|Year : 2015 | Volume
| Issue : 2 | Page : 68-71
Laparoscopic repair of Morgagni's hernia: An innovative approach
Rasik S Shah1, Pradeep Chandra Sharma2, Deepraj S Bhandarkar2
1 Department of Paediatric Surgery, P. D. Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India
2 Department of Minimal Access Surgery, P. D. Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai, Maharashtra, India
|Date of Web Publication||17-Feb-2015|
Dr. Rasik S Shah
F/5, Third Floor, Pannalal Terraces, Grant Road, Mumbai - 400 007, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To review our experience of laparoscopic repair of Morgagni's hernia (MH) using transfascial sutures. Materials and Methods: This is a retrospective review of patients presenting to the first author with the diagnosis of MH over a 15-year period. The variables analyzed included demographic data, clinical presentation, and operative details. Results: In all there were five male with a median age of 2 years. They were asymptomatic and MH was detected incidentally by observing an air-filled density in the right cardiophrenic angle on plain X-ray of the chest. Computed tomography (CT) confirmed the diagnosis in all patients. All patients underwent laparoscopic repair of MH using transfascial sutures. The average operative time was 75 min. Oral feeding was started 6 h after surgery and patients were discharged on either 3 rd or 4 th postoperative day. Postoperative follow-up X-ray confirmed the intact repair. Conclusions: Laparoscopic repair of MH using transfascial sutures is an easy and effective solution. Multiple horizontal mattress sutures taking full thickness of abdominal wall muscles with the edge of the diaphragm leads to a strong repair. As sutures are tied extracorporeally, the technique is easily reproducible.
Keywords: Laparoscopy, Morgagni′s hernia, technique, transfascial repair
|How to cite this article:|
Shah RS, Sharma PC, Bhandarkar DS. Laparoscopic repair of Morgagni's hernia: An innovative approach. J Indian Assoc Pediatr Surg 2015;20:68-71
|How to cite this URL:|
Shah RS, Sharma PC, Bhandarkar DS. Laparoscopic repair of Morgagni's hernia: An innovative approach. J Indian Assoc Pediatr Surg [serial online] 2015 [cited 2020 May 27];20:68-71. Available from: http://www.jiaps.com/text.asp?2015/20/2/68/151547
| Introduction|| |
Morgagni's hernia (MH) is an uncommon variety of congenital diaphragmatic hernia and comprises of about 3-5% of all diaphragmatic hernias. It is caused by a defect in the retrosternal region of the diaphragm and is considered to occur due to failure of fusion in the anterior part of the pleuroperitoneal membrane and deficiency in the process of muscularization. MH usually has a sac and contains colon and/or small bowel and very rarely liver may herniate through the defect. Its rarity, as well as the vague and nonspecific presentation, contributes to delay in its diagnosis.  Most MH are asymptomatic and are diagnosed incidentally as a mass or air-fluid interface on a chest X-ray undertaken for unrelated reasons. The diagnosis is confirmed by performing further imaging in the form of a barium study, computed tomography (CT), or magnetic resonance imaging (MRI). These define the size of the defect and contents of the hernial sac.
Treatment of MH is surgical closure of the defect and this has traditionally been performed via a laparotomy or a thoracotomy. Recently, various laparoscopic and thoracoscopic techniques have been described for repair of MH, which include a primary closure of the defect with intracorporeal sutures, stapler, or a mesh. This report presents the authors' experience with an innovative laparoscopic approach to the repair of MH using transfascial sutures.
| Materials and Methods|| |
This is a retrospective review of prospectively collected data of patients with MH operated by the first author from 1999 to 2014. The variables analyzed included demographic data, presentation, size and contents of the defect, operative time, intraoperative blood loss, conversion to open surgery, postoperative hospital stay, and recurrence at follow-up.
Repair of the MH was carried out under general anesthesia with endotracheal intubation. The patient was positioned supine with the hips resting at the edge of the operating table. The legs (padded and protected) hung from the end of the table. A folded towel was kept under the thighs to slightly flex the hip joint and prevent excessive stretching of the femoral nerve. The monitor was placed at the head end of the table towards the left side. The operating surgeon stood at the foot end, cameraman to his right, and nurse to his left. A nasogastric tube was inserted to decompress the stomach. The first port (either a 5 or 10 mm) was inserted at the umbilicus using an open technique. A 30°telescope was used in all cases. Carboperitoneum was maintained at 8 mmHg and the flow was set at 2 L/min. The patient was given an anti-Trendlenburg position to allow the bowel to move down towards the pelvis. Preliminary assessment was carried out to delineate the site and size of the defect and its contents. Two additional 3mm ports were inserted - one on each side of the midline - in the midclavicular line [Figure 1]a.
|Figure 1: (a-d) Line diagram showing the steps of laparoscopic repair of MH. MH: Morgagni's hernia|
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In all the patients an anterior defect in the diaphragm spanning on both sides of the midline was visualized. The large bowel herniating through the defect could be easily reduced. The falciform ligament was passing either from the right side or posterior to the defect. The falciform ligament was divided in two patients for better exposure of the defect [Figure 1]b. Then the edge of defect was diathermized and incised using a diathermy hook. The hernial sac was dissected free from the pericardium and pleura using gentle blunt dissection and excised. The excised hernial sac was parked anterior to the liver and was removed at the end of the surgery.
The edge of the diaphragm was sutured to the abdominal muscles using transfascial sutures with the knots residing in the subcutaneous plane. A stab incision was made just below the costal margin at the site of the diaphragmatic defect in the epigastric region. A nonabsorbable 2-0 suture material (silk in two and polyester in three) attached to a curved round bodied needle was inserted inside the abdomen through the incision and the needle was grasped with a laparoscopic needle holder. A horizontal mattress suture was taken ensuring an adequate bite of the edge of the diaphragm at the site of the defect. This suture was then retrieved through the same incision using either a suture loop or a port closure needle. Four to five such sutures were inserted and held with hemostats [Figure 1]c. After all the sutures had been placed, the carboperitoneum was reduced to 4mmHg; the sutures were pulled upwards to even out the tension and each one was tied. The knots of the tied sutures lay in the subcutaneous tissue [Figure 1]d. Mesh was not required in any patient.
| Results|| |
In all there were five male patients with a median age of 2 years, range 1.5-3 years. They were asymptomatic and the MH was detected incidentally on chest X-ray performed for some other reason. The presence of air-filled density in the right cardiophrenic angle led to suspicion of MH [Figure 2], which was confirmed by a CT scan of the chest [Figure 3]. The median size of the hernial defect was 12 cm 2 and content was transverse colon in all. None of the patients required conversion to open surgery, the average blood loss was < 5ml and the median operating time was 75 min (range 62-85 min). In all the patients the postoperative chest X-ray was normal. Feeding was started after 6 h in all. The postoperative recovery was uneventful without any incidence of atelectasis or other postoperative complications. The median postoperative stay was 3 days (range 3-4 days). On follow-up clinical examination, all incisions were cosmetically esthetic [Figure 4]. At a follow-up of 1-15 years none of the MH have recurred.
|Figure 2: Plain X-ray showing presence of air-filled density in right cardiophrenic angle|
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|Figure 3: CT scan confirmed diagnosis of MH by showing continuity of bowel from abdomen to chest. CT: Computed tomography|
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|Figure 4: Postoperative clinical photograph of patient showing scars of incisions of port insertion and insertion of transfascial sutures|
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| Discussion|| |
MH,an uncommon variety of diaphragmatic hernia, was first described by Giovanni Battista in 1769.  In this hernia the abdominal viscera herniate into mediastinum through the foramen of Morgagni situated just behind the sternum. Most MH are bilateral and contain transverse colon and omentum, although herniation of small bowel, stomach, liver, and even gall bladder has been reported. They are usually asymptomatic, but may present with retrosternal discomfort, dyspnea, tightness in the chest, or symptoms of colonic obstruction. Isolated case reports of intestinal obstruction and gastric volvulus attributable to MH have also been described. The posteroanterior and lateral chest X-rays can point to a MH. Oral contrast studies, CT, or MRI of the thorax may be undertaken to confirm the diagnosis. The first successful laparoscopic repair of MH in a child was described by Georgacopulo et al., in 1997. 
It is undisputed that a surgical repair is mandatory in all patients with MH to prevent possible complications of incarceration and strangulation. However, there is no unanimity on the optimal surgical approach and open abdominal, open thoracic as well as minimally invasive techniques have all been practiced. All MH in the present series were repaired by a laparoscopic approach. It was easy to reduce the contents of the hernial sac and in none of the patients any adhesions between the contents and the hernial sac were encountered. However, when such adhesions are present, the magnified view offered by the laparoscopic approach should make their division and reduction of the contents from the thorax safer.
Excision of the hernial sac in MH remains a controversial issue. Fernandez-Cebrian and De Oteyza  and Rau et al.,  recommend excision of hernia sac, whereas others prefer to leave the hernial sac in situ. , This is a crucial step that needs to be done with utmost care and gentleness to avoid pleural or pericardial injury. We routinely excise the hernial sac in MH as we believe that this reduces the chances of recurrence.
Most of the described techniques utilize either a direct repair of the hernia ora mesh. The hernial defect in MHs is tangential to the axis of the instruments/ports and also there is deficiency of tissue behind the sternum. Both these factors make intracorporeal suturing challenging. The use of transfascial sutures avoids difficulty encountered in intracorporeal suturing. This repair, by including the entire abdominal wall and tying the knots extracorporeally in the subcutaneous plane, is a stronger one.  Most surgeons do not favor repair of MH by a thoracotomy due to its associated morbidity and need for chest tube drainage. Moreover, in the thoracoscopic repair suturing of the diaphragmatic defect with posterior surface of the sternum is extremely demanding. The technique described herewith is relatively simpler then intracorporeal suturing and does not require any specialized equipment. We feel that it is more likely to be universally accepted as compared with other minimally invasive surgical approaches. 
| Conclusion|| |
In authors' experience, laparoscopic repair of MH in children using transfascial sutures is technically easy, safe, and allows secure closure of the defect. Due to deficiency or tissue on the anterior aspect of the defect of the diaphragm, the transfascial sutures appear to be a logical and reliable way to close the defect.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]