Anceslo Idicula, MS, MB, Milad Mohammadi, MD, Onur Kutlu, MD, Vernon M Williams, MD, FACS, Steven G Garcia, MD. Texas Tech Health Science Center
Morgagni hernia, encompass a rare subset of all diaphragmatic hernias, consisting of roughly 3% of all diaphragmatic hernias. In the adult populations, such hernias tend to present asymptomatically. Traditional approaches to management involved open surgical repair via transthoracic or transabdominal route. Advances in minimally invasive techniques have brought about the implementation of laparoscopic techniques as an alternative method of therapeutic utility. Furthermore, the presentation of Gastrointestinal Stromal Tumor (GIST), the most common benign non-epithelial tumor of the gastrointestinal tract constitutes a small percentage of primary GI cancer, with a greater predominance of 60% found in the stomach. The concurrent findings of both Morgagni defect and GIST present an uncommon epidemiological finding. The rarity of both pathologies operating concurrently presented a unique opportunity to utilize a laparoscopic approach to accomplish management under a single operation.
A 70 year old female presented with a 1 week history of cough and shortness and breath. The patient had radiographic findings of a right middle lobe atelectasis with a possible obstructing lesion. Computed tomography (CT) was performed of the chest showed a large anterior diaphragmatic hernia with a loop of transverse colon causing compression of the right middle lobe. The CT of the abdomen also showed a large 10 cm by 10 cm exophitic mass in the stomach consistent with a GIST. The case proceeded laparoscopically with a primary repair of the diaphragmatic hernia and hand-assisted gastric wedge resection of the GIST due to the large size. Patient had an uneventful recovery and was discharged home five days later.
Surgical management of the GIST involves resection with procurement of margins free of tumor. Moreover, the traditional approach for Morgagni hernia repair utilizes open transabdominal or transthoracic repair techniques with reduction of the primary hernia followed by closure of the defect. With the advent of minimally invasive laparoscopic techniques, alternative surgical approaches to Morgagni hernias first proposed by Kuster et al. has now gained considerable recognition. Current laparoscopic techniques include a tension free closure of the defect with or without mesh or a combination of direct suturing technique via intracorporeal continuous or interrupted, extracorporeal or a combination of the two. Therefore, after consideration of the potential increased risk of the surgical site infection with mesh, repair using direct trans-fascial suturing technique demonstrated superior advantage in reducing postoperative complications while minimizing multiple surgical procedures. Hand assisted laparoscopic surgery (HALS) is well described for colon resection and splenectomy, but review of the literature showed only one case report of GIST resection by this method. The use of HALS in this case was warranted based on the large size of the tumor as was also described by Yano et al.
The use of hand assisted laparoscopic surgery has facilitated additional surgical management options for patients in unique case presentations such as this one with concurrent Morgagni hernia and GIST. These promising advances provide alternative routes of management in order to minimize postoperative complications and a reduction in multiple surgical interventions.