Supine film Obstructed Morgagni Hernia, a Rare Cause of Acute Intestinal Obstruction in Children: Case Report Mostafa Elayoty, Mohamed El Sherbiny Pediatric Surgery Unit, Mansoura University Children Hospital Introduction Discussion Acute intestinal obstruction considered one of the commonest emergency problems in pediatric surgery, while Morgagni hernia is the rarest type of four types ofcongenital diaphragmatic hernia (CDH). It represent approximately 5% of all CDH.Diagnosis of obstructed Morgagni hernia requires a high index of suspicion and most cases are detected incidentally. Morgagni hernia mostly occurs due to the defective fusion of the septal transverses of the diaphragm and the costal arches(1). The exact aetiology of this hernia is unknown but it starts as a weakness in the diaphragm associated with stretching due to intraperitoneal pressure. The development of a hernia is facilitated by rapid changes in intra-abdominal pressure and degenerative changes to the diaphragm. It more commonly occurs on the right side of the diaphragm due to the more extensive attachment of the pericardium on the left side; however, both left-sided and bilateral cases have been reported [2]. The hernia contents include transverse colon and omentum and, less commonly, stomach, gall bladder, liver and pancreas(3). Surgery is recommended for symptomatic hernias. The transabdominal approach enabled the hernia to be reduced easily and the viscera to be pulled down to their normal position. More recently, laparoscopic surgery has offered added advantages of aiding the diagnostic process and quicker patient recovery(4).  Apart from the approach, repairs also differ on two other aspects of surgery - whether the hernia sac is excised and if a mesh is used during repair. While most surgeons prefer not to excise the sac, there are a few who excise the sac when it is small and injury of thoracic contents is unlikely, to prevent recurrence or cyst formation [5]. Present History A male child 2.5years old, Down syndrome presented to our ER complaining of persistent vomiting 3 days ago with moderate abdominal distension. The vomiting in the 1st 2 days was gastric content while becomes greenish at the day of presentation .The last time to pass stool was 3 days ago. Incarcerated colon through the hernia Clinical examination The child shows moderate abdominal distension with lax abdomen, greenish aspirate in the inserted Ryle, hyper audible intestinal sounds and empty rectal examination. Erect film Morgagni hernia defect Radiological investigation First, we ordered abdominal U.S which excludes intussception and shows minimal free fluid in the abdomen. Then we ordered an abdominal X-ray in supine and erect position which revealed air-fluid level in the erect film with abnormal air-fluid level in the chest also, so we ordered x-ray abdomen and chest in lateral position which confirm the diagnosis of Morgagni hernia. Conclusion Obstructed Morgagni hernia is a rare cause of acute intestinal obstruction in children, Diagnosis of such cases requires a high index of suspicion and rapid interference to prevent serious complications. Lateral film Operative details After confirmation of diagnosis and resuscitation of the baby we go to the emergency OR for exploration. We used upper midline incision for exploration. We found incarcerated ascending and transverse colon through Morgagni hernia in the chest with moderately distended all small intestinal loops suggesting colonic obstruction. We reduce the hernia content and empty all of intestinal content through the stomach and then we proceed to repair of defect using prolene zero with 6 interrupted mattress sutures. References Comer TP. Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966; 52:461-468. Lanteri R, Santangelo M, Rapisarda C, Di Cataldo A, Licata A. Bilateral Morgagni-Larrey Hernia: A Rare Cause of Intestinal Occlusion. Arch Surg 2004; 139:1299-1300. Ipek T, Altinli E, Yuceyar S, Erturk S, Eyuboglu E, Akcal T. Laparoscopic Repair of a Morgagni-Larrey Hernia: Report of Three Cases. Surg Today 2002; 32:902-905 Loong TPF, Kocher HM. Clinical presentation and operative repair of hernia of Morgagni. Postgrad Med J 2005; 81:41-44. Ackroyd R, Watson DI. Laparoscopic repair of a hernia of Morgagni using a suture technique. J R Coll Surg Edinburgh 2008; 45:400-402. After repair of the defect Postoperative course The patient was on fluid only for 3 days then we started oral feeding after regaining of intestinal sounds and discharged in the 5th day postoperative. Supine film