IPEG 2020 TOP ABSTRACT: Laparoscopic Repair of a Complicated Morgagni Hernia after Multiple Recurrences

We present a case of a 2-year-old male born with a Morgogny hernia with a history of multiple recurrences, with the last operation being an exploratory laparotomy for suspected infected mesh with removal and primary repair, who presented once again with a symptomatic recurrent hernia as demonstrated in this X-ray. Even though his previous operation was open, we elected to perform this repair via a minimally invasive approach by utilizing a 5 millimeter transambilical port and 23 millimeter ports as shown in the image. Here we see the defect. Adhesions are being taken down and we then begin to reduce the hernia contents which includes small bowel. Large bowel. And the left lobe of the liver. While dissecting around the liver, careful attention must be paid to the location of the hepatic veins to avoid inadvertent injury. We began to excise the hernia sac as mentioned previously. This patient had a recurrence after primary repair. It was then repaired with a biologic mesh. One month later, he presented with suspected mesh infection and underwent an exploratory laparotomy with mesh explantation and primary repair. We suspected that this large hernia sac contributed to his complicated course. At this point in the dissection, you can see the pleura, the pericardium, and the difficult surgical planes. We inevitably enter into the pleural cavity and a pneumothorax develops. Maintaining communication with the anesthesia team allowed for adequate ventilatory management. The complete defect is now visible. We then measure the size of the defect, utilizing sutures. As well as measuring the distance from the hepatic veins to the border of the diaphragm so that we may select and contour the mesh for an appropriate overlap, a different type of biologic mesh was then prepared back table with 20 ethebo sutures in a circumferential manner to allow for transfascial fixation. The mesh is then carefully inserted into the abdominal cavity with correct orientation, which will allow for ease and proper placement of the mesh over the defect. We then use a suture passer for our trans fascial fixation. It is important to note that although the same skin incision is used, the fascial and diaphragmatic insertion sites of the suture passer must be adequately spaced to evenly distribute tension. The sutures can be manipulated while untied at this point to ensure proper placement of the mesh. A needle can also be used to ensure correct location. It is important to ensure that the tenets of mesh placement are observed. At the posterior portion of the diaphragm, we notice that there is too much tension. For this reason, we return the sutures into the abdominal cavity and tie the suture to the diaphragm incorporally. This will ensure a tension-free repair, but requires a bridging technique rather than a primary pair with mesh overlay. In areas of less tension, sutures are tied in a transfascial manner. Once the mesh is in place, we utilize titanium tacks to anchor the mesh into the peritoneum in a circumferential fashion while avoiding important structures. It should be noted that tacking to the diaphragm can be challenging due to lack of counter tension. A second row of the titanium and absorbable tacks is then applied to eliminate wrinkling of the mesh and avoid possible entrapment of bowel loops into the mesh. As we approach anteriorly, close to the camera, it becomes difficult to visualize tacking, although this is still feasible. Here you can see final placement of the mesh. A postoperative X-ray did not reveal any residual pneumothorax, and the patient had an uneventful recovery.