Robotic Repair of a Morgagni Hernia in Nine Steps

Case Presentation 

A 58-year-old female was referred for evaluation of an incidentally discovered Morgagni hernia. Over time, she developed intermittent aching and sharp anterior chest pain, exacerbated by torso twisting and bending. Her medical history was notable for prior laparoscopic gastric band placement. Imaging confirmed an anterior diaphragmatic defect consistent with a Morgagni hernia. 

Given her progressive symptoms and radiographic findings, a robotic transabdominal repair was planned. The goal of the operation was to demonstrate a standardized, primary robotic repair performed in nine essential steps, emphasizing a tension-free closure without prosthetic mesh.  

The Surgery 

A robotic approach was utilized with standard foregut positioning. Initial port placement was established 13 cm inferior to the xiphoid process in the supraumbilical region. Due to the patient’s prior laparoscopic gastric band placement, ports were offset to the patient’s right to avoid adhesions and optimize ergonomics. 

The procedure was performed in the following nine steps: 

Step 1: Patient Positioning and Port Placement 

The patient was positioned in a standard foregut fashion. Robotic ports were placed in the supraumbilical region, 13 cm from the xiphoid process, with a right-sided offset to accommodate the prior surgical history and optimize access to the anterior diaphragmatic defect. A total of four 8 mm ports were used in addition to a 12 mm assistant port. 
 
Step 2: Diagnostic Exploration 

A thorough abdominal survey was performed to confirm the location and extent of the Morgagni defect and assess the hernia contents. 
 
Step 3: Reduction of Hernia Contents 

The hernia contents were carefully reduced from the anterior mediastinum into the abdominal cavity using an atraumatic technique. 

Step 4: Dissection of the Hernia Sac 

The hernia sac was meticulously dissected circumferentially from mediastinal attachments, preserving surrounding structures. 
 
Step 5: Ligation of the Hernia Sac 

Following complete mobilization, the sac was ligated to prevent seroma formation and recurrence. 

Step 6: Preparation of the Diaphragmatic Lip 

Preparation of the diaphragmatic edges was emphasized as a key component of the operation. The diaphragmatic lip was clearly defined and mobilized to facilitate secure suture placement and ensure a tension-free repair. 

Step 7: Assessment of the Defect 

The defect was assessed to confirm suitability for primary repair without undue tension. Adequate mobilization allowed for approximation without the need for mesh reinforcement. 
 
Step 8: Primary Pledgeted Suture Repair 

Primary closure was performed using pledgeted sutures. The pledgets were fashioned from glycolic acid/trimethylene carbonate absorbable mesh, cut into 0.5 x 1.0 cm segments. Sutures were passed through the upper abdominal fascia using a suture passer and tied extracorporeally, with insufflation paused to optimize tension and repair integrity. This technique provided a strong, tension-free closure without onlay or preperitoneal mesh. 
 
Step 9: Final Inspection 

The abdomen was re-insufflated, and the repair was inspected for integrity, hemostasis, and appropriate diaphragmatic contour. 
 
Postoperative Course 

The patient tolerated the procedure well and was discharged in stable condition. At postoperative clinic follow-up, she reported complete resolution of her preoperative chest discomfort and had returned to normal activities. 

This case demonstrates that a robotic meshless repair of a Morgagni hernia can achieve a strong, tension-free closure. Further investigation into long-term outcomes is warranted to compare this primary repair technique with onlay or preperitoneal mesh approaches. 

References

1. Kaiser L. Mastery of Cardiothoracic Surgery, third edition 2014.
2. Shields’ General Thoracic Surgery, eighth edition

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