Surgical repair of Morgagni hernia with liver and rib injury

Abstract

Morgagni hernias (MH) are rare congenital diaphragmatic defects that often remain undiagnosed until adulthood due to their subtle or nonspecific clinical presentation. While asymptomatic in many cases, MHs may occasionally lead to visceral herniation; among these, atraumatic liver herniation, especially in the absence of prior thoracoabdominal trauma, is exceptionally uncommon and represents a notable diagnostic and clinical challenge. We report the case of a 62-year-old male patient with no history of trauma who presented with right-sided pleuritic chest pain following a rhinovirus infection. Initial chest CT demonstrated a lateral chest wall hernia with herniation of the right lower lobe and a widened intercostal space. Conservative inpatient management was initially pursued, but the patient re-presented with persistent respiratory symptoms and right upper abdominal pain. Repeat CT imaging revealed progression of the hernia with new involvement of the right hepatic lobe, gallbladder, and omentum, alongside displaced fractures of the eighth and ninth ribs and disruption of the intercostal musculature. Surgical repair was performed via a right video-assisted thoracoscopic surgery (VATS)-assisted thoracotomy. Operative findings included a 15 × 10 cm diaphragmatic defect anterior to the caval hiatus, herniated liver, chronic empyema, and rib fractures. The defect was repaired using a 15 × 25 cm Symbotex™ mesh (Medtronic plc, Galway, Ireland), and rib fractures were stabilised using segmented STRACOS 3D clips (MedXpert GmbH, Eschbach, Germany). The patient recovered uneventfully and was discharged from the ICU on postoperative day three. This case illustrates a rare instance of progressive Morgagni hernia with visceral and hepatic herniation triggered by virus-induced coughing in the absence of trauma. It highlights the diagnostic challenges associated with atypical thoracoabdominal symptoms and emphasizes the importance of maintaining a high index of suspicion. Early imaging and timely surgical intervention are critical to prevent serious complications and achieve favourable outcomes in such complex presentations.