Laparoscopic repair of retrosternal hernia of Morgagni

May 25, 2007
Surgical Rounds®, June 2006, Volume 0, Issue 0

Mahesh S. Sharma, Fellow in Cardiothoracic Surgery, The Heart, Lung, and Esophageal Surgery Institute, The University of Pittsburgh Medical Center, Pittsburgh, PA; Desmond H. Birkett, Clinical Professor of Surgery, Tufts University School of Medicine, Staff Surgeon, The Lahey Clinic Medical Center, Boston, MA; Paresh C. Shah, Staff Surgeon, Department of Surgery, Lennox Hill Hospital, New York, NY; David M. Brams, Assistant Professor of Surgery, Tufts University School of Medicine, Staff Surgeon, The Lahey Clinic Medical Center, Boston, MA

A Morgagni hernia is a rare diaphragmatic hernia. Laparoscopic repair has been shown to provide successful treatment. The authors report a case of Morgagni hernia and provide a review of the literature, highlighting the 44 reported cases involving laparoscopic repair. A prosthesis was used in 65% of these cases. When should prosthetic material be used? Although there are no controlled studies, the authors provide a convincing case for using prosthetic material to repair a diaphragmatic hernia. The recurrence rate is not known for primary repair of diaphragmatic hernias larger than 4 cm. Extrapolation of data from studies evaluating the use of prosthetic material for ab­dominal wall hernias larger than 4 cm may not necessarily be applicable to diaphragmatic hernias. With these shortcomings in mind, I favor the authors’ recommendation for more frequent use of prosthetic material in repairing diaphragmatic hernias, especially those that are congenital. The hernia sac should also be excised whenever possible. Sharma and colleagues provide an excellent review of laparoscopic diaphragmatic hernia repair. Better follow-up studies evaluating recurrence rates of diaphragmatic hernia repair are needed.

Thomas Gadacz, MD

Series Guest Editor Professor and Chairman

Department of Surgery

Medical College of Georgia Augusta, GA

Mahesh S. Sharma, MD

Fellow in Cardiothoracic Surgery

The Heart, Lung, and Esophageal Surgery Institute

The University of Pittsburgh Medical Center

Pittsburgh, PA Desmond H. Birkett, MD

Clinical Professor of Surgery

Tufts University School of Medicine

Staff Surgeon

The Lahey Clinic Medical Center

Boston, MA

Paresh C. Shah, MD

Staff Surgeon

Department of Surgery

Lennox Hill Hospital

New York, NY

David M. Brams, MD

Assistant Professor of Surgery

Tufts University School of Medicine

Staff Surgeon

The Lahey Clinic Medical Center

Boston, MA

Morgagni hernia is a rare form of diaphragmatic hernia with an overall incidence of 1% to 3%.1 The foramen of Morgagni is a space that can arise from a defect in the retro-xiphoid sternocostal hiatus through which herniation of omentum, colon, stomach, or other viscera may occur.2 Morgagni hernias most often present later in life as a result of progressive attenuation of the diaphragm. The diagnosis of such hernias warrants operative repair. Conventionally, surgeons have treated this defect using an open approach via the thorax or by laparotomy.2,3 Recently, successful repair using a laparoscopic approach has been validated. We report a case of a retrosternal hernia of Morgagni in a 77-year-old woman who presented with intestinal obstruction. We describe our repair technique and provide a review of the literature with regard to laparoscopic repair in adults.

Case report

A 77-year-old woman with a history of rheumatoid arthritis, hypothyroidism, gastroesophageal reflux disease, and congestive heart failure presented to the emergency department because of epigastric abdominal pain associated with nausea and vomiting. She had experienced this pain intermittently over the 2 months before her admission. Plain radiographs and computed tomography (CT) scans of her chest and abdomen showed a right parasternal defect with dilated stomach and transverse colon herniating intrathoracically (Figures 1 and 2). The patient subsequently underwent a laparoscopic repair.

Under general endotracheal anesthesia, a supraumbilical incision was made and the abdomen was entered under direct vision. Four additional ports were placed into the abdomen after insufflation with carbon dioxide to a pressure of 15 mm Hg. The patient’s abdomen was examined and found to have the transverse colon and distal stomach incarcerated within an anterior lateral diaphragmatic hernia. The contents were reduced without difficulty (Figure 3). The peritoneal lining of the hernia sac was then excised using sharp dissection. The defect measured 6 x 8 cm, which was too large to repair primarily without undue tension. Therefore, a dual-sided polytetrafluoroethylene/expanded polytetrafluoro­ethylene (PTFE/ePTFE) mesh, which was approximately 8 x 12 cm and elliptical, was introduced into the abdomen. It was secured to the diaphragmatic musculature at either end with two interrupted 0-braided polyester sutures. The mesh was then fixed into place with running No. 1 polybutylate-coated polyester sutures posteriorly to the edge of the diaphragm and anteriorly to the anterior chest wall. In addition, 5-mm spiral tacks were placed circumferentially, pinning the mesh into the xiphoid and costal cartilages superiorly and into the diaphragm inferiorly (Figure 4). The patient recovered without event and was doing well with no signs of recurrence at 6-month follow-up.

Discussion

Retrosternal hernia of Morgagni is a rare form of diaphragmatic hernia that re­sults from a congenital failure of the diaphragm’s septum transversum to fuse with the costal arches.4 The anatomical defect is usually located on the right, at the level of the seventh rib on either side of the xiphoid, in a space where the superior epigastric vessels pass; however, defects may also occur on the left, at the midline, or bilaterally. A hernia through the right sternocostal hiatus is referred to as a Morgagni hernia, whereas a hernia through the left hiatus is named a Larrey hernia.5 The differential diagnosis includes pleuropericardial cyst, pleural mesothelioma, pericardial fat pad, mediastinal lipoma, tumor or cyst of the diaphragm, thymoma, and anterior chest wall tumors.2

Morgagni hernias are thought to result from an inheritable condition and may be associated with congenital abnormalities such as Down syndrome, pentalogy of Cantrell, Noonan syndrome, Prader-Willi syndrome, and Turner syndrome.6 Most Morgagni hernias present later in life as a result of progressive attenuation of the diaphragm from aging and changes in intra-abdominal pressure caused by pregnancy, obesity, and trauma.3 Patients may be asymptomatic or present with cardio­pulmonary symptoms due to compression of the thoracic organs or pulmonary infection. They may also experience gastrointestinal symptoms due to visceral herniation. Morgagni hernias are of the direct type and are composed of a sac that may contain omentum, transverse colon, stomach, other segments of intestine, or liver.7

Diagnosis can be established with routine imaging studies, including plain radiographs, CT scanning, contrast studies, or magnetic resonance imaging. Once this condition is diagnosed, surgical treatment is warranted even for patients who do not have symptoms because intestinal incarceration, strangulation, or both, may ensue.8 Operative intervention may be deferred only in the rare circumstance of an asymptomatic elderly pa­tient who would not tolerate the risks of surgery. Open repair of Morgagni hernias through the abdomen and chest has been successful.2,9 Minimally invasive techniques provide a means to repair these defects while minimizing the morbidity of open surgery. Our review of the literature up to 2005 showed 44 patients (27 men, 11 women, and 6 patients whose sex was not specified) with a mean age of 50 years (range, 17–85 years) had undergone laparoscopic repair (Table).10-41Most patients (80%) had colon within the hernia sac, 13% had omentum, 5% had either small intestine or stomach, and only 3% had either liver, round ligament, or the falciform ligament contained with­in the sac.

Considerable controversy exists re­garding the need for sac excision and whether prosthetic material should be used. Primary suture repair of the defect assumes that the apposable tissues are of good quality; however, Morgagni hernias are predicated on the fact that the diaphragmatic musculature is weak and attenuated. Therefore, we think that even if the defect may be closed primarily without tension, use of a suitable prosthesis should be considered. Although no recurrences are reported in the literature, patients may have had a failed primary repair and remained asymptomatic or did not undergo radiological monitoring. Prostheses were used in 28 of 43 cases reviewed (65%) and included polypropylene mesh and a variety of composite prostheses such as ePTFE and hydrophilic resorbable film. We prefer to use dual mesh, which allows the closure of large defects while minimizing the risks of adhesions to the prosthetic surface.

The direct hernia sac was excised in 15 of 41 patients (37%). Although some authors report that sac excision is unwarranted because of the unacceptable risk of massive pneumomediastinum and damage to the pericardium or mediastinal structures,42 excision of the sac may have the following advantages: (1) reduction of tissue trauma because only the sac is manipulated (rather than its contents) in cases where the colon or stomach are contained within the sac and the possibility for transmural visceral in­jury or neurovascular injury exists; (2) decreased chance for symptomatic fluid collection since the serous lining membrane is removed; and (3) sac excision negates the chance that the sac itself can act as a lead point for recurrent herniation.

In a prospective study, Edye and colleagues reported no cases of early reherniation in patients whose hernia sac was excised.43 Although this paper fo­cused on sac excision during paraesophageal hiatal hernia repair, we think the aforementioned arguments are valid for Morgagni herniorrhaphy and recommend excision of the sac. Laparoscopic hern­i­orrhaphy is the preferred method to repair defects in the retroxiphoid sternocostal hiatus. The hernia sac should be removed when technically safe. More­over, a prosthesis must be used when the defect’s size precludes tension-free repair.

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