the thorax Loops of intrathoracic intestine on the chest radiograph may be mistaken for pneumonia with pneumatocele formation (Fig 124.12 ) A gastrointestinal contrast study or preferably a chest and abdominal CT scan may provide clarity if the diagnosis is uncertain Potential intestinal or visceral ischemia caused by obstruction and strangulation is one of the reasons operative repair is undertaken emergently Management In the stable but symptomatic patient, surgical repair should be undertaken soon after the diagnosis is made, but may be elective in the asymptomatic patient Because the diagnosis may be made incidentally during evaluation for a condition such as pneumonia, which would increase risk during an elective operation, the timing of surgery must be tailored to the individual situation A pediatric surgeon should be consulted as soon as the diagnosis is suspected, and symptomatic patients should be admitted awaiting repair If a patient is symptomatic from acute ischemia of the herniated viscera, an urgent operation may be required Usually, a transverse or subcostal abdominal incision is used because it permits reduction or resection of compromised intestine or other abdominal viscera and allows for correction of the malrotation that usually accompanies this condition In selected patients, thoracoscopic repair has been performed safely and effectively Foramen of Morgagni Hernias A Morgagni diaphragmatic hernia results from a defect in the anterior diaphragm just behind the sternum Patients are often asymptomatic or present with vague symptoms of abdominal discomfort Substernal or epigastric pain and bowel obstruction resulting from a narrow defect may occur spontaneously or be precipitated by any condition that increases intra-abdominal pressure (Fig 124.13 ) A lateral chest radiograph should clarify the abnormality as anterior and demonstrate that the herniation is not through the esophageal hiatus A contrast esophagram or a CT scan in stable patients should be considered if doubt remains Surgical repair, indicated to prevent incarceration of bowel even in asymptomatic patients, may be performed laparoscopically or through an upper abdominal incision