Laparoscopic-assisted Repair of Morgagni Hernia

This video will demonstrate laparoscopic assisted repair of Morgagni diaphragmatic hernia. The technique will be demonstrated in several patients with different variations of Morgagni hernia. The patient is operated in the supine position. A 5 millimeter port is used at the umbilicus for the camera. Stab incisions, or 3 millimeter trocars are placed in the right and left upper quadrants for dissecting instruments. Once the hernia is visualized by laparoscopy, a short transverse incision of approximately 1.5 to 2 centimeters is made in the epigastrium at a point directly overlying the site of the hernia. The first patient is a 2-year-old boy with trisomy 21. Anteposterior and lateral chest films are shown here. A diaphragmatic hernia, seen centrally on the anteposterior view and anteriorly on the lateral view, is a Morgagny hernia. No further imaging is required. A bilateral defect can be seen containing small and large intestine. A stab incision is made in the left upper quadrant. An a traumatic grasper introduced through this incision is used to reduce the bowel and expose the entire defect. A short transverse incision is made overlying the anterior abdominal wall at the level of the defect. Through this incision, new stitches of oprole are placed between the anterior abdominal wall and the posterior rim of the defect, using a suture passer. The suture passer pierces the anterior abdominal wall and the posterior rim of the defect, carrying the suture. The suture is then released. The passer is withdrawn and reinserted a few millimeters away from the initial entry point, again passing through the anterior abdominal wall and posterior diaphragmatic rim. It pulls the suture back through the diaphragm and abdominal wall. Once all sutures are placed, the peritoneal attachments of the liver to the diaphragm are divided to further release the posterior rim of the defect. The sutures are then tied sequentially in the subcutaneous space to close the defect by bringing the diaphragmatic rim up to the anterior abdominal wall. This completes the repair. The patient recovered well and was discharged the following day. A chest X-ray performed one year after the repair is shown here. The 2nd patient is a 1-year-old boy with significant gastroesophageal reflux and failure to thrive. An upper GI contrast study incidentally showed a distal ileum and cecum in the left chest on a follow-up film. Chest x-rays confirmed Iorgagny hernia. In this case, following reduction of the right colon, the falciform ligament was found to be tethering the liver to the posterior rim of the defect. The cephalic portion of the ligament is taken down with cautery to release the hernia defect. This dissection is continued onto the diaphragmatic rim, keeping in mind the proximity of the hepatic veins. The posterior rim of the defect is now clearly visible and completely free of the liver. A similar U stitch procedure is used. In this case, grasping the posterior rim with an atraumatic grasper. Facilitates passing of the suture through it. The sutures are again tied externally under laparoscopic vision. In this case, the anterior abdominal fascia was extremely weak. The sutures were therefore passed through a small piece of cortex, placed in the transverse abdominal incision, and tied over the cortex to prevent tearing through the fascia. The 3rd patient is an 18-month-old healthy boy with an incidental Morgagny hernia, discovered on chest X-ray performed in the emergency department during an episode of acute upper respiratory tract infection. Despite the incidental discovery, a major portion of the small and large bowel is found herniated through the defect. In this case, a hernia sac was present. It was found to be quite adherent to the mediastinum and was left in situ. Again, the liver is found tethered to the posterior rim of the diaphragmatic defect and has to be mobilized. Quite a large defect is seen in this case. It is again closed using a series of new stitches as previously demonstrated. A total of 6 new stitches were necessary to obtain closure of the defect. The patient's chest x-rays one month and one year after repair are shown here. What appeared to be some fluid accumulation within the residual sack at one month can no longer be seen at one year. The final patient is an 18-month-old girl with an incidentally discovered Morgagny hernia on chest X-ray. The position of the trochars, instruments, and epigastric incision are shown here. In this case, a 5 millimeter trochar was used at the umbilicus for the camera. A 5 millimeter trochar was used on the left side, and a stab incision was used on the right side. The appearance of the hernia is shown. At the time of repair, the hernia contained only omentum. The falciform ligament is again found attached to the posterior rim. After reduction of the omentum, the ligament is taken down to free the posterior rim of the defect and provide ample room for suturing. A sack can again be seen and is left in place. The site of the short transverse epigastric incision is determined. A prominent vessel is cauterized to avoid bleeding during suturing of the defect. The junction of the sac with the posterior muscular rim is clearly seen. In this case, the distance between the anterior abdominal wall and the posterior diaphragmatic rim is quite short. An alternate, simpler technique is therefore used to close this defect. Oethebo sutures on CTX needles are passed from the anterior abdominal wall. Grab a good bite of the posterior rim and exit back through the abdominal wall as shown. The US sutures are not tied until all sutures are passed. However, intermittent tension on the 1st stitch facilitates the passing of the 2nd. The two sutures purposefully overlap to avoid any gaps in closure. This narrow gap is nearly obliterated with only 2 sutures, but a 3rd 1 is placed for added security. All the sutures have now been passed. The sutures are then tied externally under laparoscopic vision, resulting in excellent closure of the defect. The epigastric incision is then closed in two layers, and all trochar and stab incisions are also closed. The final result is shown. This procedure can be used in patients of all ages, and is associated with a low risk of recurrence and excellent cosmetic results. The results in an overweight 14 year old boy with a Morgagny hernia are shown here.