J Thorac Cardiovasc Surg 2008;135:955-956
© 2008 The American Association for Thoracic Surgery
A new type of diaphragmatic hernia: Anterolateral hernia
Jérôme Mouroux, MD, PhD,
Daniel Pop, MD*,
Patrice Guiraudet, MD,
Ricardo Giovanetti, MD,
Jérôme Lauron, MD,
Nicolas Venissac, MD
Thoracic Surgery Department, Pasteur Hospital, Nice, France
Received for publication September 14, 2007; accepted for publication December 4, 2007.
* Address for reprints: Daniel Pop, MD, Thoracic Surgery Department, Pasteur Hospital, Buiding H1, 30 Avenue de la Voie Romaine, 06002 Nice, France. (Email: danielpopch{at}yahoo.com).
Heterogenous types of acquired hernias in the diaphragm have been described in the literature: the hiatal hernia through the esophageal foramen and the posterolateral hernia through the Henle costolumbar orifice or anterior foramen of Larrey-Morgagni hernia (retroxiphoid hernias).1,2
To our knowledge, no anterolateral hernia has been reported. We describe the case of a hernia between the eighth and ninth anterior costochondral insertion of the muscular fibers of the diaphragm.
Clinical Summary
A 76-year-old man had a medical history of diabetes mellitus, arterial hypertension, a bilateral inguinal hernia (operated), and a 2/3 gastrectomy for gastric ulcer (50 years ago). In 1999, a chest x-ray showed an air-filled opacity in the left thoracic base. No further investigations were done. In September of 2005, the patient experienced a blocking respiration symptom in the left hemithorax, especially after meals and occasionally associated with vomiting. The chest x-ray showed colic haustration at the left thoracic base. A gastroesophageal endoscopy showed no anomaly. The cardial sphincter was 40 cm from the incisor teeth, and the gastric stump and duodenal-gastric anastomosis were healthy. The barium esophagography showed a normal cardial region. The chest computed tomography scan demonstrated a colic ascent in the left thorax and the small intestine through an anterolateral hole of the diaphragm (
Figure 1).
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Figure 1. Saggital computed tomographic scan showing the diaphragmatic hernia; transversal slice in frame.
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Surgery was performed via a low left posterolateral thoracotomy. We found the peritoneal sac containing the digestive loops (
Figure 2). After clearly identifying the edges, we resected and closed the sac. These edges corresponded to the muscular fibers of the diaphragm inserted at the eighth and ninth chondrocostal cartilage. The hole measured 10 cm in the anteroposterior diameter, was located far from the retroxiphoid region, and ended at the central tendon. The closure was done with nonabsorbable sutures. The postoperative period was uneventful, and the follow-up was marked by a normal chest x-ray and the disappearance of symptoms.
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Figure 2. Perioperative view with the muscular fibers of the diaphragm (peritoneal sac resected). Peritoneal sac and colon (upper right). The defect is repaired (lower right).
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Conclusions
There are two anatomic types of classic retroxiphoid hernias: The first type is located in a median weakness area situated between the sternal muscular fibers of the diaphragm, also known as Marfan's foramen. The second type is located between the muscular fibers of the xiphisternum and the costal margins traversed by the internal thoracic artery (that becomes the superior epigastric artery), also known as Larrey's space or Morgagni's foramen.1,2 Most authors think that the lack of fusion or muscularization of the pleuroperitoneal membrane leads to a defect in the costosternal trigones.3,4 In 90% of cases, retroxiphoid hernias are located on the right side.1 We observed a left anterolateral hernia outside these weakness points of the diaphragm. Laterally, from an anatomic point of view, the muscular fibers of the diaphragm extend from the central tendon to the rib cage, where they are mixed with the insertions of the abdominal transverse muscle. Each insertion allows the passage of the intercostal pedicle.5 We suppose that this area of passage can be exposed to weakening. Our patient had no trauma in his medical history, and the prior gastric surgery (via median laparotomy) is an unlikely cause because it was performed several years ago.
This anterolateral hernia must be considered as a "weakness" hernia, similar to the inguinal hernia the patient previously had. The surgical treatment of this hernia was correct because of the potential life-threatening complications similar to the other types of diaphragmatic hernias.
References
- Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-468.[Medline]
- Mouroux J, Venissac N, Alifano M, Padovani B. Morgagni hernia and thoracic deformities. Thorac Cardiovasc Surg 2003;51:44-45.[Medline]
- Kelly KA, Bassett DL. An anatomic reappraisal of the hernia of Morgagni. Surgery 1964;55:495-499.[Medline]
- Shumpelick V, Steinau G, Schulper J, Prescher A. Surgical embryology and anatomy of the diaphragm with surgical application. Surg Clin N Am 2000;80:213-239.[Medline]
- Rouvière H. Anatomie Humaine. 10th Edition. Paris: Masson & Co; 196787-92.
