Tips for the Surgical Management of a Morgagni Hernia

Position of the Patient

The patient was positioned supine on the bed with a footrest. This secures the patient well, especially when a steep reverse Trendelenburg position is required. A steep reverse Trendelenburg position was used to allow the abdominal contents to fall away from the diaphragm. The patient was positioned flush to the right side of the operating room (OR) table, which optimized access for the operating surgeon. The patient was intubated with a single-lumen endotracheal tube.

Port Placement Pearl: The Rule of Thirds

Mark the patient:

• Subcostal margin, xiphoid process, falciform
• A line was drawn from the xiphoid process to the umbilicus, divided into three equal parts
• The camera port was positioned two fingerbreadths below mark 2
• The working port, located to the right of the surgeon, was at mark 2
• The rest of the placements were the same as in the Nissen procedure

Figure 1—Orientation of the Patient 

Step 1: Reducing Hernia Contents

The typical transverse colon and omentum were found in the hernia sac. In some cases, the distal stomach has been seen in the hernia sac, which results in an acute gastric outlet syndrome. Inspection revealed that both the greater omentum and a part of the transverse colon were herniating into the right chest thoracic cavity with a 4 cm Morgagni defect.

Figure 2—Hernia Content Reduction 

Step 2: Reducing Tension 

The falciform ligament was cut to reduce tension on the lip of the Morgagni hernia and  fully expose the edges of the hernia sac. The tension was relieved from the anterior diaphragm and, ultimately, improved access to the hernia defect.

Step 3: Reduction of Hernia Sac 

The peritoneum was incised, allowing the surgeon to meticulously reduce the hernia sac.  Reducing the hernia sack has shown to help prevent reoccurrence of the hernia.

Figure 3—Tension Reduction and Hernia Sac Incision

Step 4: Dissection of Hernia Sac

The hernia sac was dissected off the parietal pleura and the diaphragmatic surface. Surrounding preperitoneal fat was also mobilized and included in the resected specimen.

Step 5: Removal of the Sac 

A ring forceps was inserted into the chest cavity through one of the existing laparoscopic ports (right paramedian port). The hernia sac and associated preperitoneal fat were grasped and carefully extracted using the ring forceps. The sac was then sent in formalin.

Figure 4—Hernia Sac Removal 

Step 6: Diaphragmatic Repair

The diaphragmatic defect was closed using 0 size simple interrupted non-absorbable sutures. Stitches were placed every 1 cm, with a total of four stitches used to sew the inferior lip of the hernia to the abdominal wall. A suture passer was used. Four 1 mm incisions were made on the abdominal wall to tighten the knots and ensure a strong purchase on the abdominal wall. Due to the prior division of the falciform ligament, the tension-free repair allowed for secure closure.

Figure 5—The Diaphragmatic Repair 

Step 7: Apply the Mesh

A bioresorbable mesh was applied over the repaired defect. The mesh was made from P4HBThe. The two sides of the mesh were labeled “S” for smooth and “R” for rough prior to insertion. Next:

• The smooth side (S) faced the abdominal cavity (outward).
• The rough side (R) faced the hernia (inward).
• The mesh was circumferentially tacked into place against the abdominal wall, chest wall, and diaphragm.
• The smooth, resorbable side was coated with hydrogel to reduce the incidence of intra-abdominal adhesions.

The mesh dissolves gradually during a 12 to 18 month period but provides a matrix for collagen deposition to strengthen the repair. The absorption process occurrs through hydrolysis, leaving behind a strong, functional tissue repair as the poly-4-hydroxybutyrate (P4HB) material is broken down and eliminated from the body.

Figure 6—The Mesh Application 

Step 8: Conclusion 

The ports were closed in a standard fashion. The surgeon was happy with the repair.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.

Figure 7—Before and After of the Patient’s Procedure  

Credits 

The authors want to give a special thanks to Katelyn Moore for editing the surgical video and for creating all the medical illustrations. This video is narrated by Kousha Ehsani, a student at the University of Toronto who shadows Dr. Irshad.

References

1. Deeken CR, Matthews BD. Characterization of the Mechanical Strength, Resorption Properties, and Histologic Characteristics of a Fully Absorbable Material (Poly-4-hydroxybutyrate-PHASIX Mesh) in a Porcine Model of Hernia Repair. ISRN Surg. 2013 May 28;2013:238067. doi: 10.1155/2013/238067. PMID: 23781348; PMCID: PMC3679684.
2. Murdock CM, Wolff AJ, Van Geem T. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol. 2000 May;95(5):704-9. doi: 10.1016/s0029-7844(00)00781-x. PMID: 10775733.

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