Bilateral Morgagni hernia: operative discovery of appendix lying on superior pulmonary vein

Abstract

A patient presented having an acute abdomen on a background of a twelve-month history of worsening asthma. Computed tomography showed giant bilateral intrathoracic hernias extending to both thoracic apices. Our case was unusual as the defect was bilateral and left-sided. Surgical repair revealed each hernia sac measuring >20 cm and to contain the entirety of the small bowel and colon (including retroperitoneal bowel). The appendix was discovered adjacent to right superior pulmonary vein. Both sacs were excised and the defects dissected and transfixed in a single stage operation. In the post-operative stage, he developed a 6.3 cm fluid collection anterior to the right atrium and a left-sided pleural effusion. Morgagni hernias can escape detection and be attributed to other diagnoses courtesy of false localising signs on clinical examination and symptoms in the history.

Symptomatic bilateral Morgagni diaphragmatic hernias in an elderly patient

“…5 In the few prior case reports of bilateral hernia in adults the age of presentation is typically lower (4th to 5th decade); our patient was unique in presenting so late in life, having been completely asymptomatic up until her 9th decade. 6 , 7 …”

“…Contrast fluoroscopy may also be normal. 1 , 7 , 10 , 11 Though the diagnosis of Morgagni hernia is most commonly made incidentally on plain radiography, in the acute setting the findings are insufficiently sensitive or specific to be relied on in isolation. Thus where there is diagnostic uncertainty or a clinical suspicion of diaphragmatic hernia, CT is the gold standard for investigation due to the near-perfect sensitivity and allowing for detailed surgical planning.…”