Laparoscopic Repair of Morgagni Hernia Combined with Right Hemicolectomy for Bleeding Ascending Colon Carcinoma Lodged within the Chest: A Case Report and Review of the Literature

Background Morgagni hernias are rare in adults and may be asymptomatic but, nevertheless, require surgical repair, with laparoscopy offering an excellent option. The colon dislodged into the chest through diaphragmatic hernias may be affected by various disorders, including malignancies. Case Report. A 70-year-old obese male presented with fatigue and shortness of breath. CT scan showed the right colon lodged in the chest through a Morgagni hernia. He was anaemic, and colonoscopy revealed a colon cancer. He underwent combined laparoscopic hernia repair with bioabsorbable mesh and right hemicolectomy. Recovery was uneventful, but the patient died 5 months later from chemotherapy-associated cardiac failure. Literature review revealed eight similar published cases, and including ours, there were seven Morgagni hernias, one traumatic hernia, and one Bochdalek hernia. Median age of the five men and four women was 66 (range 49-85) years. Surgical approach was thoracotomy (2), laparotomy (5), and laparoscopy (2). Conclusion Outcome of the rare condition is determined by the course of the colon cancer. Hernia repair was successful in ours and all other published cases. A combined laparoscopic approach can be safely done.


Introduction
Diaphragmatic hernias may be congenital, such as Bochdalek and Morgagni hernias, or acquired, such as traumatic hernias [1,2]. Morgagni hernia is less common than Bochdalek hernia. They are more frequent in women (female : male = 3 : 1), have a hernia sac, and may contain intraabdominal viscera; left-sided anterior hernias are extremely rare [3]. Adults with diaphragmatic hernias may remain asymptomatic for a prolonged time or present with nonspecific gastrointestinal symptoms such as right upper quadrant pain or bloating or with respiratory symptoms including chest pain and shortness of breath. These hernias may be incidentally found on imaging [4]. Hernia contents predominantly include the greater omentum and transverse colon; and less frequently the small intestine, liver, and stomach [4]. Bowel obstruction and perforation of intestine within the chest mandate emergent surgery. Due to the risk of visceral strangulation, elective surgical repair is recommended, even in asymptomatic patients [3].
Traditionally, hernia closure was done using laparotomy and thoracotomy; however, laparoscopy and thoracoscopy now offer a less invasive approach [2,5]. Surgery involves reduction of herniated organs, removal of the hernia sac from the mediastinum to prevent recurrence [3], and closure of the defect with running or interrupted sutures, such as transfascial closure using a suture passer. Mesh reinforcement and interposition are options and depend on the size of the hernia.
If the colon is lodged within the chest through a diaphragmatic hernia, it may be affected by various pathologies such as colitis and diverticulitis, as well as colon polyps and colon cancer [6][7][8][9][10][11][12][13][14]. Laparoscopy has emerged as the preferred surgical approach for oncologic colectomy [15], which is followed by stage-dependent adjuvant chemotherapy.
We herein report a patient with a Morgagni hernia harboring a bleeding ascending colon adenocarcinoma, and also report data from a review of the literature on similar cases.

Case Presentation
A 70-year-old obese male presented to the emergency room (ER) with fatigue and shortness of breath. He reported that during the past few weeks, he had developed progressive breathing difficulties and weakness. He had no fever and only mild right upper quadrant and right chest discomfort. On physical examination, diminished breath sounds in the right lower lung were found. The patient was anaemic (haemoglobin 8 mg/dl), and leukocyte count was normal. The CT scan showed a large Morgagni-type hernia with the entire right hemicolon, parts of the transverse colon and terminal ileum, and ample omentum trapped in the chest (Figure 1), causing atelectasis of the right lower lobe. After stabilization in the ER, he was admitted to the hospital, and workup for the blood loss anaemia was initiated. He had a positive stool guaiac test and underwent a colonoscopy showing a large mass in the right colon ( Figure 2). During colonoscopy, the endoscope was maneuvered with extra care to avoid any injuries; the colonoscope entered the right chest but could ultimately be advance to the ileocecal valve. Biopsies of the mass in the proximal ascending colon revealed an adenocarcinoma.
He consented for laparoscopic repair of the diaphragmatic hernia and resection of the right colon. Surgery was done in the supine position and was initiated by insertion of a 5 mm 1 st entry port in the left upper quadrant. An additional 5 mm port was inserted in the left lower quadrant and a 10-12 mm port above the umbilicus. A large right-sided diaphragmatic defect (7 cm diameter) was encountered anteriorly to the liver with the entire right hemicolon and terminal ileum and omentum trapped inside. The hernia contents were gently reduced from the mediastinum (Figure 3(a)). The peritoneum at the anterior aspect of the defect was incised using an Enseal, and the entire hernia sac was care-fully mobilized out of the mediastinum, avoiding injury to the pleura or phrenic nerve. The Valsalva maneuver was applied to protrude the hernia sac from the chest facilitating exposure. The anterior portion of the hernia sac was resected and placed into a retrieval bag. The hernia defect was closed with multiple transfascial sutures. As this was a clean contaminated case, a 10 × 7 cm bioabsorbable Phasix™ ST Mesh (Bard, Warwick, RI, USA) was placed to protect the reconstruction ( Figure 3(b)); and the mesh was extraperitonealized using the dorsal flap of the hernia sac.
The redundant and partially twisted ascending colon was completely mobilized. The mesentery and omentum were thickened and chronically inflamed from displacement in the chest. The vascular pedicle was isolated and stapled. A 4 cm periumbilical incision including the 10-12 mm port site was made, and the colon was eviscerated and resected, with creation of an extracorporeal ileocolic anastomosis using two loads of the 75 mm GIA. The hernia sac was then removed from the abdomen. Pathology revealed pT3N1M0 moderately differentiated adenocarcinoma (4 cm diameter) with one of 50 harvested lymph nodes being positive.
The patient had no postoperative complications and was discharged after three days, with returned bowel function. A port-a-cath was placed two weeks later, and chemotherapy was initiated. He did well, and chest X-ray showed no evidence of a recurrent diaphragmatic hernia. He died five months later from a cardiac event possibly associated with chemotherapy.

Discussion
We herein report the first st patient undergoing right hemicolectomy together with Morgagni hernia repair using a   Case Reports in Surgery complete laparoscopic approach. This is only the second nd case of a colon cancer in a Morgagni hernia in the US, and the seventh th case worldwide. A review of the literature was undertaken using PubMed and Google Scholar databases, with search criteria including: Morgagni hernia, Bochdalek hernia, diaphragmatic hernia, hiatal hernia, and paraesophageal hernia; combined with colon cancer/carcinoma. This revealed only eight similar patients. A case in which barium enema suggested colon cancer but intra-operatively no colon mass was found, was excluded [16]. Karakis et al. described a left colon cancer projecting in the chest due to left diaphragmatic eventration and not a diaphragmatic hernia [17]. Table 1 summarizes the previously reported eight similar cases and our case. The first case of colon cancer in Morgagni hernia was published in 1977 by Dawson and Jansing [7] from Kentucky, USA, within a series of Morgagni hernias. Doutre et al. [8] in 1980 in France and subsequently Kochling et al. in 1990 in Germany [10] reported the next cases. Kochling et al.'s patient had liver metastases at the time of diagnosis and received palliative chemotherapy. He had later an open ileocolonic bypass for bowel obstruction. The cancer was in the distal transverse colon, and the diaphragmatic defect was on the left side, therefore more likely being a Bochdalek or left Morgagni hernia. The next report from Norway described a patient with a chest mass and pleural empyema, which was drained, and after recovery, transthoracic surgery was done, but no operative details are provided [6]. A case from Greece described the only colon cancer in a traumatic left diaphragmatic hernia, which was approached through a thoracoabdominal incision [11]. Turner et al. from New Zealand reported an appendix adenocarcinoma in a Morgagni hernia, and they used a Chevron incision for access [13]. The last two cases came from Bosnia-Herzegovina and Spain [9,12]; one patient underwent emergent laparotomy, and the other case by Rabal Fueyo published in 2018 was the first st case with a laparoscopic approach of the hernia, but the colectomy was done in an open fashion. Outcome in the reported cases was deter-mined by the course of the malignancy. The diaphragmatic hernia repair was done in most cases with interrupted sutures, but mesh repair was used in three patients and no recurrent diaphragmatic hernia was reported. In our case, transfascial absorbable sutures were used and the reconstruction was reinforced with a Phasix Mesh. This was done prior to the colon resection, and the mesh was covered with the posterior flap of the hernia sac to protect against infection. Morgagni hernia repair has in general a good prognosis, with low operative morbidity and mortality and low recurrence rates [4].
Intrathoracic colon cancers associated with diaphragmatic hernias are very rare occurrences. It is unclear why colon cancer in Morgagni hernias is much more common than in other diaphragmatic hernias. We have not found a single case of colon cancer associated with a type 4 hiatal hernia; however, large paraesophageal hernias have been found to contain gastric cancer [18] and other tumors such as gastrointestinal stromal tumors [19], with Wolfe et al. reporting ovarian cancer metastases causing a symptomatic paraesophageal hernia [20]. One explanation for the differences seems to be the much higher incidence of ascending colon compared to descending colon cancer. In addition, the right colon is rather mobile and can easily protrude through a Morgagni hernia. If the transverse colon contains a cancer, proximal colonic dilatation may push the colon through a preexisting right-rather than a left-sided diaphragmatic defect. Herniation of the sigmoid colon, which has the second nd highest cancer rate in the colon, through the diaphragm is very unlikely. Development of a left-sided iatrogenic diaphragmatic hernia has been reported after laparoscopic resection of a splenic flexure cancer [21].
Our patient presented with anaemia, and colonoscopy established diagnosis of a colon cancer. Colonoscopy was done extremely carefully especially during passage through the chest. Only one of the previously reported patients had a colonoscopy as well; however, this patient's diagnosis had been already established by biopsy of his liver metastases [10].

Case Reports in Surgery
To summarize, colon cancer in diaphragmatic hernias is extremely rare. Combined laparoscopic repair of the hernia and oncologic colectomy can be safely undertaken.

Data Availability
The data cannot be shown due to HIPAA restrictions.

Conflicts of Interest
The authors declare that they have no conflicts of interest.