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Table of Contents
CASE REPORTS
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 135-139

Robotic transabdominal preperitoneal morgagni hernia repair technique: A case report


1 Department of Surgery, Creighton University School of Graduate Medical Education, Phoenix, Arizona, USA
2 Department of Surgery, Mayo Clinic School of Graduate Medical Education, Phoenix, Arizona, USA

Date of Submission07-Oct-2021
Date of Acceptance22-Oct-2021
Date of Web Publication01-Sep-2022

Correspondence Address:
Dr. Conrad Ballecer
Department of Surgery, Creighton University School of Graduate Medical Education, Phoenix, Arizona
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_71_21

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  Abstract 

Robotic transabdominal preperitoneal Morgagni hernia repair: A step-wise approach.
Morgagni hernia (MH) is an atypical and rare type of diaphragmatic hernia that presents surgical challenges given its location and proximity to vital structures. Classically, these hernias have been repaired either open or laparoscopically with the use of an intraperitoneal onlay mesh without defect closure. Borrowing from the groups’ excellent experience in robotic transabdominal preperitoneal hernia repair (rTAPP) ventral and atypically located hernias, this approach has shown promise in repairing MHs in albeit a small cohort of patients. The rTAPP technique in our opinion overcomes many of the challenges and pitfalls associated with atypical hernias, including those of the diaphragm, providing excellent visualization and facilitating wide preperitoneal dissection with a complete reduction of the hernia sac located in the anterior mediastinum. The wide preperitoneal exposure allows for directed diaphragmatic closure, minimizing the risk of injury to mediastinal structures, placement of a large uncoated mesh sandwiched in between layers of the abdominal wall, and safely targeted fixation at cardinal points. Preperitoneal mesh allows for the use of a more cost-effective uncoated mesh that is not exposed to the viscera. It also allows for minimal and targeted fixation without the use of tacks, leading to decreased postoperative pain and complications. In this article, we are detailing the rTAPP approach in managing MHs.

Keywords: Morgagni hernia, robotic diaphragmatic hernia repair, robotic hernia repair, robotic transabdominal preperitoneal hernia repair (rTAPP)


How to cite this article:
Janowski C, Sioda N, Liu S, Sabatino A, Ballecer C. Robotic transabdominal preperitoneal morgagni hernia repair technique: A case report. Int J Abdom Wall Hernia Surg 2022;5:135-9

How to cite this URL:
Janowski C, Sioda N, Liu S, Sabatino A, Ballecer C. Robotic transabdominal preperitoneal morgagni hernia repair technique: A case report. Int J Abdom Wall Hernia Surg [serial online] 2022 [cited 2022 Oct 7];5:135-9. Available from: http://www.herniasurgeryjournal.org/text.asp?2022/5/3/135/355264




  Introduction Top


The MH is an atypical and rare hernia compared with other diaphragmatic hernias. The incidence of MH is estimated to be between 1 in 2,000 and 1 in 5,000 live births, comprising approximately 2–5% of all congenital diaphragmatic hernias.[1],[2],[3] More than 90% of MHs develop a hernia sac, which can be enlarged overtime due to persistent weakness and increases in intra-abdominal pressure.[1] Most of the MH sacs contain the large intestine (54–72%) and omentum (65%).[1] The proportion of MH cases that are symptomatic is high, with a reported incidence of up to 72% and symptoms typically occur later in life when compared with other congenital diaphragmatic hernias.[1],[4] The most notable complications associated with MHs include difficulty with breathing, bowel obstruction, strangulation, incarceration, and volvulus.[5] Because of these potentially dangerous complications, it is recommended for patients to undergo surgical repair. Many techniques for repairing MH have developed over the years, including thoracotomy, open, laparoscopic, and recently robotic repair approaches. Classically, MHs have been repaired either open or laparoscopically with the use of an intraperitoneal onlay mesh without defect closure. Recently, there have been reports of robotically repaired MHs with successful hernia reduction, resolution of preoperative symptoms, and limited postoperative complications.[4]

In this article, we detail the rTAPP MH repair. This approach involves wide dissection of the preperitoneal/pre-transversalis space, reduction of the hernia sac, primary defect closure, and placement of mesh reinforcement The purported benefits experienced within our practice are consistent with those seen in rTAPP ventral hernia repairs, including but not limited to: short length-of-stay, minimal postoperative pain, primary diaphragmatic defect closure, and avoidance of costly coated mesh prosthetics and mechanical fixation.


  Anatomy Top


The foramen of Morgagni, also known as the sternocostal triangles, are small areas on either side of the sternum, between the sternal and costal attachments of the thoracic diaphragm [Figure 1].[6] MHs occur when bowel or other abdominal visceral contents herniate into the thorax through the foramen of Morgagni, located posterolaterally to the sternum. The MH is rare, with most diaphragmatic hernias occurring through the foramen of Bochdalek.[7] The MHs occur on the right side of the diaphragm 90% of the time due to the pericardial attachments on the left side that provide added support and protection from herniation.[1] The MH is due to a failure of the pars sternalis to fuse with the pars tendinalis of the costochondral arches.[1]
Figure 1: Anatomic depiction of the diaphragm, detailing both the foramen of Morgagni and foramen of Bochdalek.[10]

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  Surgical Technique Top


The following provides step-by-step instructions to a novel approach for repairing MHs, utilizing the same technique seen in r-TAPP for hernias of the anterior abdominal wall. Relative to other approaches, this technique provides the benefits of minimal fixation and an uncoated mesh hidden from the visceral contents, ultimately leading to less postoperative pain and complications.

After the patient is prepped and draped, intra-abdominal access is gained via an open Hasson technique in the supraumbilical midline position. Three additional 8 mm robotic trocars are then placed under direct vision: one in the right mid-quadrant and two in the left mid-quadrant across the abdomen. The Hasson trocar is double cannulated with an 8 mm robotic bariatric trocar [Figure 2]. The patient is positioned in reverse Trendelenburg, and the Da Vinci Xi (intuitive surgical) patient cart is docked on the patient’s side with trocars and instruments aiming cephalad. We drape the fourth robotic arm to be used as an assist for any potential difficulties in retraction that may arise.
Figure 2: Four robotic trocars placed across the upper abdomen

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Safe reduction of the hernia contents is performed by utilizing a fenestrated bipolar (intuitive surgical) and a tip-up grasper (intuitive surgical). Low grip strength graspers may minimize the risk of iatrogenic bowel injury [Figure 3]. After the hernia contents are reduced [Figure 4], a preperitoneal flap is created by incising the peritoneum at least 5 cm anterior/caudal to the edge of the hernia defect [Figure 5]. Dissection in the preperitoneal/pre-transversalis plane is performed, ensuring minimal disruption to the peritoneum. Dissection of the preperitoneal space is continued widely in all dimensions surrounding the Morgagni defect until a “volcano sign” is formed, whereby the defect and hernia sac is clearly delineated [Figure 6].
Figure 3: Safe reduction of the hernia sac with low grip strength graspers, colon noted within the hernia sac

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Figure 4: Successful reduction of hernia contents within hernia sac

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Figure 5: Creation of preperitoneal flap by incising the peritoneum at least 5 cm anterior/caudal to the edge of the hernia defect

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Figure 6: Dissection of the preperitoneal/pre-transversalis plane with wide dimensions until defect and hernia sac are well delineated

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The hernia sac is then reduced while taking great care to avoid overzealous retraction, which may breach incorrect planes such as pleura and pericardium. Dissection is continued in the cephalad and posterior dimension until the central tendon is exposed [Figure 7]. At minimum 5 cm of overlap is required in all dimensions surrounding the diaphragmatic defect. Once dissection of the preperitoneal space and hernia sac are complete, the MH is closed primarily with a 0 permanent interrupted or running barbed suture [Figure 7]. An adequately sized uncoated midweight macroporous polypropylene mesh is secured at the cardinal points with interrupted sutures [Figure 8]. The peritoneal flap is then closed with a 3-0 absorbable barbed suture in a running Connell fashion [Figure 9]. Finally, the repair of any significant peritoneal defects is performed in an interrupted fashion to prevent mesh adherence to intra-abdominal contents and herniation of bowel content into the extraperitoneal space.
Figure 7: Dissection is continued until the central tendon is exposed. The hernia defect is closed primarily with 0 permanent interrupted or running barbed sutures

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Figure 8: Uncoated midweight macroporous polypropylene mesh is secured with interrupted sutures

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Figure 9: The peritoneal flap is closed with a 3-0 absorbable barbed suture in a running Connell fashion

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  Discussion Top


At our institution, from 2015 to 2020, five patients underwent the r-TAPP MH approach. With our experience, there are several benefits to utilizing the r-TAPP approach for an MH repair. Utilizing this approach allows for a reduction of the hernia sac, which may decrease seroma rates. Reduction of the hernia sac remains controversial since the MH is typically intimately associated with the pericardium and pleura. This increases the risk of potentially injuring the pericardium or creating a pneumomediastinum with a reduction of the hernia sac.[8] However, all hernia sacs were successfully reduced using the r-TAPP approach without visceral injuries or damage to the underlying pleura or pericardium, likely due to the increased dexterity that the robotic platform affords to the operating surgeon. In addition, with the reduction of the hernia sac, none of the patients experienced recurrence or complications associated with seroma formation.

Each mesh was placed with minimal fixation, which limited postoperative pain and avoidance of cardiac complications associated with tack fixation. Within the medical literature, there have been documented series that report that up to 92% of cardiac injuries associated with diaphragmatic hernia repair are secondary to tack fixation.[9] Fortunately, the r-TAPP approach allows for increased dexterity and use of focused suture fixation, thus avoiding the need for tack fixation. The r-TAPP approach also allows the mesh to be placed in the intraperitoneal space, resulting in an uncoated mesh that is protected from visceral contents. This mesh will subsequently become incorporated into the parietal and visceral surface of the diaphragm in the extraperitoneal space with time, providing added strength and reduction in hernia recurrence.

Given the relatively uncomplicated postoperative course of the patients who underwent this procedure as well as the benefits afforded by using the rTAPP approach, we propose this is an effective surgical technique to repair MHs.


  Conclusion Top


MHs are rare congenital or acquired diaphragmatic hernias that have varied presentations and associated complications. We believe our rTAPP approach to the repair of MH leads to less postoperative pain and complications. The ability to close the hernia defect primarily, as well as to reinforce the repair with a piece of uncoated mesh that is hidden from the viscera, is a large benefit of this technique. However, further studies will be indicated to validate our hypothesis in the future.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for 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.







[10]



 
  References Top

1.
Svetanoff WJ, Rentea RM Morgagni Hernia. [Updated 2021 Jun 9]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557501/. [Last accessed on 10 Sep 2021].  Back to cited text no. 1
    
2.
Arora S, Haji A, Ng P Adult morgagni hernia: The need for clinical awareness, early diagnosis and prompt surgical intervention. Ann R Coll Surg Engl 2008;90:694-5.  Back to cited text no. 2
    
3.
Al-Salem Ahmed H Congenital hernia of Morgagni in infants and children. J Pediatr Surg 2007;42:1539-43.  Back to cited text no. 3
    
4.
Wei B, Pittman BC Jr. Robotic morgagni hernia repair: An emerging approach to a congenital defect. J Robot Surg 2019;13:309-13.  Back to cited text no. 4
    
5.
Horton JD, Hofmann LJ, Hetz SP Presentation and management of morgagni hernias in adults: A review of 298 cases. Surg Endosc 2008;22:1413-20.  Back to cited text no. 5
    
6.
Hacking C, Knipe H Foramen of Morgagni. Available from: https://radiopaedia.org/articles/39186. [Last accessed on 19 Sep 2021].  Back to cited text no. 6
    
7.
Al-Salem AH, Nawaz A, Matta H, Jacobsz A Herniation through the foramen of morgagni: Early diagnosis and treatment. Pediatr Surg Int 2002;18:93-7.  Back to cited text no. 7
    
8.
Park A, Doyle C Laparoscopic morgagni hernia repair: How I do it. J Gastroint Surg 2014;18:1858-62.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Haroun H Congenital diaphragmatic hernias: A review article. Semantic Scholar2018. Available from: https://www.semanticscholar.org/paper/Congenital-Diaphragmatic-Hernias%3A-A-Review-Article-Haroun/9fbc7861c19f4f04b3589268de92f36058908431. [Last accessed on 15 Oct 2021].  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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