg, a body position where the body is tilted with the head higher than the feet. The surgeon locates at the foot end of the bed, and depending on the defect’s size, the falciform ligament, a thin membrane that rests between the livers left and right lobes, may need to be separated for better exposure.
The hernia contents are pushed back to their rightful place; the sac gets cut off at this time if required. The defect closure may be done using sutures through the abdominal wall. If the defect is too large and requires a patch, the patch is sutured to the back rim of the hernia defect. Then, non-absorbable sutures are used that travel through the front abdominal wall and are tied in the fatty layer beneath the skin. Such type of repair is beneficial when there is no diaphragmatic rim at the front, and it’s easier to perform than sutures within the body.
In most cases, patients recover smoothly, and most are discharged within three days of surgery. The robotic technique has also been used, offering improved handling, motion, and reducing involuntary tremors, providing benefits to this minimally invasive approach.
What else can Morgagni Hernia be?
When a physician is trying to diagnose a medical condition, several other conditions may appear similar on initial tests. These could include the following:
- a chest cyst (pericardial cyst)
- a localized pocket of air in the chest (loculated pneumothorax)
- a condition where part of the stomach pushes into the chest (hiatal hernia), which can be spotted if parts of the intestines seem to be pushing through a hole in the diaphragm on a chest X-ray
- part of the fat-storing organ (omentum) or liver may look solid on chest X-rays but this might also be seen with other conditions
- conditions like a lung collapse (atelectasis), lung infection (pneumonia), fat pad around the heart (pericardial fat pad), chest fat tumor (intrathoracic lipoma), lung cancer (bronchial carcinoma), cancer of the chest lining (pleural mesothelioma), or an unusual tumor in the space between the lungs (atypical mediastinal tumor).
Additional tests like a different angle chest X-ray or a CT scan can help confirm the exact condition.
What to expect with Morgagni Hernia
If a baby is born with a Morgagni hernia, which is a birth defect, several factors can make it more likely that they will have serious health problems. These factors include being born too soon (prematurity), being a low weight at birth, being born early in pregnancy (gestational age), and having low APGAR scores. The APGAR test is a quick measure to evaluate a newborn’s physical condition and determine any immediate need for extra medical care.
Another factor that can increase risk is the presence of other birth defects. Even though uneven lung growth (pulmonary hypoplasia) is not a common issue with Morgagni hernias, other elements that might affect the baby’s wellbeing are identifying the hernia before birth (prenatal identification) and the size of the hernia, especially if a sac is included.
Yet, the long-term effects of having a Morgagni hernia as a child are still unknown. But once the hernia is treated by a medical professional, most patients get better and their symptoms before the operation go away. Furthermore, it’s rare for the hernia to come back after treatment.
Possible Complications When Diagnosed with Morgagni Hernia
Nonhiatal transdiaphragmatic hernias in adults are uncommon and can either be present from birth (congenital) or result from injury (posttraumatic). These need to be distinguished from paraesophageal hernias. Expert medical materials suggest these hernias often show up as surprising diagnoses. They may involve a mix of digestive issues along with respiratory or heart problems. Even if a person with a hernia has no symptoms, they should still undergo surgical correction to avoid serious complications such as bowel obstruction, strangulation, volvulus (twisting of the intestine), and necrosis (death of tissue) that can happen in up to 10% of cases.
After surgery, there might be some complications like wound infections, hernias at the cut site or port site, stitch abscesses (a pocket of pus), and bowel obstruction.
There is a broad range in the rate of hernias coming back, from 2% to 42%. However, many studies reported that there were no cases of hernias returning even after 10 years. Factors that increase the chance of a hernia returning include not using a patch when closing a wound under tension, not removing the sac, using dissolvable stitches for repair, and if the patient has Down syndrome.
Different ways of repairing hernias exist and each comes with its own challenges. For example, the technique where the chest is entered (transthoracic approach) might overlook other abnormalities, isn’t the best for sac removal, might need ventilator support afterwards, and could possibly cause chest wall abnormality in children. The open laparotomy, that is best for complex cases or those that need immediate attention, has longer recovery time, higher rate of complications at the wound site, and worse cosmetic results compared to minimally invasive techniques. However, all types of repair techniques can have good results if their pros and cons are well known.
- Adult transdiaphragmatic hernias are rare and can be present at birth or due to injury.
- These can result in a range of digestive, respiratory, or heart problems.
- Even if there are no symptoms, surgery is advised to prevent serious complications.
- Post-surgery complications may include wound infections, hernias, stitch abscesses, and bowel obstruction.
- The return rate for hernias is varied, but in several cases, no recurrence is reported even after long follow-ups.
- Several factors contribute to hernia recurrence, including surgical methods and patient’s individual health conditions.
- Different repair techniques exist, each with their unique challenges and results.
Preventing Morgagni Hernia
A Morgagni hernia is a rare type of hernia. It might be suspected in individuals who frequently get lung infections, have trouble breathing, or find their stomach pain or vomiting getting worse. If you’re dealing with these symptoms, it’s essential to see a doctor. The typical course of treatment is often surgery, either through the chest or the abdomen. In cases where the hernia is big, a man-made patch may be used to fix the defect. After surgery, the chances of the hernia coming back are low and most people find their symptoms completely relieved.
