PICTURES IN DIGESTIVE PATHOLOGY

 

Morgagni's hernia containing an appendicular mucocele

Hernia de Morgagni conteniendo mucocele apendicular

 

 

María Díaz-Tobarra¹, Marina Garcés-Albir¹, Roberto Martí-Obiol¹, Carlos María Hevia-Ivars¹, Alfonso Morcillo-Aixela² and Fernando López-Mozos¹

¹Unit of Esophago-Gastric Surgery. Department of General and Digestive Surgery
²Department of Thoracic Surgery
Hospital Clínico Universitario. Valencia, Spain

 

 

Case report

A 61-year-old female patient was admitted in EA presenting with dyspnea and inespecific postprandial complaints. The chest X-ray (Fig. 1) showed abdominal content into the right side of the thorax. A diaphragmatic hernia was suspected and a computed tomography (CT) was performed (Fig. 2). CT showed a Morgagni's hernia with the small bowel, the right and transverse colon and a tubular structure with calcifications which seemed an appendicular mucocele inside of it.

 

 

 

Surgery was indicated and a thoracic approach was first performed to remove adhesions to hernia sac. During the abdominal approach hernia content was reduced, the diaphragmatic defect repaired with a PTFE mesh and ileocecal resection was made. Pathological report informed a calcified mucinous cystoadenoma. The patient was discharged without complications and no recurrence has been observed after 18 months of follow-up.

 

Discussion

Morgagni's hernias are a type of diaphragmatic hernias representing about 3-4 % of total hernias (1). They are due to a defect in the right retroesternal region of the diaphragm (2) between diaphragm muscle fibers arising from the xiphoid to the right costal margin and insert into the central tendon of the diaphragm (1). Although they are usually asymptomatic and are diagnosed incidentally on a chest X-ray, some patients can have dyspnea, chest pain, intestinal obstruction or other symptoms (3). The suspected diagnosis is made by chest X-ray and confirmed by a thoraco-abdominal CT.

Surgery is the treatment for the symptomatic patients and also to avoid the complications such as obstruction or incarceration (4). The approach can be either thoracic or abdominal, or both if there are adhesions to hernia sac and reduction is impossible. In selected cases thoracoscopic and/or laparoscoscopic approach can be use. There is no consensus about which is the best type of surgery to treat the appendicular mucocele. We consider the ileocecal resection as the best curative treatment for it (5).

 

References

1. Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9.         [ Links ]

2. Aghajanzadeh M, Khadem S, Jahromi SK, Gorabi HE, Ebrahimi H, Maafi AA. Clinical presentation and operative repair of Morgagni hernia. Interact Cardiovasc Thorac Surg 2012;15:608-11.         [ Links ]

3. Iso Y, Sawada T, Rokkaku K, Furihata T, Shimoda M, Kita J, et al. A case of symptomatic Morgagni's hernia and a review of Morgagni's hernia in Japan (263 reported cases). Hernia 2006;10:521-4.         [ Links ]

4. Tallón Aguilar L, Ibáñez Delgado F, Vázquez Medina A, Hernández de la Torre JM, Alcántara Gijón F. Hernia de Morgagni de presentación en edad adulta. Rev Esp Enferm Dig 2009;101:881-9.         [ Links ]

5. Utrillas Martínez AC, Muniesa Soriano JA, del Val Gil JM, Cruces Conde A, López Peris P, et al. Mucocele apendicular. Rev Esp Enferm Dig 2008;100:730-8.         [ Links ]