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| CASE REPORT |
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| Year : 2018 | Volume
: 1
| Issue : 2 | Page : 66-68 |
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Laparoscopic transabdominal Morgagni hernia repair
Rebekah Macfie1, Sean Orenstein1, David Tse2
1 Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
2 Department of Surgery, Kaiser Permanente Northwest, Clackamas, Oregon, USA
| Date of Submission | 10-May-2018 |
| Date of Acceptance | 28-Jun-2018 |
| Date of Web Publication | 16-Aug-2018 |
Correspondence Address:
Dr. David Tse
Department of Thoracic Surgery, Kaiser Sunnyside Medical Center, 10180 SE Sunnyside Rd, Clackamas, Oregon 97015
USA
 Source of Support: None, Conflict of Interest: None  | 2 |
DOI: 10.4103/ijawhs.ijawhs_7_18
Morgagni hernias are a rare finding in the adult population and represent 1%–3% of all congenital diaphragmatic hernias. Multiple approaches to these rare hernias have been described in the literature. Here, we present a novel technique of laparoscopic transabdominal repair using a combination of the Endo-Close device (Medtronic, Minneapolis, MN, USA) and the Ti-KNOT (LSI Solutions, Victor, NY, USA). In a patient with a large left anterior diaphragmatic defect, we performed transabdominal suturing utilizing the Endo-Close to perform primary closure of the defect, using the Ti-KNOT to secure the pledged sutures along the anterior fascia. Due to the size of the defect (7 cm × 10 cm), this primary repair was buttressed with polyester mesh. In a second patient with a smaller (6 cm × 8 cm) classic right-sided anterior diaphragmatic defect, we similarly performed laparoscopic transabdominal suturing using the Endo-Close to traverse both the anterior and posterior fascia and the Ti-KNOT to secure the sutures to perform a primary repair of the hernia. Both patients presented had an uneventful postoperative course and no indication of recurrence at 4 months. Morgagni hernias present unique technical challenges. In our experience, the combined use of transabdominal suture with laparoscopic knot placement device allowed for completion of both cases laparoscopically with minimal tension on the repairs.
Keywords: Hernia, laparoscopy, mesh, Morgagni hernia
How to cite this article:
Macfie R, Orenstein S, Tse D. Laparoscopic transabdominal Morgagni hernia repair. Int J Abdom Wall Hernia Surg 2018;1:66-8 |
| Introduction | |  |
Morgagni hernias are rare finding in the adult population and represent 1%–3% of all congenital diaphragmatic hernias.[1] These retrosternal diaphragmatic hernias develop from a congenital failure of the pars sterna to fuse with the costal arches. Most commonly, these hernias occur on the right; however, rarely, they can occur on the left, termed a Morgagni-Larrey hernia. Unlike infants who frequently present with acute respiratory distress or failure, adults may present with chronic symptoms or a Morgagni hernia may be found incidentally.[2],[3] Due to the risk of incarceration or atelectasis, surgical treatment is recommended for Morgagni hernias identified in the adult population.[4]Multiple approaches to these rare hernias have been described in the literature. Here, we report two cases, a right-sided Morgagni, and a left-sided Morgagni-Larrey hernia and present a novel approach to Morgagni hernia repair using a laparoscopic transabdominal approach.
| Case Reports | | |
Case 1
Patient I is a 35-year-old woman who presented to the emergency room with an acute worsening of chronic abdominal pain. She stated that at baseline she has many food intolerances but that her pain had recently gotten much worse. The patient complained of debilitating pain with any oral intake of liquids or solids. On examination, her abdomen was soft and nontender. She had a slight leukocytosis of 11.21K her laboratory evaluation was otherwise unremarkable. A computed tomography (CT) scan demonstrated a left-sided diaphragmatic hernia containing the majority of the stomach, transverse colon, splenic flexure, and proximal descending colon in the lower left hemithorax [Figure 1]. Of note, this was initially thought to represent a Type IV hiatal hernia and was read as such by the radiologist reviewing; however, review of the images clearly demonstrates a diaphragmatic defect unique from the hiatus.
After multidisciplinary review by both the General and Thoracic Surgery teams, the decision was made to go to the operating room with the thoracic surgery team for laparoscopic hernia repair. This was discussed with the patient who agreed.
Intraoperatively, the patient was positioned, and ports placed as is standard for Nissen fundoplication. The patient had a Morgagni hernia defect characterized by an anterior medial diaphragmatic defect of the left hemidiaphragm. There was viable stomach, transverse colon, and omentum traversing the diaphragmatic defect into the left hemithorax. These were gently reduced back into the abdominal cavity.
We began the repair by performing partial reapproximation of the lateral edges of the diaphragmatic defect. 2–0 Ti-Cron pledgeted sutures were placed into the peritoneal cavity. Through multiple stab incisions overlying the superior rim of the defect, an Endo-Close device (Medtronic, Minneapolis, MN) was placed through the anterior fascia and posterior rim of the defect to retrieve the ends of the pledgeted 2–0 Ti-Cron sutures. This was performed along the entirety of the defect. Using a Ti-KNOT suture knot replacement device (LSI Solutions, Victor, NY, USA), the pledgeted sutures were secured along the anterior fascia.
As the defect measured approximately 7 cm × 10 cm, a composite dual-sided 10 cm × 15 cm Parietex mesh (Medtronic, Minneapolis, MN) was used to buttress the repair. It was secured to the bordering soft tissues with 2–0 Ti-Cron sutures. These sutures were placed through the mesh into the posterior diaphragmatic crura and secured with Ti-KNOT. This was continued circumferentially along the periphery of the hernia defect. Away from the vicinity of the pericardium, two Protack (Medtronic, Minneapolis, MN, USA) spiral tacks were used to secure the mesh to the retrosternal soft tissues away from the pericardium.
The patient is now doing well 8 weeks postoperative, has returned to work and normal activity. No reimaging has been done.
Case 2
Patient II is a 52-year-old woman who presented to thoracic surgery after a ground-level fall. During her workup for chest pain following the fall, a chest X-ray demonstrated a smoothly marginated right pericardiac density [Figure 2]. A follow-up CT chest demonstrated a large right-sided anterior Morgagni hernia with fat in the defect [Figure 3]. She was a good surgical candidate and complained of ongoing chest pain; therefore, she was taken to the operating room for repair.
Again, this patient was positioned as is standard. In Nissen fundoplication with similar port placement. The right-sided anterior diaphragmatic defect was identified without placement of a liver retractor. The hernia contents were reduced. The omentum was viable. The falciform ligament was transected at its entry point into the hernia sac. The 8 cm × 6 cm hernia defect was amenable to primary repair. As in Case 1, we introduced 2–0 Ti-Cron pledgeted sutures into the peritoneal cavity through the laparoscopic ports. Through multiple stab incisions overlying the superior rim of the defect, an Endo-Close device was placed through the anterior fascia and then traversing the defect into the posterior rim to retrieve the ends of the pledgeted 2–0 Ti-Cron sutures. This was performed along the entirety of the defect. Using a Ti-KNOT device, the pledgeted sutures were secured along the anterior fascia. Thereafter, the second layer of interrupted 2–0 Ti-Cron sutures was placed between the soft tissues of the approximated edge of the hernia defect and secured with the Ti-KNOT.
Postoperatively, the patient did well and was discharged on postoperative day 2. A chest X-ray demonstrated no recurrence despite postoperative constipation and a viral upper respiratory infection with coughing and sneezing. She is now 16 weeks status postrepair and is doing well.
Comment
These cases illustrate the usefulness of a transabdominal approach to Morgagni hernia repair. In both of these cases, this facilitated a robust repair through a laparoscopic approach. While similar procedures have been described previously this report represents a unique series of both a right-sided Morgagni and a left-sided Morgagni-Larrey hernia. Here, we present a unique approach of transabdominal suture repair of these anterior diaphragmatic hernias, using the Endo-Close device to place sutures through the diaphragmatic defect. This was facilitated in our case by the use of the Ti-KNOT laparoscopic knot replacement device. The combination of these techniques allowed us to complete both cases laparoscopically with minimal tension on the repair. These cases also illustrate a trend that has been reported but not commented on in the literature. For the smaller of the two defects, we performed a tension-free primary tissue repair. A mesh-free approach in small (<6 cm) hernia defects is supported by the literature. Multiple series have demonstrated a low rate of recurrence without the use of mesh; this is true in both right-and left-sided hernias.[3],[5] There a number of isolated reports of larger hernias (>8 cm) in which the authors did perform mesh repair.[6],[7],[8],[9] As has been noted elsewhere, diaphragmatic tacking, particularly on the left side, should be avoided due to the potential for cardiac injury.[10] As such, we relied primarily on sutures secured with the Endo-Close device for securing the mesh in Case 1. Both patients presented had an uneventful postoperative course and no indication of recurrence at 4 months.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Aydin Y, Altuntas B, Ulas AB, Daharli C, Eroglu A. Morgagni hernia: Transabdominal or transthoracic approach? Acta Chir Belg 2014;114:131-5. |
| 4. | Minneci PC, Deans KJ, Kim P, Mathisen DJ. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9. |
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| 6. | Schiergens TS, Koch JG, Khalil PN, Graser A, Zügel NP, Jauch KW, et al. Right-sided diaphragmatic rupture after repair of a large morgagni hernia. Hernia 2015;19:671-5. |
| 7. | Ikarashi M, Matsuda M, Murayama I, Fujii M, Takayama T. Laparoscopic repair of Morgagni hernia with composite mesh in an elderly woman: Report of a case. Asian J Endosc Surg 2015;8:216-8. |
| 8. | Kaida T, Ikeda A, Shimoda H, Sako H, Uchida H, Wada M, et al. Laparoscopic mesh repair of a Morgagni hernia using the double-crown technique: A case study. Asian J Endosc Surg 2014;7:323-6. |
| 9. | Palanivelu C, Rangarajan M, Rajapandian S, Amar V, Parthasarathi R. Laparoscopic repair of adult diaphragmatic hernias and eventration with primary sutured closure and prosthetic reinforcement: A retrospective study. Surg Endosc 2009;23:978-85. |
| 10. | Köckerling F, Schug-Pass C, Bittner R. A word of caution: Never use tacks for mesh fixation to the diaphragm! Surg Endosc 2018;32:3295-302. |
[Figure 1], [Figure 2], [Figure 3]
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