Laparoscopic Treatment of Morgagni-Larrey Hernia: Technical Details and Report of a Series

Management of complicated diaphragmatic hernia in the acute setting: a WSES position paper

BACKGROUND

Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable.

METHODS

A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations.

RESULTS

CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients.

CONCLUSIONS

Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving.

When laparoscopic repair is feasible for diaphragmatic hernia in adults? A retrospective study and literature review

BACKGROUND

Diaphragmatic hernia (DH), congenital or traumatic, is uncommon but sometimes can lead to a serious surgical emergency. There are no clinical guidelines or approved recommendations for the management of this condition, and most data are from retrospective, single-institution series. The aim is to analyze the management of the DH at our institution and review the indications for laparoscopic repair.

METHODS

A retrospective serie of patients diagnosed of DH with surgical treatment at our institution between 2009 and 2019. Literature review was carried out to establish the current indications of laparoscopic repair in each type of DH.

RESULTS

Surgery was carried out in 15 patients with DH, 5 congenital and 10 traumatic hernias. Traumatic hernias were classified as acute (n = 2) and chronic (n = 8). 53.4% of all cases (8 patients) required urgent surgery using an abdominal approach (5 open and 3 laparoscopic) and elective surgery was performed in 46.6% of all cases (7 patients) with an abdominal approach (3 open and 4 laparoscopic) and 2 patients with a combined approach. Primary repair was performed in 4 patients (26.6%), closure and mesh reinforcement in 9 cases (60%) and only mesh placement in 2 patients (13.4%). Postoperative morbidity and mortality were 20% and 0%, respectively. No recurrences were detected.

CONCLUSIONS

DH may pose different scenarios which require urgent or elective surgical treatment. Laparoscopic approach may be a first option in elective surgery; and in emergency setting taking into account hemodynamic stability and associated injuries.

Laparoscopic management of symptomatic congenital diaphragmatic hernia of Morgagni in the adult

BACKGROUND

Currently, there is a relative paucity of literature regarding the management of symptomatic congenital diaphragmatic hernia of the foramen of Morgagni in the adult. This study aims to describe our unique surgical technique and outcomes in adult patients undergoing laparoscopic repair of symptomatic Morgagni hernia.

METHODS

This is a retrospective review of adult patients from 2003 to 2020 who underwent a laparoscopic Morgagni hernia repair at our institution. All patients underwent a similar laparoscopic approach, utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect and mesh reinforcement with permanent mesh if the primary repair was subjectively under tension.

RESULTS

The study population consisted of 12 consecutive patients with a Morgagni hernia. Patients presented with a variety of symptoms attributed to the hernia, including pain 83% (n = 10), respiratory symptoms and shortness of breath 58% (7), and gastrointestinal obstruction 25% (3). Other complaints included: nausea 33% (4), reflux 50% (6), early satiety 8% (1), palpitations 16% (2), a gurgling sensation in the chest 8% (1), and weight loss 8% (1). Primary repair was possible in all patients following complete reduction of hernia contents including the hernia sac. Mesh reinforcement was used in 5 of 12 patients. Average surgical operative time was 93 (± 37) min. Median length of stay was 1.3 days (range 0.5-5.5 days). At a median follow-up of 10.9 months (IQR 8.0-41.5 months), all symptoms attributed to the hernia had resolved. No recurrences were identified.

CONCLUSIONS

Adults with symptomatic Morgagni hernia should undergo surgical repair. A laparoscopic approach utilizing the surgical principles of reduction of intra-abdominal contents, complete resection of the hernia sac, followed by primary repair of the hernia defect (when possible), with or without mesh reinforcement can be performed safely and effectively.

Paraesophageal Hernia as a Cause of Chronic Asymptomatic Anemia in a 6 Years Old Boy; Case Report and Review of the Literature

Esophageal hiatal hernia is defined as the prolapse of one or more intra-abdominal organs through the esophageal hiatus. Four types are identified: type Ι or sliding hiatal hernia, type II or paraesophageal hernia (PEH), type III or mixed hernia and type IV. Congenital type II esophageal hiatal hernia is caused by a remaining gap after the formation of pleuroperitoneal membrane. We present a case of a six years old boy admitted to our department, appearing with asymptomatic anemia, who was incidentally diagnosed with Type II esophageal hiatal hernia. After diagnostic investigation, the prolapsing stomach pouch was reduced, the hernia sac was excised, the crura of diaphragm were converged and a total fundoplication was performed, via open method. The patient had an uncomplicated postoperative period. We conclude that: 1) esophageal hiatal hernia should be included within diagnostic approach of a child with chronic non-hereditary anemia, 2) after a Type II esophageal hiatal hernia is diagnosed, a hernia repair surgery is indicated in short time, due to the severity of possible complications and 3) through the performance of total fundoplication, it is secured that the subdiaphragmatic abdominal part of esophagus will be retained, preventing the development of post-operative gastroesophageal reflux disease.

Morgagni hernia presenting as a right middle lobe compression

A 25-year-old woman with a history of chronic bronchitis since age 12 and 3-4 previous episodes of pneumonia presented to the emergency room with cough and shortness of breath. A CT scan of her chest revealed findings consistent with Morgagni hernia with herniation of omental fat, causing near complete compressive atelectasis of the right middle lobe. The diaphragmatic defect was successfully treated with a laparoscopic repair. The patient was discharged home on the first postoperative day after tolerating regular diet.

Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a pediatric patient: advancement in single-port technology allows effective intracorporeal suturing

We report a case of a foramen of Morgagni hernia repaired by a single-port laparoscopic technique. A 20-month-old (10 kg) boy underwent a 97-minute procedure through a 15-mm umbilical incision and had no complications. Although other pediatric single-port case series have been reported in the literature, this case represents the first time a diaphragmatic defect has been addressed. Moreover, unlike previous experiences that involved procedures of resection (appendectomy, cholecystectomy, etc), this case required operative repair and reconstruction with intracorporeal suturing via a single-access site. Advancement in instrument and port technology makes such procedures feasible in pediatric patients.

Laparoscopic repair of paraesophageal hiatus hernia in infancy

Paraesophageal hiatus hernia (PEHH) is an uncommon type of diaphragmatic hernia in the pediatric age group. Two patients aged 5-months and 8-months presented with respiratory symptoms and underwent a laparoscopic repair. Preoperative assessment included chest x-ray and CT scan. We suggest that laparoscopic repair of PEHH in infants is safe and preferred mode of the treatment.

Congenital retrosternal (Morgagni) diaphragmatic hernias in three horses

CASE DESCRIPTION

3 Horses were examined and treated because of sudden onset of signs of abdominal pain.

CLINICAL FINDINGS

All horses had a retrosternal (Morgagni) hernia involving the right side of the diaphragm. In each horse, the large colon was incarcerated in a right muscular defect in the diaphragm with a large hernial sac.

TREATMENT AND OUTCOME

Definitive surgical repair of the hernia was not performed during the initial celiotomy. The hernia was repaired with mesh herniorrhaphy, but without resection of the hernia sac in 2 horses. For 1 horse, conservative management was applied. In the 2 horses treated with surgical correction, no major postoperative complications developed, and all 3 horses have been free of signs of abdominal pain.

CLINICAL RELEVANCE

Horses with retrosternal hernias involving the diaphragm can develop clinical signs of intermittent obstruction of the large colon and chronic colic. In horses, retrosternal diaphragmatic hernias appear to develop exclusively in the right ventral aspect of the diaphragm and could represent an embryologic defect of diaphragm formation. Affected horses can be successfully treated with mesh herniorrhaphy or, in some instances, with conservative management.

Surgical technique and complications during laparoscopic repair of diaphragmatic hernias

Diaphragmatic hernias can present as retrocostoxiphoid hernias (RCXH) or diaphragmatic dome hernias. The RCXH include the Larrey hernia (LH), the Morgagni hernia (MH), and the Larrey-Morgagni hernia (LMH). These congenital hernias are usually asymptomatic, and the diagnosis is simplified by two exams: chest X-ray, and thoraco-abdominal computed tomography (CT) scan. The potential risk in this condition is small-bowel incarceration in the hernia defect and subsequent obstruction. We report two cases of LH and one case of LMH treated by laparoscopy between February 2004 and October 2005, with a review of the surgical techniques. Two different laparoscopic techniques were used: the tension-free technique, and resection of the hernia sac with closure of the defect and reinforcement by prosthesis. One patient presented a postoperative cardiac tamponade due to a clip-induced bleeding of an epicardial artery at the inferior surface of the heart. Treatment by laparoscopy is feasible, but a consensus regarding the best laparoscopic repair is needed.