Jurnal Kedokteran Syiah Kuala ISSN: 1412-1026

Volume 17, Number 2, Agustus 2017 E-ISSN: 2550-0112

Pages: 93-102 DOI: https://doi.org/10.24815/jks.v17i2.8988

BILATERAL MORGAGNI HERNIA IN INFANT, A RARE TYPE IN

CONGENITAL DIAPHRAGMATIC HERNIA: A CASE SERIES
1
Agung Wibawanto, 2Yopie Afriandi Habibie, 2Arman

1
Division of Thoracic Cardiac & Vascular Surgery, Departement of Surgery,
Persahabatan General Hospital, Medical Faculty of Indonesia University, Jakarta
2
Division of Thoracic Cardiac & Vascular Surgery, Departement of Surgery,
Zainoel Abidin General Hospital, Medical Faculty of Syiah Kuala University, Banda Aceh
Email: yopie98@yahoo.com

Abstrak. Hernia Diafraghma Kongenital (HDK) merupakan kelainan kongenital yang jarang ditemukan pada bayi. Hernia
Morgagni bilateral merupakan kasus yang sangat jarang ditemukan. Kami melaporkan kasus ini karena lokasi hernia
Morgagni yang bilateral yang sangat jarang dijumpai (kanan dan kiri). Kami laporkan dua kasus dari HDK. Kasus pertama
bayi perempuan usia 4 bulan dengan keluhan usus halus dan hati lobus kiri berada di dalam rongga dada yang berhubungan
dengan defek anterior dari hernia diafraghma. Kasus kedua neonatus perempuan usia 22 hari datang dengan keluhan
distress pernafasan, sesak nafas dan muntah. Pendekatan insisi subcotal dilakukan pada kedua pasien, dan defek dari hernia
diafrahgma ditutup dengan menggunakan goretex pacth dengan hasil yang sangat baik. Pasca operasi, kedua pasien dengan
kondisi sbaik, dan dipulangkan dari rumah sakit tanpa komplikasi. Berbagai macam teknik tindakan operasi telah
dipaparkan, dan pendekatan dengan tindakan laparotomy telah menjadi salah satu standar teknik operasi. Tindakan ini
dapat memungkinkan untuk mereduksi dan melihat isi dari hernia diafraghma tersebut, memudahkan untuk prosedur
operasi dalam merepair bileteral hernia diafraghmatika. Dan sekaligus juga dapat mengkoreksi jika terdapat kelainan
malrotasi dari usus halus. (JKS 2017; 2: 93-102)
Kata Kunci : Bilateral Morgagni Hernia, kondisi klinis non spesifik, pendekatan abdominal.

Abstract. Congenital diaphragmatic hernia (CDH) is a rare congenital anomaly in infant. Bilateral Morgagni Hernia is an
absolute rarity. We describe this case because of the absolute rarity of bilateral localization in Morgagni hernia.We present
2 case series of CDH, First case a 4-month-old baby girl was an intrathoracic bowel and left lobe liver associated with
anterior diaphragmatic defects in a symptomatic. Second case was a 22 days neonates girl, presented with respiratory
distress, shortness of breath and vomiting. Subcostal incision were done for both patients, defect was repair with goretex
pacth with a good result. Postoperatively, both of patient enjoyed an uneventful course and was discharged home without
any further events. Numerous approaches have been described and, particularly the significance of laparatomy has been
emphasized as an operative technique. This allows easy reduction and inspection of contents, allows access and repair of
bilateral hernias, and corrects an associated malrotation if present. (JKS 2017; 2: 93-102)

Key Words : Bilateral Morgagni Hernia, Non spesific Presentations, Abdominal Approach.

Introduction thoracic cavity based on observations made

Congenital diaphragmatic hernia (CDH) is a
rare congenital anomaly characterized by a
defect in diaphragm development with
subsequent herniation of abdominal contents
into the chest during fetal life. The two most
CDH are posterolateral (Bochdalek) and
anteriorly (Morgagni) hernias.1-6. First
described by Vincent Bochdalek in 1848, these
hernias usually become evident during the
neonatal period with signs and symptoms of
respiratory failure. In 1769, Giovanni Battista
Morgagni first described the substernal
herniation of abdominal contents into the
during autopsy examinations.3,4
Incidence of CDH varies from 1 in 2200 to 1 in
5000 births. Morgagni hernia is a rare
pathologic finding, representing approximately
3% to 5% of diaphragmatic hernias. Its
bilateral presentation is an absolute rarity, and
its description is based only on isolated case
reports. 80%-90% of Bochdalek hernia occur
on the left side. Between 5% to 25% of all
posterolateral hernias present after the newborn
period. Numerous approaches have been
described and, particularly the significance of

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 Wibawanto et al.- Bilateral Morgagni Hernia in Infant
laparatomy has been emphasized as an
operative technique.1,2,5-8
The mortality rate of infants born with CDH
remains high, despite optimal perinatal care,
has been attributed to pulmonary hypoplasia
and associated persistent pulmonary
hypertension. Newer management strategies
such as permissive hypercapnia, high
frequency oscillatory ventilation (HFOV),
inhaled nitric oxide (NO), extracorporeal
membrane oxygenation (ECMO) and delayed
surgical repair have emerged in the care of
high-risk CDH patients, which offer some hope
of improving overall survival.1,2,5,6
We present two case series with congenital
diaphragmatic hernia. First case was a
symptomatic 4-month-old baby girl with
intrathoracic bowel and liver associated with
bilateral anterior diaphragmatic defects.
Second case was a 22-days neonates girl who
presented with respiratory distress, with
intrathoracic bowel and spleen, lung hypoplasia
in the affected site who suspected as anterior
hernia, but found posterolateral diaphragmatic
defects intra operatively. Those patient were
successfully treated with abdominal approach.
We describe this case because of the absolute
rarity of bilateral localization in Morgagni
hernia and unsuspected posterolateral
diaphragmatic defects found intra operatively.
Case Report
Case 1
A 4-month-old baby girl was referred to our
centre with the diagnosis of the bilateral
anterior diaphragmatic hernia. Presented with
non specific symptoms of failure to thrives,
decreased of body weight, feeding difficulties,
often vomiting when breast milk, and
respiratory tract infection. Vital sign was
stable. No associated anomalies was found.
Physical examination found scaphoid
+abdomen, epigastric, intercostal and
suprasternal retraction, with normal breath
sounds on the affected side. Chest radiography
revealed a multiple fibro infiltrate in the right
lung and possible anterior diaphragmatic hernia
consist of bowel intrathoracic. In barium
enema shows bowel placed in left intrathoracic.
Laboratory findings shows leucocytosis
18.460/l, respiratoric acidosis in blood gas
analysis with pH 7.345, PO252.9 mmHg, PCO2
48.4 mmHg and oxygen saturation 85.6%.
Patient was admitted to neonatal intensive ward,
spontaneous breathing with 3 liters nasal
oxygen and bowel decompression with naso-
gastric-tube for stabilize her condition. During
hospitalization, she got fever up to 38.50C
caused by bronchopneumonia and suspicious
of sepsis, was given double broad spectrum
antibiotics. IT ratio was 0.16 revealed
borderline to sepsis. Blood culture result was
Acinetobacter spp. Her serial blood gas
analysis remain good without any worsening.
Also performed brochoscopy with normal
result.
After the condition was stable with normal
leucocyte 8.580/l and no fever, patient then
scheduled for surgery. Surgery was performed
through abdominal approach. Left Sub
costochondral insicion was made. During
exploration, ileum and transverse colon are
heading to cranially. These organs were
withdrawn into the abdomen and returned to
normal color. Found defect in bilateral anterior
diaphragm with teres hepatic ligament between
it, size 6x3 cm, consist of ileum, transverse
colon and left lobe liver, located medial to the
esophageal hiatus. Lateral and posterior parts
of the diaphragm were intact. Teres hepatic
ligament was excise, due to defect closure, and
was closed using Gore-tex pacth 6-0 with
interrupted suture. Patient then transferred to
ICU, the condition improved dramatically.
Blood gas analysis shows good results with pH
7.385, PO2 80.3 mmHg, PCO2 37 mmHg,
Oxygen saturation 95.8 %. He was extubated
on the 1st postoperative day, and was
discharged home on the 10th postoperative day,
with the chest radiograph showing good lung
expansion.
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 Jurnal Kedokteran Syiah Kuala 17 (2): 93-101, Agustus 2017

A B C
Figure 1. Case 1(A). Pre Op AP Chest X-Ray. Reveals shifting of the mediastinum to the right, look
bowel enema in the left chest and a paucity of gas in the abdomen. (B) Intra Op ; Finding ileum,
transverse colon and left lobe liver, in the anterior chest were withdrawn into the abdomen. (C) Defect
in bilateral anterior part of diaphragm with treitz ligament (arrow) between it, size 6x3 cm, located
medial to the esophageal hiatus.

A B C

Figure 2. Case 1(A). Intra Op : Shows the defect already closed by gore-texpacth 6-0. (B) Post Op
Pleuroscopy; Finding both lung were in good expansion, no mediastinal shift and air-filled loops
bowel in the chest. (C) Post op clinical picture, shows good wound healing and no scaphoid abdomen.

Case 2 loops of the bowel in the chest, dextocardia.

A 22-days neonates girl was came to our center
with the diagnosis of the left posterolateral
diaphragmatic hernia. Presented with a sign of
respiratory distress, shortness of breath,
feeding difficulties, and vomiting when breast
milk since one week ago. Vital sign was stable,
except increasing of respiratory rate of 80
times per minutes. No associated anomalies
was found. Physical examination found scapoid
abdomen, epigastric, inter costal and
suprasternal retraction, with decreased breath
sound on the affected side. Lateral view on
chest radiography demonstrating a sign of
anterior diaphragmatic hernia with air-filled
Laboratory findings shows leucocytosis
11.060/l, severe respiratoric acidosis in blood
gas analysis with pH 7.285, PO241.9 mmHg,
PCO254.0 mmHg and oxygen saturation
69.7 %. Patient was admitted to neonatal
intensive ward, spontaneous breathing with 5
liters nasal oxygen and bowel decompression
with naso-gastric-tube for stabilize her
condition. During hospitalization, she got
stable condition, was given double broad
spectrum antibiotics to prevent sepsis. Her
serial blood gas analysis remain good without
any worsening. Also performed brochoscopy
with edematous in left main stem bronchus.

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 Wibawanto et al.- Bilateral Morgagni Hernia in Infant

Patient then scheduled for surgery. Surgery
also performed through abdominal approach.
Left Sub costochondral insicion was made.
During exploration, ileum, yeyenum,
transversal colon are heading to posteriorly.
These organs were withdrawn into the
abdomen and returned to normal color. Found
defect in left posterolateral diaphragm with size
3x3 cm. Hernial sac content of ileum, jejenum,
transversal colon, and spleen. Anterior part of
the diaphragm were intact. Also there is lung
hypoplasia in the affected site, measurement of
intra abdominal pressure was 8 cmH2O. Defect
was closed using Gore-texpacth 6-0 with
interrupted suture.

A B C
Figure 3. Case 2(A). Pre Op AP Chest X-Ray. Reveals shifting of the mediastinum to the right, air-
filled loops bowel in the left chest and a paucity of gas in the abdomen and dextrocardia (B) Lateral
Chest X-Ray; shows numerous cystic and tubular lucencies filling the anterior left chest consisted with
herniated bowel.(C) Intra Op Finding: ileum, transverse colon in the left posterolateral chest were
withdrawn into the abdomen.

A B C

Figure 4. Case 2(A). Intra Op Finding :Spleen also herniated in the left posterolateral chest. (B)
Defect in the left posterolateral of diaphragm size 3x3 cm.(C) Shows the defect in already closed by
gore-texpacth6-0.

Patient then transferred to ICU, the condition
improved dramatically. Blood gas analysis
shows good results and no respiratoric acidosis
with pH 7.364, PO2 101.4 mmHg, PCO2 42.9
mmHg, Oxygen saturation 97.4 %. He was
extubated on the 1stpostoperative day, and was
discharged home on the 8th postoperative day,
with the chest radiograph showing good lung
expansion. Postoperatively, both of patient
enjoyed an uneventful course and was
discharged home without any further events.
Discussion
Congenital diaphragmatic hernia (CDH) is an
abnormal opening in the diaphragm,
characterized by a defect in diaphragm

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 Jurnal Kedokteran Syiah Kuala 17 (2): 93-101, Agustus 2017
development with subsequent herniation of
abdominal contents into the chest during fetal
life.7 Still remains a challenging problem for
both surgeons and neonatologists. Improved
knowledge in pathophysiology mechanisms
explaining the respiratory failure has led to
changes in the management of newborn infants
with CDH. The mortality rate of infants born
with CDH first 12 hours of life remains high,
although survival can be as close as 90% at
advanced perinatal centers. The primary cause
of mortality is refractory pulmonary
hypertension because of pulmonary hypoplasia
with reduced alveolar surface area, reduced
pulmonary perfusion, persistent shunting from
right to left, hypoxia and surfactant
deficiency.7-13
Newer CDH management strategies are
“gentle ventilation” (preservation of
spontaneous respiration, permissive
hypercapnia and avoidance of high ventilation
pressure) HFOV, ECMO and delayed surgical
repair to stabilize it for at least 72 hours, which
offer some hope of improving overall
survival.8,14-16
There are several types of congenital
diaphragmatic hernia, which includes
Bochdalek, Morgagni and Central (septum
transversum) diaphragmatic hernia.7,9
Embryologically the diaphragm has four
components.7
(1) Septum transversum (central tendon)
developed from the anterior thorax,
(2) Pleuroperitoneal membranes developed
from the posterior thorax,
(3) Dorsal mesentery of the esophagus,
(4) Muscular components developed from
the body wall
Diaphragmatic hernias due to embryological
deficiencies of the diaphragm are usually of
three main types.18
(1) Those through the pleuro peritoneal hiatus,
(2) Those due to the lack of formation of the
posterior portion of the diaphragm
(3) Those through the foramen of Morgagni
(Larrey’s spaces).
Described by Bochdalek in 1848, CDH usually
become evident during the neonatal period with
Table 1 . Shows Bochdalek and Morgagni hernia symptoms in infant
signs and symptoms of respiratory failure in
first hours or day of life.4,19 Bochdalek hernia
account for 85% -90% of all diaphragmatic
defects; 80%-90% of these defects occur on the
left side. Between 5% and 25% of all
posterolateral hernias present after the newborn
period.20 Bochdalek hernia results from
incomplete closure of the normal pleuro
peritoneal canal during fetal
development.11,16,17,19,21 Our second case was
neonatal, who presented with respiratory
distress and suspected as anterior hernia, but
intraoperative found that defect was left
posterolateral. This misleading was caused by
preoperative chest radiograph, the bowel was
placed anteriorly in the chest.
In 1769, Morgagni first described the
substernal herniation of abdominal contents
into the thoracic cavity,3,4,16,22
is a rare case, less than 5% of all types of CDH.
Bilateral Morgagni it may rarely be found and
its description is based only on isolated case
reports. Two different theories exist about its
origin: congenital vs acquired. A symptomatic
in most cases, but it can also manifest with
abdominal or thoracic symptoms and
nonspecific presentations, contributes to the
delay in diagnosis.23,24,25,26 Our first case also
present with bilateral Morgagni hernia and non
symptomatic symptoms of failure to thrive and
respiratory tract infection. Caused when normal
development of the diaphragm and of the
digestive tract do not occur; there is an
improper fusion of structures during fetal
development. Diagnosis is based on findings
from conventional radiography and computed
tomography.7,12,22
The majority of hernias (about 85%) are left
sided and they may contain any or all of the
following: stomach, small bowel, colon, liver,
spleen, kidney and supra adrenal gland. The
size of the defect varies from small (2 or 3 cm)
to very large, involving most of the
hemidiaphragm12,16,19,27. In our case, the
Morgagni defect was bilateral and consist of
bowel, colon and left lobe liver, but in
Bochdalek it was the same as the literature
said.
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 Wibawanto et al.- Bilateral Morgagni Hernia in Infant

Bochdalek Morgagni

 Respiratory distress  Life  1/3 patients asymptomatic.

threatening  Most frequent :cramping pain,
 Feeding intolerance. constipation from partial colonic
 Some patients have no symptoms. obstruction.
 Older InfantGI symptoms  Rare case : Gastric volvulus or GI
obstruction/incarceration/ strangulation
 Cardiorespiratory symptoms <Gastro-
Intestinal symptoms.
 Trauma, exercise and pregnancy can
cause the occurrence.
Extra diaphragmatic anomalies such as mediastinal shift to the left.15 Postnatal
congenital heart defects, neural tube defects, diagnosis made by symptoms which are
genitor urinary, skeletal, and cranio facial cyanosis, tachypnoea and grunting respirations
defect are present in 25% to 57% of all cases of within minutes or hours after birth. Physical
CDH. 19,28 Position of the liver in the chest, examination reveals a scaphoid abdomen, an
polyhydramnions, fetal abdominal increased anteroposterior diameter of the
th 0
circumference < 5 /00, size of contra lateral thorax and mediastinal shift. Breath sounds are
lung measured as a ratio of lung area to head absent on the affected side. Chest radiography
circumference, lung volume, Mc Goon Index < and abdomen by demonstration of air-filled
1.31, Pulmonary Artery Index (PAI) < 90and loops of the bowel in the chest and a paucity of
associated anomaly have been made to identify gas in the abdomen.8
prognostic factors based on prenatal ultrasound
findings in infant with CDH.16,19,29 Both our patient were infant and neonates.
Found scaphoid abdomen, epigastric,
Ultrasound allows prenatal diagnosis of CDH intercostal and suprasternal retraction, with
in the first trimester. For left CDH mediastinal decreased breath sounds on the affected side.
shift and rightwards displacement of the heart Chest radiography shows hernia with air-filled
can be seen, a fluid-filled stomach or bowels loops of the bowel in the chest. No history of
are later on present within the thoracic cavity. polyhydramnios in mother pregnancies. Age,
An important feature to look for is presence of symptoms and radiographic findings were the
(a portion of) the liver in the thorax. With right same as in the literature mentioned above,
CDH, the right lobe of the liver usually except for their mother history of pregnancies,
herniates into the chest, combined with we have got no data about it.

Management Strategies (1) Delivery of a “depressed baby” (no

The antenatal and postnatal management of
patients with CDH is still evolving. Given the
wide variations in the management, it is not
surprising that there are no predictors that are
reliable.10 After the newborn infant with CDH
is transferred to a center with ECMO
capabilities, an effort is made to stabilize it for
at least 72 hours before operative repair is
considered.19 To achieve this goal, a new
management strategy for antenatal diagnosed
CDH including: 30
breathing and swallowing) by c-section;
(2) Exclusive use of HFO in the NICU
prior to surgery;
(3) Delayed surgery following short-term
stabilization
Prenatal Management
Advances in prenatal assessment, lung-sparing
ventilation, and extracorporeal interventions
have improved survival and decreased
morbidity associated with CDH.31 Once a
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 Jurnal Kedokteran Syiah Kuala 17 (2): 93-101, Agustus 2017
prenatal diagnosis of CDH was confirmed by
ultrasound and the parents expressed their wish
to continue their pregnancy. They will received
genetic counseling including fetal karyotyping,
and repeated ultrasound examination to
determine the following:30,32
(1) Lung-thorax transverse area ratio (LT ratio),
which is calculated by a simple ratio of right
and left lung area to thorax area in a cardiac
four-chamber view, to assess the severity of the
pulmonary hypoplasia;
(2) Presence of congenital abnormalities,
particularly those affecting the cardiovascular
system, the central nervous system, and airway
structures.
Serial measurements of LT ratio are also
important because it changes with the progress
of pregnancy. LT ratio < 0.25 indicates that the
fetus has a severely hypoplastic lung and
requires close attention to determine the timing
of delivery.30
Despite regular progress in NICU, CDH
diagnosed antenatal is still associated with up
to 80 % mortality. It is impossible to predict
which fetus with CDH will survive or not.
Antenatal parameters included: gestational age
at diagnosis, herniated organs, associated
malformations and presence of polyhydramnios
and LV hypoplasia. 33
Management during delivery
Antenatal diagnosis of CDH has not been
thought to mandate the necessity for cesarean
section for the delivery of CDH babies.
Although they are routinely intubated on birth
in the delivery room and are immediately
transferred to the NICU, some neonates have
already developed pneumothorax and/or
intestinal distention on admission to the NICU.
These complications are postulated to be
attributed to the struggle or gasp during the
initial resuscitation, bucking after intubation,
and inadvertent high peak inspiratory pressure
during transport. Since the neonates with CDH
have pulmonary hypoplasia and a fixed number
of alveoli, a single pneumothorax requiring a
chest tube or mediastinal shift due to intestinal
distension compressing the contra-lateral lung
will result in a lung that is less capable of
performing its function than it was prior to
injury.30
Postnatal management
Regardless of the clinical presentation, HFOV
was initiated on admission to the NICU, and
was exclusively used before surgery. The
patient received extensive medical therapies to
achieve preoperative stabilization, which
included; infusion of sedatives and muscle
relaxants; inotropic support and volume
infusion to maintain stable circulation;
administration of pulmonary vasodilators such
as prostaglandin E1, or inhaled nitric oxide;
administration of surfactant to improve
oxygenation. Preoperative stabilization was
defined by the following criteria:30
(1) Normal hemodynamic variables with
minimal circulatory support,
(2) No signs of persistent pulmonary
hypertension (PPHN) evidenced by no
difference in
pre-/post-ductal oxygen saturation;
(3) Adequate oxygenation and ventilation by
minimal setting of HFOV (FIO2 < 0.3, mean
airway pressure < 8 cmH2O, peak to peak
pressure level < 50 cmH2O).
Surgical correction was attempted only when
the preoperative stabilization was achieved.
According to the literature said, what occurred
in both our cases also shows that they have
respiratoric acidosis in blood gas analysis at the
first time they arrived in our center, not doing
emergency surgery, but stabilize them at
neonatal intensive ward. During hospitalization,
first case got fever up to 38.50C due to
bronchopneumonia and suspicious of sepsis,
was given double broad spectrum antibiotics.
Timing of Surgery and Surgical Approach
Delayed surgical repair is now widely placed
for at least 72 hours before operative repair is
considered.19 Most institutions perform surgery
in NICU when the patient was stable. The
correction of CDH can be performed
abdominal through paramedian or subcostal
insicion or thoracic approach through
thoracotomy. Also can be performed with
laparoscopy or thoracoscopy.11,21,33 The
significance of laparatomy has been
emphasized as an operative technique. This
allows easy reduction and inspection of
contents, allows access and repair of bilateral
hernias, and corrects an associated malrotation
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 Wibawanto et al.- Bilateral Morgagni Hernia in Infant
if present. When diaphragmatic tissue is
adequate, primary repair with non absorbable
suture can be done. But if too large, prosthetic
material can be used for a tension-free repair.
Implantation of foreign material can expose
patients to the risks of infection, displacement,
or erosion into adjacent structures.16,34
Both our patient also performed abdominal
approach through subcostal incision. In first
case it was bilateral Morgagni hernia,
abdominal incision was the best approach,
especially for bilateral hernias, it allows easier
reduction of the hernia. And in second case
because it was unsuspected posterolateral
defect, the defect can be seen through
abdominal incision. We didn’t performed
ECMO for both our patient, because no
indication was attempted, patients were stable
with spontaneous breathing, despite that, in our
center don’t have ECMO facilities if those
infant need that treatment.
Abdominal compartment syndrome as a
complication after CDH repair has not been
reported. These conditions, are associated with
insufficient room in the abdominal cavity (ie,
loss of domain) to accommodate all of the
organs without elevation of intraabdominal
pressure. Defined as intraabdominal pressure >
25 to 30 mmHg. If pressure is high, the
abdomen may be closed with a constructed silo
of prosthetic material, patch, or VAC system.
With fluid shifts and abdominal wall stretching
for several days, the abdomen can be closed in
the operating room.22 Abdominal compartment
syndrome didn’t found in both our patient after
abdominal closure.
Because of degree of pulmonary hypoplasia
determines survival in infant with CDH,
another strategy has developed to reverse the
pulmonary hypoplasia. Open fetal
surgerywhich called tracheal occlusion
(TO)leads to increased levels of lung tissue
stretch, triggers lung growth, and reverses
pulmonary hypoplasia before birth. Timing and
duration of the occlusion period are crucial for
the quality and response. Oral sildenafil also
can be give to infant with CDH in appear to
reduce pulmonary vascular resistance as
measured by functional
15,19,35,36
echocardiography.
The most common surgical outcomes in infants
with CDH include diaphragmatic hernia
recurrence, chest hernia incarceration, gastro
esophageal reflux disease, midgut small bowel
obstruction, volvulus, chest deformity, wall and
spinal deformities. 37,38
Conclusion
Bilateral Morgagni hernia is a rare type
congenital anomaly, Nonspecific presentations,
contributes to the delay in diagnosis, and
preoperative chest radiography can be possible
misleading for diagnosis in Morgagni hernia.
Numerous approaches have been described
and, particularly the significance of laparatomy
has been emphasized as an operative technique.
This allows easy reduction and inspection of
contents, allows access and repair of bilateral
hernias, and corrects an associated malrotation
if present
Acknowledgments
The authors would like to thank the Dr. Agung
Wibawanto, Cardiothoracic Surgeon and Dr.
Arman, Cardiothoracic Surgeon for his expert
surgical and editorial advice.
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