Recently I had the opportunity to treat a female patient with a Morgagni’s hernia in the left side of the sternum (also called Larrey’s hernia), using a laparoscopic approach with extra-abdominal transfascial sutures. This case is now published in BMJ Case Reports.
Morgagni's hernia diagnosis is usually delayed or incidental because the majority of patients are asymptomatic, or present with non-specific gastrointestinal, respiratory or cardiac symptoms. Hernia size and hernia contents will dictate symptoms. Although usually asymptomatic, life-threatening complications can occur with bowel strangulation meaning surgical repair is always indicated.
In the ancient Surgery C Department of “Centro Hospitalar e Universitário de Coimbra – Hospital Geral (Covões)” in Coimbra, Portugal, a female patient was incidentally diagnosed with a Morgagni’s hernia during an echocardiogram. She was asymptomatic till then but resorted to emergency department due to colic abdominal pain and nausea. An abdominal CT scan for hernia defect characterization was crucial to plan surgical repair. A left-sided Morgagni’s hernia with 4x3 cm (12cm2) ring was found, containing transverse colon and omentum but without signs of strangulation. A laparoscopic repair was performed.
Minimal invasive approach to treat Morgagni's hernia is the gold standard. We performed a laparoscopic repair.
Minimal invasive approach is the gold standard since the first laparoscopic repair performed by Kuster in 1992. Although thoracic approach is also a possibility with similar morbidity, the transabdominal approach is the first option for many authors assuming it is less invasive for the patient. For small defects a simple repair with non-absorbable suture is all what is need. On the contrary, for bigger defects (>20-30 cm2) a mesh is usually necessary for a tension free repair.
Extra-abdominal transfascial sutures were used to close the Morgagni's hernia defect without tension.
In the case we treated, a laparoscopic simple repair with separated sutures was possible because it was a small defect. Since the Morgagni’s hernia defect does not have an anterior ring, it is technically difficult to close it. In that setting we decided to use extra-abdominal transfascial sutures. With this technique we were able to suture the posterior ring to the full thickness of the anterior abdominal wall, achieving a tension-free repair. Three ports were used. The patient was in a split leg position with inverted Trendelenburg. A straight needle with 00 non-absorbable suture was used. Each suture included the full thickness of the anterior abdominal wall and the posterior ring of the defect, making a U figure with a pledjet (Figure). To retrieve the straight needle in the correct direction a 14-gauge needle was passed and its lumen used to guide the needle out of the abdomen. Knots were tied extracorporeally and laid in the subcutaneous tissue. No prosthesis was used.
Patient was discharged home in the day after, with a chest-film revealing no hernia. At three-months follow-up the patient was doing fine.
Hernia sac was left in place.
One of basic principles to treat a hernia (wherever it is) is to deal with the sac. There are two main options: remove the sac; push it back into the abdomen. Is there a third option? Removing the sac in a Morgagni’s hernia can result in serious complications like pneumothorax, pneumopericardium and massive pneumomediastinum with circulatory and respiratory complications. For this reason we decided to leave the sac in place. In fact, there seems to be no reason to remove it since the results reported in the literature are similar.
Do not forget one major rule of surgery: do not hurt the patient more than it is necessary to treat him properly.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon