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Discussion |
Morgagni’s hernia is a rare cause of a diaphragmatic hernia. The defect tends to be small and asymptomatic. When symptomatic, a trans-thoracic or trans-abdominal repair has been carried out. We report asymptomatic case, presenting in an elderly patient, repaired successfully using a laparoscopic approach and discuss various aspects of technique.
Keywords: Diaphragm, hernia of Morgagni, laparoscopy, repair
J.R.Coll.Surg.Edinb., 45, December 2000, 400-402
Morgagni's hernia, a congenital anterior diaphragmatic defect, is uncommon, representing only 3% of all diaphragmatic hernias.1 The defect is usually relatively small, with a greater transverse than anterior-posterior diameter.2 The condition is often asymptomatic and, it is often diagnosed incidentally during the investigation of other conditions.3,4 Where symptoms are present, these are often due to compression of thoracic organs. Alternatively, herniation of intra-abdominal viscera can cause vomiting, abdominal pain and bleeding.5 Traditional surgical management has involved an open trans-thoracic or trans-abdominal approach, with suturing of the edge of the diaphragm to the retrosternal and retrocostal endothoracic fascia and/or posterior rectus sheath.6 However, these approaches can involve significant wound relatedmorbidity. In view of this, the laparoscopic approach offers a potentially attractive alternative. However, previous reports are limited and there is no consensus about the optimum laparoscopic technique.3,4,7,8 We report the successful laparoscopic repair of an anterior diaphragmatic defect using a direct suture technique.
An 80-year-old woman presented with an 8 month history of intermittent severe upper abdominal pain, occurring once every 2 to 3 weeks, typically lasting for up to 6 hours, and associated with episodes of absolute constipation. Clinical examination was unremarkable and both abdominal ultrasound scan and upper gastrointestinal endoscopy revealed no significant abnormality. A barium meal and follow-through radiograph, looking for evidence of small bowel obstruction, however, demonstrated an anterior diaphragmatic hernia with colon present in the thoracic cavity (Figure 1).
Figure 1: Lateral chest radiograph during barium follow-through examination, demonstrating transverse colon passing through an anterior diaphragmatic defect into the anterior mediastinum
Due to concern that the colon was intermittently obstructed within the hernia, we proceeded to laparoscopic repair. Surgery was performed through four laparoscopic ports (2 x 5 mm, 2 x 11 mm). The presence of an anterior diaphragmatic hernia containing transverse colon was confirmed (Figure 2). The hernia contents were easily reduced, revealing a 40x100mm transversely oriented defect in the diaphragm at its origin from the anterior chest wall (Figure 3). The hernia sac was fully excised from the mediastinum, and the edges of the defect were then approximated using eight figure of eight configuration, interrupted 2/0 monofilament non-absorbable sutures. Suture placement commenced at the lateral margins of the defect, and progressed medially until a satisfactory repair had been achieved. No drain was employed, and the operating time was 55 minutes. The patient made an uncomplicated post-operative recovery, and at 12 months she remains well, with no recurrence of her symptoms and no evidence of recurrent herniation.
Figure 2: Laparoscopic view of diaphragmatic hernia of Morgagni with transverse colon partly contained within the sac
Figure 3: Laparoscopic view of undissected hernia defect following removal of the contents of the sac
The diagnosis of a Morgagni's hernia can be difficult, and patients often undergo extensive testing, sometimes to no avail. However, laparoscopy should provide the diagnosis in all cases, without exhaustive radiological tests. Furthermore, laparoscopy can be therapeutic, as well as diagnostic. The technique reported in this article was relatively straightforward and reduction of the herniated contents and closure of the defect was readily achieved, despite the increased intra-abdominal pressure associated with the use of a pneumoperitoneum.
Whilst various laparoscopic techniques have been reported, each with their own merits, the optimum approach is not known due to the relative rarity of the condition. Most previous reports describe the use of prosthetic mesh to repair and cover the defect, using either sutures or staples to maintain the mesh in position.3,4,7 However, unless mesh is covered with a layer of peritoneum, intra-abdominal viscera may adhere to it, creating a setting in which small bowel obstruction is more likely at a future time.
The use of staples alone to close the diaphragmatic defect has also been described.4 However, this method, although relatively attractive because it appears simple to perform, is only possible when a very small defect is present. Primary suture repair has also been described, with various different techniques reported recently, usually entailing repair using a continuous suture technique.3,7 A plication technique has also been described.9
Whilst all these methods have been successfully employed, there may be difficulties with intra-corporeal knotting if there is any tension on the repair as it progresses. Our technique entailed interrupted suture repair with extra-corporeal knotting, which allowed closure of the defect to be started at either end, with progression towards the middle, as necessary, to limit the tension on individual sutures, and to assess tension as the repair progressed.
The issue of sac removal is controversial. Some authors do not recommend removal of the hernial sac, believing this step to be potentially hazardous.4,9 However, others believe that sac removal is a necessary and desirable part of the procedure.3 We believe that the major benefit of sac excision is that a mesothelial-lined cavity is not left behind in the chest.
Laparoscopy provides an excellent route for both diagnosis and repair of a Morgagni's hernia. With careful dissection, the hernial sac can be easily removed and, where possible, this should be done. The technique of interrupted suture repair, with extra-corporeal knotting, is relatively quick and straightforward, and provided there is no excessive tension on the repair, this method provides an excellent method of repair. If the defect is too large to allow approximation of the edges, then a mesh repair technique may be a better option.
Copyright date: 16 May 2000
Correspondence: Mr D.I. Watson, University of Adelaide Department of Surgery, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia
E-mail: dwatson@medicine.adelaide.edu.au
©2000 The Royal College of Surgeons of Edinburgh, J.R.Coll.Surg.Edinb. 45, 6: 400-402