Laparoscopic-assisted Repair of Morgagni Hernia

Morgagni diaphragmatic hernia appears centrally on anteroposterior chest X-ray and anteriorly on lateral chest X-ray

No further imaging beyond AP and lateral chest films is required for diagnosis of Morgagni hernia

The patient is operated in the supine position with 5mm umbilical camera port and 3mm or stab incision working ports in right and left upper quadrants

A short transverse epigastric incision of approximately 1.5 to 2 centimeters is made directly overlying the hernia site

U-stitches of Prolene are placed between the anterior abdominal wall and the posterior rim of the defect using a suture passer

The peritoneal attachments of the liver to the diaphragm are divided to further release the posterior rim of the defect

The sutures are tied sequentially in the subcutaneous space to close the defect by bringing the diaphragmatic rim up to the anterior abdominal wall

The first patient (2-year-old with trisomy 21) recovered well and was discharged the following day

The falciform ligament can tether the liver to the posterior rim of the defect and must be taken down with cautery

During dissection of the falciform ligament onto the diaphragmatic rim, the proximity of the hepatic veins must be kept in mind

When the anterior abdominal fascia is extremely weak, sutures can be passed through a small piece of cortex placed in the transverse abdominal incision and tied over the cortex to prevent tearing through the fascia

When a hernia sac is present and found to be quite adherent to the mediastinum, it can be left in situ

Large Morgagni defects may require six U-stitches to obtain adequate closure

Fluid accumulation within the residual sac at one month post-repair may resolve by one year

When the distance between the anterior abdominal wall and the posterior diaphragmatic rim is quite short, an alternate simpler technique using Ethibond sutures on CTX needles can be used

In the simplified technique, sutures are passed from the anterior abdominal wall, grab a good bite of the posterior rim, and exit back through the abdominal wall

The U-sutures are not tied until all sutures are passed, but intermittent tension on the first stitch facilitates passing of the second

The two sutures purposefully overlap to avoid any gaps in closure

This laparoscopic-assisted procedure can be used in patients of all ages

The laparoscopic-assisted Morgagni repair is associated with a low risk of recurrence and excellent cosmetic results