Acta chir belg, 2007, 107, 432-435

Larrey Hernia Complicated with Colonic Obstruction in a 77-Year-Old Woman :

a Case Report
O. Mentes*, M. Balkan*, E. Kesim*, M. Eryilmaz**, U. Bozlar***, R. Senocak*, O. Kozak*, T. Tufan*
Department of General Surgery*, Department of Emergency Medicine**, Department of Radiology***, Gülhane
Military Medical Faculty, Ankara/Turkey.

Key words. Larrey hernia ; intestinal obstruction.

Abstract. Congenital Larrey hernia has a rare incidence and is frequently diagnosed in the later decades of life. This
case study presents a 77-year-old woman with Larrey hernia and an intestinal obstruction complication, treated with
laparatomic surgery.

Introduction Since Larrey hernias or left-sided diaphragm hernias

Subcostosternal diaphragmatic hernia is an uncommon
form of diaphragmatic hernia. In 1769, during his autop-
sy examinations, Morgagni first described the substernal
herniation of abdominal contents into the thoracic cavi-
ty. In 1828, Larrey described a surgical approach to the
pericardial cavity through an anterior diaphragmatic
defect (1).
The space of Larrey, or foramen Morgagni, is a defect
in the diaphragmatic musculature usually caused by the
failure of the anterolateral component to fuse with sep-
tum transversum. It occurs at the level of the seventh rib
on either side of the xiphoid in a space usually filled
with fat, through which the superior epigastric arteries
and veins pass (2). A congenital disorder of the embry-
ologic fusion of fibrotendinous elements of the costal
and sternal parts of the diaphragm muscles is a possible
cause for the development of this rare herniation (3).
Larrey hernias result from a weak area in the anterior
retrosternal muscle at the minor apertures, where the
superior epigastric artery and vein and associated lym-
phatic vessels pass from the thorax into the rectus
sheath. The location is parasternal rather than mid-
line (4).
A hernia through the right sternocostal hiatus is
referred to as a Morgagni hernia, while a hernia through
the left hiatus is termed a Larrey hernia and a bilateral
hernia is a Morgagni-Larrey hernia (5).
While patients with these hernias may present with
chest pain or obstructive symptoms, including vomiting,
many remain asymptomatic and their hernias are dis-
covered incidentally during chest radiograms or other
studies. Surgical repair of these hernias is indicated even
in asymptomtomatic patients because of the danger of
intestinal incarceration (6).
with colonic obstruction are rarely encountered in the
literature, we hereby present a rare case complicated by
intestinal obstruction due to an incarcerated omentum
within a Larrey hernia.
Case report
A 77-year-old woman was admitted to the emergency
surgical unit with acute symptoms of intestinal obstruc-
tion without previous episodes. She had diffuse abdom-
inal pain, constipation and had failed to pass flatus for
4 days. Historically, she had been suffering chronic con-
stipation for 15 to 20 years. On her physical examina-
tion, she had mild abdominal distension and tenderness.
The bowel sounds has increased. There was no medical
history of abdominal surgery or trauma. Abdominal
radiograms obtained in the upright position revealed
multiple air-fluid levels beneath the diaphragm, proba-
bly due to colonic obstruction (Fig. 1). However, on
anteroposterior chest radiogram, a soft tissue density on
the left side was noticed (Fig. 2). Thoraco-abdominal
CT was done, which showed fat and air densities just
above the liver extending through the right hemithorax,
and dilated colonic segments with air-fluid levels.
Consequently, intestinal obstruction and diaphragmatic
hernia was suspected (Fig. 3). Elective surgery was car-
ried out through a midline laparotomy. The size of the
Larrey hernia was 4
3 cm, and the gap was through the
right hemithorax front of the pericardium (Fig. 4). The
hernia contained incarcerated omentum majus and small
segments of transvers colon. The hernia was the proba-
ble cause of the colonic obstruction. The defect on the
left anterior diaphragma was repaired with non-
absorbable running sutures and patched with a tailored
polyprolen mesh. Then a closed suction drain was
Larrey Hernia with Colonic Obstruction 433

Fig. 2
Chest x-ray demonstrates soft tissue density in the left chest

Fig. 1
Abdominal radiographs obtained in the upright position
reveals multiple air-fluid levels beneath the diaphragm, due to
colonic obstruction.

placed in the end of the operation. The drain was left for
4 days and the patient was discharged on the 7th post-
operative day.

Discussion

Morgagni hernias are usually diagnosed during the first

decade of life, but most of them are asymptomatic and
may be discovered in adult life because of acquired con-
ditions (e.g. obesity or pregnancy, constipation and trau-
ma) that increase abdominal pressure enlarging the her-
nia with age (7).
About 30% of cases are asymptomatic and diagnosed
incidentally by routine examinations. While dsypne
caused by a herniated sac increasing in size is common
in early childhood, retrosternal and chest pain is more
likely in elderly patients (8).
Fig. 3
Symptoms are usually related to abdominal pain, The reformatted multislice CT image on coronal plane, fat and
intestinal obstruction, chest pain or obstruction of the air densities above the liver in the right chest.
herniated organs. If the bowels are strangulated, abdom-
inal symptoms will become acute (9).
Although a Morgagni hernia is secondary to incom- effort or obesity (10, 11). It is thought that chronic
plete development of the diaphragm, it can be caused by constipation lasting 15 to 20 years was responsible in
various factors such as chronic cough, trauma, severe the etiology of the hernia formation in this patient.
434
Fig. 4
Intra-operative view of a Larrey hernia defect on the left
diaphragm following reduction of omentum and transverse
colon.
It is stated that Morgagni-Larrey hernias usually have
a covering or sac that contains omentum, the transverse
colon and, on rare occasions, the stomach or liver, but
may also occur without any sac. In our patient, omentum
and the transverse colon were found in the hernia con-
tents but there was no hernial sac (2, 12, 13).
Differential diagnosis in considering Morgagni-
Larrey hernia include ; epicardial fat pads, evantrations
of the diaphragm, hiatal hernia, Bochdalech hernia, trau-
matic diaphragmatic rupture, diaphragmatic tumour,
large anterior mediastinal mass, right middle hepatic
lobe shrinkage, pneumonic consolidations, mediastinal
lenfoma and pericardial cyst (14-17).
In diagnosis, the most appropriate and least invasive
imaging modalities are routine chest upright plain radi-
ography and CT (18). Most Morgagni hernias appear as
a gas-fluid level in bowel loops, or a soft tissue mass
above the right dome of the diaphragm (8, 19). The lat-
eral plain radiogram may be helpful in identifying the
location of the hernia (18). Diagnosis is usually made by
frontolateral chest radiograms and a barium enema or
barium swallow test to confirm the diagnosis (20).
Radionuclide liver scans may be required to exlude liver
herniations (21).
CT scan is the best imaging method for demonstrat-
ing omental fatty tissue and intestinal air out of their
location, without the need for contrast studies (22). The
use of CT scan as a diagnostic tool in patients with
Morgagni-Larrey hernia has increased reliability during
pre-operative diagnosis (1).
Surgical treatment
In symptomatic patients presenting with obstruction or
other symptoms, the management is controversial.
O. Mentes et al.
Although some authors recommend that asymptomatic
hernia in adults does not require surgery (23, 24), many
authors advocate surgical correction for both sympto-
matic and asymptomatic cases in order to prevent possi-
ble complications of strangulation and enlarging of the
herniated sac, and to avoid unnecesary morbidity (6, 22,
25, 26). However, in asymptomatic elderly patients the
surgical approach may be avoided if the surgical risk is
estimated to be high (4).
Recently, uncomplicated endoscopic surgery with
primary suturing or mesh repair has been described as a
safe and effective method for treating Morgagni-Larrey
hernias. The developments in minimally invasive thora-
coscopic and laparoscopic techniques have decreased
the incidence of morbidity. These minimally invasive
laparoscopic technniques seem likely to replace the tra-
ditional open transabdominal approach as a preferred
option for repair (1, 4, 27, 28).
Debate continues regarding the modality of hernia
defect closure ; whether to use only primary repair or to
add prosthetic mesh material. Some investigators choose
primary closing rather than continuous suture ; others
prefer to use interrupted non-absorbable sutures in cases
of small defect repairs. Prosthetic mesh may be pre-
ferred, depending on the size of the defect (5). The use
of a drain in the residual cavity of the hernia is recom-
mended in order to avoid the formation of a cyctic space
and to allow the tissue integration of the sac with the
mesh side. Closed suction drains are probably preferable
as the primary option (4). We placed a closed suction
drain to prevent cyctic formation.
In conclusion, Larrey hernia complicating with intesti-
nal obstruction is so rare that patients are usually asymp-
tomatic. Routine basic radiographic studies such as
anteroposterior chest radiogram may be sufficient to
diagnose, however CT scan may be added for pre-oper-
ative work-up. Once diagnosed, these hernias should be
referred for surgical repair. The transabdominal
approach with interrupted nonabsorbable sutures
remains the preferred method of repair, as is used in the
currently presented case.
References
1. MINNECI P. C., DEANS K. J., KIM P., MATHISEN D. J. Foramen of
Morgagni Hernia : changes in diagnosis and treatment. Ann
Thorac Surg, 2004, 77 : 1956-1959.
2. LIN S. T., MOSS D. M., HENDERSON S. O. A case of Morgagni
hernia presenting as pneumonia. J Emerg Med, 1997, 15 : 297-
301.
3. PERCIVALE A., STELLA M., DURANTE V., DOGLIOTTI L., SERAFINI G.,
SACCOMANI G., PELLICI R. Laparoscopic treatment of Morgagni-
Larrey hernia : technical details and a report of a series. J Laparo-
endosc Adv Surg Tech A, 2005, 15 : 303-307.
4. CONTINI S., VALLE R. D., BOTANI L., ZINICOLA R. Laparoscopic
repair of a Morgagni hernia : a report of a case and review of the
literature. J Laparo-endosc Adv Surg Tech A, 1999, 9 : 93-99.
Larrey Hernia with Colonic Obstruction
5. LIMA M., DOMINI M., LIBRI M., MORABITO A., TANI G., DOMINI R.
Laproscopic repair of Morgagni-Larrey hernia in a child. J Pediatr
Surg, 2000, 35 : 1266-1268.
6. PURI P. Congenital diaphragmatic hernia. Curr Prob Surg, 1994,
31 : 787-847.
7. BORTUL M., CALLIGARIS L., GHELLER P. Laproscopic reapir of a
Morgagni-Larrey hernia. J laparo-endosc Adv Surg Techn, 1998,
8 : 309-313.
8. BERMAN L., STRINGER D., EIN S. H., SHANDLING B. The late pre-
senting pediatric Morgagni hernia : a benign condition. J Pediatr
Surg, 1989, 24 : 970-972.
9. BARUT I., TARHAN O. R., CERCI C., AKDENIZ Y., BULBUL M.
Intestinal obstruction caused by a strangulated Morgagni hernia in
an adult patient. J Thorac Imaging, 2005, 20 : 220-222.
10. BRAGG W. D., BUMPERS H., FLYNN W., HSU H. K., HOOVER E. L.
Morgagni hernias : an uncommon cause of chest masses in adults.
Am Fam Physician, 1966, 54 : 2021-2024.
11. EREN S., GÜMÜŞ H., OKUR A. A rare cause of intestinal obstruction
in the adult : Morgagni hernia. Hernia, 2003, 7 : 97-9.
12. SORTEY D. D., MEHTA M. M., JAIN P. K., AGRAWAL S. R.,
GADGARI S. M., RAGHAVAN M., BHANSALI S. K. Congenital hernia
through the foramen of Morgagni (a case report). J Postgrad Med,
1990, 36 : 109-111.
13. NURSAL T. Z., ATLI M., KAYNAROĞ LU V. Morgagni hernia in a
patient with Morgquio syndrome. Hernia, 2000, 4 : 37-39.
14. ANTHES T. B., THOONGSUWAN N., KARMY-JONES R. Morgagni hernia
: CT findings. Curr Probl Diagn Radiol, 2003, 32 : 135-136.
15. POKORNY W. J., MCGILL C. W., HARBERG F. J. Morgagni hernias
during infancy : presentation and associated anomalies. J Pediatr
Surg, 1984, 19 : 394-397.
16. GOSSIOS K. J., TATSIS C. K., LYKOURI A., CONSTANTOPOULOS S. H.
Omental herniation through the foramen of Morgagni. Diagnosis
with chest computed tomography. Chest, 1991, 100 : 1469-1470.
17. YEAGER B. A., GUGLIELMI G. E., SCHIEBLER M. L., GEFTER W. B.,
KRESSEL H. Y. Magnetic resonance imaging of Morgagni hernia.
Gastro-intest Radiol, 1987, 12 : 296-298.
18. EREN S., CIRIS F. Diaphragmatic hernia : diagnostic approaches
with a review of the literature. European Journal of Radiology,
2005, 54 : 448-459.
19. ELLYSON J. H., PARKS S. N. Hernia of Morgagni in a trauma
patient. J Trauma, 1986, 26 : 569-570.
435
20. DEL CASTILLO D., SANCHEZ J., HERNANDEZ M. et al. Morgani’s
hernia resolved by laparoscopic surgery. J Lapro-endosc Adv
Surg Techn, 1998, 8 : 105-108.
21. KONSTANTINOS J. G., CHROSTOS K. T., LYKOURI A., CONSTANTO-
POULOUS S. Omental herniation throuhg the foramen of Morgagni.
Chest, 1991, 5 : 1469-1470.
22. FEDERICO J. A., PONN R. B. Foramen of Morgagni hernia. In :
SHIELDS T. W., LOCICERO III J., PONN R. B. (eds.). General thoracic
surgery. 5th ed. Philadelphia : Lippincott Williams and Wilkins,
2000, p. 647-60.
23. WOLLOCH Y., GRUNEBAUM M., GLANZ I., DINTZMAN M.
Symptomatic retrosternal (Morgagni) hernia. Am J Surg, 1974,
127 : 601-605.
24. SOYLU H., KOLTUKSUZ U., KUTLU N. O., SARıHAN H., SEN Y.,
USTUN N. et al. Morgagni hernia : an unexpected cause of respira-
tory complaints and a chest mass. Pediatr Pulmonnol, 2000, 30 :
429-433.
25. HUSSONG R. L., LANDRENEAU R. J., COLE F. H. Diagnosis and repair
of a Morgani hernia with video assisted thoracic surgery. Ann
Thorac Surg, 1997, 63 : 1474-1475.
26. NGUYEN T., EUBANKS P. J., NYGUEN D., KLEIN S. R. The laparo-
scopic approach for the repair of Morgagni hernias. J Soc Laparo-
endosc Surg, 1998, 2 : 85-88.
27. KURKCUOGLU I. C., EROGLU A., KARAOĞLANOĞLU N., POLAT P.,
BALIK A. A., TEKINBAS C. Diagnosis and surgical treatment of
Morgagni hernia : a report of three cases. Surg Today, 2003, 33 :
525-528.
28. TARIM A., NURSAL T. Z., YıLDıRıM S., EZER A., CALISKAN K.,
TORER N. Laparoscopic repair of bilateral Morgagni hernia. Surg
Laparosc Endosc Percutan Tech, 2004, 14 : 96-97.
O. Mentes
GATA Genel Cerrahi AD 06018
Etlik / Ankara / TURKEY
Tel. : +90.312.304 50 15
Fax : +90.312.304 51 00
E-mail : onermentes@yahoo.com