Minimally Invasive Repair of Pediatric Morgagni Hernias Using Transfascial Sutures with Extracorporeal Knot Tying

Recurrence of anterior congenital diaphragmatic hernia after laparoscopic repair in children

PURPOSE

To report our experience with laparoscopic repair of anterior congenital diaphragmatic hernia (CDH) using extracorporeal subcutaneous knot tying and to define recurrence risk factors.

METHODS

This retrospective unicentric study included children who underwent laparoscopic repair of anterior CDH without patch, using extracorporeal knot tying of sutures passed through the full thickness of the abdominal wall (2013-2020). A systematic review of the literature with meta-analysis was performed using the MEDLINE database since 2000.

RESULTS

Eight children were included (12 months [1-183]; 10.6 kg [3.6-65]). Among the two patients with Down syndrome, one with previous cardiac surgery had a recurrence at 17 months postoperatively. In our systematic review (26 articles), among the 156 patients included, 10 had a recurrence (none with patch). Recurrence was statistically more frequent in patients with Down syndrome (19.4%) than without (2.5%) (p < 0.0001), and when absorbable sutures were used (50%) instead of non-absorbable sutures (5.3%) (p < 0.0001).

CONCLUSION

Laparoscopic repair of anterior CDH without patch was a safe and efficient surgical approach in our patients. The use of a non-absorbable prosthetic patch should be specifically discussed in anterior CDH associated with Down syndrome and/or in case of previous cardiac surgery to perform a diaphragmatic tension-free closure.

Previously undiagnosed Morgagni hernia with bowel perforation detected during repeat screening colonoscopy: A case report

BACKGROUND

Morgagni hernia (MH) is a form of congenital diaphragmatic hernia (CDH) characterized by an incomplete formation of diaphragm, resulting in the protrusion of abdominal organs into the thoracic cavity. The estimated incidence of CDH is between 1 in 2000 and 1 in 5000 live births, although the true incidence is unknown. MH typically presents in childhood and can be diagnosed either prenatally or postnatally. However, it can also be asymptomatic and carry the risk of developing into a life-threatening condition in adulthood.

CASE SUMMARY

A 76-year-old female with no history of prior abdominal surgeries presented for an elective colonoscopy for polyp surveillance. During the procedure, when approaching the hepatic flexure, the scope could not be advanced further despite multiple attempts. The patient experienced mild abdominal discomfort, leading to the abortion of the procedure. While in the recovery area, she developed increasing abdominal pains and hypotension. Urgent abdominal imaging revealed herniation of the proximal transverse colon through a MH into the chest with evidence of perforation. The patient underwent laparoscopic urgent colonic resection and primary hernia repair and was discharged uneventfully 2 d later.

CONCLUSION

A MH is a rare condition in adults that can present as a life-threatening complication of colonoscopy, even in patients with a history of uneventful colonoscopies. This case highlights the importance of considering congenital and internal hernias when faced with sudden and unexplained difficulties during colonoscopy. If there is a suspicion of MH, the endoscopist should halt the procedure and immediately obtain abdominal imaging to confirm the diagnosis.

Laparoscopic repair of Morgagni hernia by primary closure with extra-abdominal suture: a case report and review of the literature

We report a case of a Morgagni hernia repaired by primary closure with an extra-abdominal suture. Moreover, we reviewed cases of laparoscopically repaired Morgagni hernia, in which the size of the hernia defect was known, to establish a size criterion for mesh utilization. An 87-year-old woman presented to our hospital with right upper abdominal pain and vomiting. She had no history of abdominal surgery or trauma. Chest radiography and computed tomography (CT) revealed a Morgagni hernia, with the stomach and transverse colon herniated into the right chest cavity. Initially, an endoscopic repair was performed for the herniated stomach due to her age, which was successful. However, she had a recurrence 2 days later, prompting us to perform a semi-emergent laparoscopic surgery. Laparoscopic examination revealed a Morgagni defect, with the omentum, transverse colon, and stomach herniated, with the stomach reduced by pneumoperitoneum. Fortunately, the herniated organs could be easily relocated into the abdomen with no adhesions. The hernia defect measured 6 x 3 cm. We performed primary closure with an extra-abdominal suture. No sac resection was performed. The operation lasted 98 min. Oral intake was initiated on postoperative day 1, and the patient was discharged on postoperative day 3 without complications. Chest radiography and CT scans at 1 month postoperatively showed no recurrence, and the patient remained asymptomatic at the 9-month follow-up examination. According to our review findings, primary closure is an efficient method for small hernia defects (rule of thumb: width, <4 cm; length, <7 cm).

Laparoscopic Repair of Morgagni Hernia in Children

PURPOSE

This study aimed to evaluate our patients who underwent laparoscopic-assisted transabdominal repair for Morgagni hernia (MH).

METHODS

We retrospectively reviewed patients who underwent laparoscopy-assisted transabdominal repair using loop sutures for MH between March 2010 and April 2021. Demographic data, symptoms, operative findings, operation methods, and postoperative complications of the patients were reviewed.

RESULTS

A total of 22 patients with MH were treated with laparoscopy-assisted transabdominal repair using loop suture. There were 6 girls (27.2%) and 16 boys (72.7%). Two patients had Down syndrome, and two patients had cardiac defects (secundum atrial septal defect, patent foramen ovale). One patient had a V-P shunt due to hydrocephalus. One patient had cerebral palsy. The mean operation time was 45 min (30-86 min). The hernia sac was not removed, and a patch was not used in any of the patients. The mean hospitalization time was 1.7 days (1-5 days). One patient's defect was very large, and another patient's liver was densely attached to the liver sac, causing bleeding during dissection. In total, two patients were converted to open surgery. There was no recurrence during the follow-up.

CONCLUSION

Laparoscopy-assisted transabdominal repair is an efficient and safe choice for the repair of MH. Leaving the hernia sac does not increase the recurrence, so there is no need to dissect the sac.

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.

An Incidental Finding of Morgagni Hernia in an Elderly Female and Its Successful Management: A Rare Case Report and Review of Literature

Morgagni hernia is one of the congenital diaphragmatic hernias, but it can also occur in adults. It usually manifests in childhood, but in rare cases, it may also present in adults. It is linked to a congenital defect during the embryological development of the diaphragm. Uncommon diaphragmatic hernias, also called the foramen of Morgagni hernias, often affect the right side and are found in the anterior mediastinum. Typically asymptomatic in adult patients, the foramen of Morgagni hernia is linked to obesity, trauma, or other causes of elevated intraabdominal pressure. Diagnostic aids include plain pulmonary roentgenograms, contrast-enhanced radiographic investigations of the gastrointestinal tract, computerised tomography, and magnetic resonance imaging tests. We report a rare case of an 85-year-old female with a Morgagni hernia that was incidentally detected on a chest X-ray and was managed successfully.

Robotic assisted transabdominal preperitoneal approach for repair of Morgagni hernia in elderly female

Morgagni hernia's are relatively rare congenital diaphragmatic hernias that are typically described in pediatric populations. It is rare for patients to present with symptoms related to this defect in adulthood. Several techniques have been successfully utilized. This case report offers the successful utilization of the robotic assisted transabdominal preperitoneal approach (r-TAPP) for primary repair of a symptomatic Morgagni hernia in a high risk patient. To date, there are few publications describing the r-TAPP technique for Morgagni hernia repair, and no publications were found in the context described in our case. From this, we are able to provide increasing evidence of the efficacy and deployment of r-TAPP in age variable presentation of this pathology.

Tension-free thoracoscopic repair of congenital diaphragmatic hernia combined with a percutaneous extracorporeal closure technique: how to do it

PURPOSE

Thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) is associated with a higher recurrence rate than the conventional open method. We evaluated the effectiveness of our strategy for quality improvement, named "tension-free TR of CDH".

METHODS

The subjects of this retrospective analysis were 11 consecutive patients with CDH who underwent TR at our hospital between 2017 and 2021. Tension-free TR of CDH included the proactive use of an oversized patch for dome-shaped reconstruction and gapless suturing. We developed a percutaneous extracorporeal closure technique for secure suturing using a commercially available needle.

RESULTS

Patch repair was performed in 8 (73%) patients and none required conversion to open surgery because of technical difficulties. Recurrence developed in one patient (9%), who underwent successful reoperation via TR. All patients had an uneventful postoperative course.

CONCLUSION

Tension-free TR combined with extracorporeal closure could reduce the difficulty of suturing and the risk of recurrence of CDH.

[Diagnostics and treatment of morgagni-larrey hernia]

OBJECTIVE

To analyze the peculiarities of diagnosis, surgical treatment and laparoscopic suturing of Morgagni-Larrey hernia.

MATERIAL AND METHODS

Morgagni-Larrey hernias were diagnosed in 20 out of 78 patients (26%) with diaphragmatic hernias. Mean age was 56 years. Nineteen patients had right-sided hernia, 1 patient - left-sided hernia. Abdominal approach was used in all cases.

RESULTS

In 50% of patients, hernias were asymptomatic and found during X-ray examination. Symptoms were shortness of breath (4), cough (3), chest pain (1), epigastric pain (6), stool and gas retention (3), vomiting (1), belching (1). Hernia sac included omentum in all patients, transverse colon in 9 cases and small bowel in 1 patient. CT data completely coincided with intraoperative findings. Intraoperative dimension of hernia was 7.4±1.7 cm. Hernia sac was excised in all cases. Median laparotomy was performed in 10 patients, transrectal incision - in 3 cases. Laparoscopic suturing of hernia orifice with imposing 3-5 extracorporeal transfascial-muscular U-shaped polypropylene sutures was performed in 7 cases. We passed the thread through abdominal wall (two skin incisions up to 2 cm) and diaphragm using a straight needle for suturing the wound from the port EndoClose. Ligatures were tied in subcutaneous fatty tissue. No postoperative complications and recurrent hernias were observed.

CONCLUSION

Morgagni-Larrey hernias occur in adults aged over 50 years as a rule. These hernias are usually right-sided, asymptomatic in 50% of cases and detected during routine X-ray examination. Laparoscopic suturing of hernia orifice using extracorporeal transfascial-muscular sutures with fixation of ligatures in subcutaneous tissue ensures adequate closure of defect.

Management of Morgagni's Hernia in the Adult Population: A Systematic Review of the Literature

BACKGROUND

Morgagni's hernia (MH) is defined by the protrusion of abdominal viscera through an anterior retrosternal diaphragmatic defect. The objective of this study was to systematically review current literature on MHs in adult population and assess their clinical characteristics and therapeutic approach.

METHODS

PubMed and Cochrane bibliographical databases were searched (last search: 15^th January 2021) for studies concerning MHs.

RESULTS

Inclusion criteria were met by 189 studies that included 310 patients (61.0% females) with an age of 57.37 ± 18.41 (mean ± SD) years. Pulmonary symptoms, abdominal pain, and nausea-vomit were among the most frequent symptomatology. MHs were predominantly right-sided (84.0%), with greater omentum (74.5%) and transverse colon (65.1%) being the most commonly herniated viscera. The majority of cases underwent an open procedure, while 42.3% of patients had a minimally invasive procedure. Abdominal approach was mostly preferred, while a thoracic one was chosen at 20.6% of cases and a thoracoabdominal at 3.2%. Thirty-day postoperative complications were recorded at 29 patients and 30-day mortality was 2.3%.

CONCLUSIONS

MH is a rare type of congenital diaphragmatic hernia which rarely manifests in adult population with atypical pulmonary and gastrointestinal symptoms. Surgery is the gold standard for their management. Open surgical approach is preferable in emergency cases, while laparoscopic surgery is favored in elective setting and is associated with shorter hospitalization. Further studies are crucial in order to elucidate etiology and optimal therapeutic approach.