A Novel Laparoscopic Hernia of Morgagni Repair Technique

Case Report

A 44-year-old gentleman presented to our institution with right heart failure. A previously active and healthy individual, he noted no significant medical or surgical history. Initial vital signs demonstrated no evidence of hemodynamic instability with a nasal cannula oxygen requirement of 5-liters. Arterial blood gas assessment revealed significant hypercapnea (PCO₂: 83). Chest x-ray demonstrated right lower lobe collapse with possible compromise of the right hemithorax. Chest computed tomography confirmed a hernia of Morgagni with passage of colon, small bowel, and stomach into the thorax (Figure 1). Preoperative heart catheterization demonstrated elevated right atrial (18 mmHg) and pulmonary artery (59/18 mmHg) pressures. Following optimization of his cardiopulmonary function, the patient was consented for laparoscopic hernia repair. Supraumbilical Veress needle entry into the abdomen achieved adequate pneumoperitoneum and bilateral subcostal trocars were placed. The hernia contents were reduced without complication into an intra-abdominal position. Following complete excision of the hernia sac to optimize visualization for mesh placement, an underlying 10×7 cm diaphragmatic defect was visualized with an absence of the anterior diaphragmatic rim. In the presence of insufficient innate diaphragmatic muscle for primary closure, a Prolene mesh prosthesis was created. Three 3-0 braided polyester sutures were placed in interrupted fashion into the anterior portion of the mesh prior to placement into the sub-diaphragmatic space. A laparoscopic suture passer was inserted through corresponding stab incisions in the anterior abdominal wall, allowing retrieval and subsequent anterior diaphragm reconstruction (Figure 2). Three transfascial sutures provided optimal approximation of the mesh to the anterior abdominal wall with no deformation. Interrupted endostitch fixation to the native diaphragm achieved circumferential coverage with 2–3 cm of mesh-to-defect overlap. Staple deployment provided controlled layering of the mesh. Pneumoperitoneum was evacuated and the patient was recovered. The patient followed an uncomplicated postoperative course with discharge on postoperative day one. He remains symptom-free at two postoperative years with no baseline oxygen requirement or functional limitation.

Figure 1.

Chest computed tomography demonstrating a hernia of Morgagni with displacement of the stomach, small bowel, and colon into the thorax.

Figure 2.

Diagram demonstrating mesh configuration in axial view with intracorporeal and extracorporeal knot orientation.

Discussion

The Morgagni-Larrey hernia comprises 3% of all diaphragmatic hernias that necessitate surgical repair¹. The triangular retrosternal foramen of Morgagni is formed by muscle fibers originating from the sternum and costal margin as they join the central tendon of the diaphragm¹. Incomplete congenital muscle fiber development predisposes patients to intra-thoracic abdominal visceral herniation, with 91% of Morgagni hernias occurring on the right². Intra-thoracic compressive symptoms are the predominant subjective complaint, with pulmonary limitations noted in 36% of patients². Our patient’s presentation represents the potentially fatal cardiopulmonary compromise that may be imposed on patients with significant visceral herniation and intra-thoracic compression.

Operative intervention for the hernia of Morgagni is supported at the time of diagnosis to limit the potential for visceral incarceration and subsequent requirement for a more challenging emergent surgical repair¹. Laparoscopic approaches to repair have provided diagnostic and therapeutic advantages with shorter operative times, less postoperative pain, and an earlier return to full activity compared to traditional thoracotomy and laparotomy³. Intra-operative evaluation of the presented patient revealed an absence of the anterior diaphragmatic rim, which inspired our use of the laparoscopic suture passer for retrieval of pre-placed anterior mesh sutures. To our knowledge, this is the first report of laparoscopic suture passer use in the prosthetic repair of a Morgagni hernia.

Significant discussion persists regarding the appropriate technique for laparoscopic repair of the hernia of Morgagni. In meta-analysis, 64% report use of a mesh prosthesis to achieve a tension-free repair, while 69% remove the hernia sac prior to closure of the defect². Successful repair has been achieved by laparoscopic-assisted extracorporeal and intracorporeal mesh prosthesis and primary repairs^4,5. There is no current established guideline for the application of a mesh prosthesis, with reports of primary repairs up to 50 cm^{2, 5}. Proponents of mesh repair advocate universal application in defects larger than 20–30 cm² to achieve a tension-free repair, with 1.5–2.5 cm of overlap to the native diaphragm³. Prolene mesh was chosen for our patient to accomplish dependable strength in repair of a defect with no directly adjacent bowel; however, composite mesh may also be appropriate for this technique. Our experience with the successful repair of a large hernia of Morgagni supports the efficacy of hernia sac excision followed by laparoscopic-assisted prosthetic mesh reconstruction and extracorporeal knot fixation.

The laparoscopic suture passer provides a novel and adaptable method for prosthetic repair of the foramen of Morgagni. This technique allows direct visualization and controlled placement of the mesh prosthesis to the anterior abdominal wall. As we seek to better understand developmental mechanisms for Morgagni hernia development, laparoscopy promises to optimize our approach as a well-tolerated diagnostic and therapeutic instrument for individualized care.