INCIDENTAL MORGAGNI HERNIA FOUND DURING PANCREATITIS ACUTE: CASE REPORT

Ratbi El. Amine, Bakali Youness, Lemhouer Walid, Alaoui Mhamdi Mouna, Sabbah Farid, Raiss Mohamed and Hrora Abdelmalek Surgical Clinic C, University Hospital Ibn Sina, Rabat, Morocco. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 05 June 2020 Final Accepted: 10 July 2020 Published: August 2020

Morgagni hernia or parasternal hernia is a very rare entity of congenital diaphragm hernia with a frequency of 3% of all diaphragmatic hernias, is defined as the intrathoracic protrusion of abdominal viscera through a defect in anterior diaphragm. We report a case of 60-years-aldfemale with no past medical history, incidentally discovered Morgagni hernia during an abdominal CT for acute pancreatitis. Her vital signs were normal, while physical examination was founded discomfort and tenderness during epigastric palpation without any other associated signs.Abdominal TC was performed, and images before the administration of contrast material showed the Morgagni hernia with the presence of abdominal viscera inside chest cavity associated to the diastasis of the 5 (mm? cm?) diaphragmatic fibres, the hernial sac containing a part of stomach and transverse colon and none signs of obstruction. The patient underwent the reduction of the content hernia excision of the sac and mesh-free repair method using non-absorbable sutures an laparoscopy, the patient evolved favourably. The aim of this study was to describe theclinical characteristics and surgical outcomes of MH repair based on operative approach.

Introduction:-
Morgagni hernia or parasternal hernia is a very rare entity of congenital diaphragm hernia with a frequency of 3% of all diaphragmatic hernias (1). It was foremost designated by the Italian pathologist and anatomist Giovanni Morgagni in 1769 (2), characterized by the protrusion the abdominal viscera inside the thoracic cavity, through a defect in the anterior diaphragm, known as foramina of Morgagni (3). In adult, most cases is asymptomatic and usually discovered during a chest x-ray, but that can be complicated in 10 to 15% of cases, most often of intestinal obstruction (4).We are representing a case of Morgagni hernia revealed by a pancreatitis acute.

Presentation of case:-
A 60-years-old-femalebrutally presenting abdominal pain pancreatic type with vomiting, his medical story was without notable pathological. Her vital signs were normal, while physical examination was founded discomfortand tenderness during epigastric palpation without any other associated signs. Laboratory examinations revealed a lipasemia to 600 U/L, CRP to 110 mg/land white count a 10000/mm3. After the initial conditioning, the patient was hemodynamically stable, abdominal ultrasound as etiological check-up was normal. Abdominal computed tomography (TC) was performed, and images before the administration of contrast material showed the Morgagni ISSN: 2320-5407 Int. J. Adv. Res. 8(08), 206-210 207 hernia with the presence of abdominal viscera inside chest cavity associated to the diastasis of the 50mmdiaphragmatic fibres, the hernial sac containinga part of stomach and transverse colon and none signs of obstruction ( Figure 1). After 3 weeks' time needed to decrease the acute pancreatitis, the patient underwent a surgical laparoscopic, upon entering the abdominal cavity, a huge anterior diaphragmatic defect was identified, with part of the greater omentum, transversal colon, and gastric protruding through inside the right thoracic cavity. No adhesions were encountered, the hernia's sac contents and their reduction back in abdominal cavity was achieved through laparoscopy and excision of the sac was next performed with a tension free closure of the diaphragmatic defect according Raphy (Figure 2). The patient evolved favourably and was discharged on her fourth postoperative day. a. b.

Discussion:-
Morgagni hernias are a rare type of congenital diaphragmatic hernia that may not be clinically apparent until adulthood. That result of weakness or defect in the diaphragmatic musculature and the difference in the pressure gradient between the abdominal and pleural cavities.
The incidence among adults with all types of diaphragmatic hernia is about 3% (5). in the pediatric age group, it occurs in about 5% of the patients, but great differences exist among series.
The most of Morgagni hernia evolves from right sternocostal trigone. Left-sided Morgagni hernia as our case, is observed in 9% of all cases (5% isolated and 4% bilateral (4). Such rare occurrence is attributed to the protective effect of the pericardial sac (6) 209 Almost any intra-peritoneal structure can be found in a Morgagni hernia especially omentum exclusively (34%) or colon and omentum (29%), stomach, liver and small intestine may be also seen (4).
In adult, the symptoms of MH are related to the content of hernia or the pressure exerted on the thoracic stuctures with common symptoms including pulmonary symptoms (dyspnea and persistent cough) and retrosternal chest painor gastric symptoms (7). Horton et al reported that less than on third of patient (28%) have no symptoms at time of presentation and are discovered incidentally (4) as our patient. A few cases of reported MH describe patients with acute abdominal symptoms due to gastric obstruction (6).
Chest X-ray, MH may appear as homogenous masses around or overlying the cardiac silhouette, or air-fluid levels include bowel or stomach (8). CT play an important role in the diagnosis, and most often identifies the extent and content of hernia (6). Additionally, gastrointestinal contrast can be detecting Morgagni's hernia if the sac contains parts of the stomach and proximal small bowel (1). In our case the diagnosis was made by the CT.
Surgery repair prompt even on asymptomatic patients to avoid the risk of incarceration and strangulation of abdominal content in the chest once the Morgagni hernias was diagnosed (7,9).In the literature, the primary repair via laparotomy or thoracotomy has been the preferred surgical approach and has been shown to be a safe procedure and produces a durable repair (10). Currently, the laparoscopic approach become more commonplace giving a better exposure and visualization of the hernia and its contents thus allows performing out gestures intra-abdominal. Although this approach in compared as the traditional open approach give higher patient satisfaction and a shorter hospital stay (4,11).
Frequently primary closure of the defect may be effected with non-absorbable, but larger defects may require the use of mesh (11). Monsivais et al. (12) used single-incision laparoscopic port with adequate reduction of the hernia, excision of the sac, and applying mesh over the diaphragmatic defect from 2 cm incision. Furthermore, Hassan et al. (13) choose to leave the hernia sac in-situ to avoid the risk of pneumomediastinum and injury to thoracic structures. Although some authors prefer the excision of the sac especially as it decreases the rate of morbidity as the fluid collection and reduces the tissue trauma, because the sac is manipulated instead of the content (4).Monsivais et al., (12) used single-incision laparoscopic port with adequate reduction of the hernia, excision of the sac, and applying mesh over the diaphragmatic defect from 2 cm incision.
In our case, we adopted the mesh-free repair method, using non-absorbable sutures with excision of the sac, The complication and operative mortality is rare for both laparoscopic and open surgical methods; among 50 cases there were no deaths and no known recurrences (5,14), no such complications were noticed in our case.