Operation for repair of obstructed substernocostal (Morgagni) hernia.

A complicated case of large substernocostal hernia in a 67-year-old man is described. A new surgical approach via upper laparotomy which can be extended by a lower median sternotomy, allowing complete access to the hernia was tried successfully and the patient's recovery was uneventful. A hernia occurring through a retrosternal defect first described by Morgagni in 1769 has received many names, among which that of substernocostal hernia' appears more appropriate. The embryology and anatomical variations of this type of hernia have been fully reported.2-4 It has been pointed outl 3 5 that these herniae are rare and many do not require repair. For those patients requiring operation, abdominal,2 3 thoracic,2 or substernal4 approaches may be used according to the experience of the operator, and the anatomical variations of the herniae. In six previous cases we undertook the repair through a thoracotomy in three patients and a laparotomy in the other three with relative ease. In a particularly complicated case such as the one reported below these approaches may prove inadequate and arduous. This paper concerns a new surgical approach and operation (abdomino-mediastinal) for such herniae. A 67-year-old man was transferred to our unit from another hospital as an emergency because of vomiting, haematemesis, and melaena for two to three days. He was thought to have a "Morgagni' hernia the exact details of which were not known. On admission the patient was shocked with signs of upper alimentary tract obstruction. Initially, he was treated by anti-shock therapy, blood transfusion, and naso-gastric tube suction for decompression. Full investigations including chest radiograph, endoscopic examination, and barium swallow confirmed the diagnosis of obstructed substernocostal Humberside. hernia containing the stomach, the first part of duodenum, and some small bowel loops. An emergency operation was planned. Operation The patient was placed in the supine position. A laparotomy was carried out through an upper midline incision. This confirmed the diagnosis of a substernocostal hernia with a sac containing the upper abdominal viscera protruding into the anterior mediastinum, the left chest, and predominantly the right chest. A complete assessment of the hernia and its contents was impossible because of the relatively narrow opening of the defect. Even incising the edges of the neck of the sac did not allow reduction of the sac or the contents. The skin incision was therefore extended upwards over the xiphoid process and the lower part of the body of the sternum. A …