Morgagni Hernia (Subcostal sternal hernia)

Morgagni Hernia (Subcostal sternal hernia)

 

Morgagni hernia is a less common variety of congenital diaphragmatic hernia. Here the herniation occurs via the anterior  sternocostal hiatus called  the foramen of morgagni. Morgagni hernia accounts for about 3 to 4% of all diaphragmatic hernias. These hernias are small and mostly asymptomatic. When they are large they can cause respiratory or gastrointestinal symptoms. Surgical intervention is generally recommended because of the risk of intestinal strangulation and gangrene.

 

Anatomy

The triangular space between the muscle fibres of the xiphisternum and the costal margin is called as the foramen of morgagni. It is through this foramen the internal mammary artery passes to become superior epigastric artery.  Failure of the fusion of the sternal and the costal fibrotendinous elements of the diaphragm is the attributed cause of morgagni hernia.  Almost 90% of  Morgagni hernia occur in the right while it is less likely on the left side as the foramen is covered by the pericardium. The hernial content is usually the omentum but rarely other abdominal contents also are herniated.

 

Presentation

Dull pain in the subcostal region and in the epigastric region

Intestinal obstruction

Exercise may precipitate the symptoms

Obstruction, incarceration and gangrene are rare

The symptoms may be exacerbated by increase in abdominal pain like exercise and pregnancy

 

Investigations

CXR

CT-Chest

Barium study of the upper GI tract

 

CXR - Rounded opacity is seen in the right cardiophrenic angle. In the lateral CXR the opacity is localized to the anterior retrosternal space. Earlier artificial pneumoperitoneum was created to see the outline of morgogni hernia. But this technique is not used currently as CT scans are widely available. Most of the anterior retrosternal hernias are diagnosed in routine chest X rays taken in asymptomatic patients for other reasons. Air filled bowel loops in the thorax can be seen in thoracic radiology. Barium study can be done to confirm the diagnosis.

 

Treatment

Surgical correction needs to be done in view of the chance of incarceration and strangulation. The procedure can be done by laproscopy. Hernial sac is usually present in morgagni hernia.  Excision of the hernial sac and repair of the muscular defect is recommended. Recurrence after surgical repair is rare. Most often only a piece of omentum is caught in the hernia sac.

 

Associated anomalies

Morgagni hernia is generally associated with obesity. Congenital anomalies like Down ’s syndrome, Noonan’s syndrome are seen in some cases. Bowel malrotation and genitourinary malformation can also occur.

 

Date: 
Tuesday, July 8, 2014