Morgagni hernias are infrequently seen. Although their actual incidence is difficult to determine because generally to be asymptomatic, of all surgically treated diaphragmatic hernias, the frequency of Morgagni hernia was reported as 1%-3%
2. The organs generally found in this hernia are transverse colon and omentum; stomach and portions of the liver were rarely reported in the literature
3,4.
Patients are usually asymptomatic and present with an anterior mediastinal mass on chest radiographies. The preoperative diagnosis of Morgagni hernias may be aided by the use of CT scans as in our case. Differential diagnosis to consider with Morgagni hernia include: Epicardial fat pads, eventration of the diaphragm, hiatal hernia, Bochdalek hernia, traumatic diaphragmatic rupture, diaphragmatic tumor and large anterior mediastinal masses 5.
Although usually asymptomatic, especially in older patients, the contents of the sac may be large enough to lead acute symptoms such as acute dyspnea and coughing 3. Moreover, Morgagni hernia may rarely become complicated as a result of incarceration or volvulus of the contents of the hernia sac. The pressure exerted by the hernial contents on intrathoracic structures causes various symptoms related to the respiratory, cardiovascular and the gastrointestinal system. Our case had been also asymptomatic for years, but stomach volvulus, acute distention of the stomach filling the one-third of the right hemithorax caused the mediastinal shift and acute respiratory distress. Our patient is one of the few cases of acute gastric volvulus reported in the literature 6,7,8.
All authors suggest operation in symptomatic diaphragmatic hernias without taking patient’s age into the consideration 3. While asymptomatic hernia in adult does not require operation, many authors advocate surgical correction in children because increase in the amount of fat tissue in the mesentery and omentum is believed to increase the chance of intestinal obstruction 9,10.
Whereas both abdominal and thoracic approach can be performed, abdominal approach is recommended because it is more easier and more tolerable for patients 11. Ketonen and colleagues recommended that if the diagnosis is not definite, thoracic approach should be chosen 2. Also Kılıç at al. recommended transthoracic approach, in patients with Morgagni hernia as it provides sufficient exposure, easy repair of the hernia sac and an acceptable morbidity when compared with transabdominal approach 12. Taking her older age and poor condition into the consideration abdominal approach was thought to be more tolerable and less painful for our patient. However, laparoscopic and thoracoscopic surgical techniques offer innovative approaches to the surgical treatment of Morgagni hernia 4,13.
As a result, Morgagni hernia always has a risk of causing severe complications. It should be operated even it is asymptomatic. Because, like our patient, in the elderly gastrointestinal obstruction and acute distention of herniated viscera and mediastinal shift are less tolerable.
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