JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 2, 1992 Mary Ann Liebert, Inc., Publishers
Brief Clinical
Report
Diaphragmatic Hernia Through the Foramen of Morgagni: Laparoscopic Repair Case Report GUSTAVO G. R. KÜSTER, M.D., LAWRENCE E. GABRIEL GARZO, M.D.
KLINE, D.O.,
and
ABSTRACT
Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.
INTRODUCTION of Morgagni are congenital hernias of the retroxiphoid region which account for 1-3% of surgically treated diaphragmatic hernias. ' Until now, the surgical treatment of these hernias has consisted of transabdominal or transthoracic suture of the edge of the diaphragm to the retrosternal and retrocostal peritoneum and periosteum.'2 We report a patient with a Morgagni hernia who underwent repair with a technique performed laparoscopically. Prompt recovery and complete resolution of the symptoms were accomplished.
Hernias approximately
of the foramen
CASE REPORT A 67-year old woman had shown, in yearly chest x-rays done since 1987, the presence of a 5 cm mass in the right cardiophrenic angle. She remained asymptomatic until January 1991 when she began to experience nausea, abdominal distention, and irregularity of bowel movements. Chest x-rays at this time showed that the
Departments of Surgery and Medicine, Scripps Clinic and Research Foundation, La Jolla, 93
California.
KÜSTER ET AL. had enlarged to 10 cm in diameter (Fig. 1 ). A CT scan of the chest and abdomen confirmed the presence large fat-density mass in the lower anterior mediastinum bulging into the right chest (Fig. 2). A barium enema showed the mid transverse colon tented up into the diaphragm. The physical examination of the chest and abdomen revealed no abnormalities. To confirm the diagnosis, laparoscopy was performed on March 19, 1991. A 10 mm, 0° angle scope was introduced through the umbilicus. Pneumoperitoneum with C02 was maintained at 8 mmHg. Examination of the upper abdomen showed the presence of a defect measuring 10 cm in diameter in the anterior aspect of the diaphragm, containing almost the entire omentum and part of the transverse colon (Fig. 3). Through two other 5 mm ports placed in both sides of the subcostal areas, the contents of the hernia were gently pulled down with grasping forceps, reducing them entirely into the peritoneal cavity (Fig. 4). Electrocautery was used to separate adhesions encountered at the edge of the hernial sac. The hernial defect could be easily inspected and the exposure was excellent, allowing ideal conditions to repair the defect laparoscopically. The sac was not removed. A No. 1 monofilament polypropilene suture on a curved needle (1-Prolene, Ethicon 8455 H, taper CTX needle) was passed percutaneously through the abdominal wall into the peritoneal cavity just inferior to and left of the xiphoid. Using the instruments introduced through the subcostal accesses, an over-and-over continuous closure was done by suturing the subcostal and retrosternal peritoneum anteriorly to the full thickness of the edge of the diaphragm posteriorly (Fig. 5). At this level the suture was percutaneously brought back outside the abdomen on the right side of the xiphoid. A 2 cm incision in the skin was made, through which the two ends of the suture were tied in the subcutaneous tissue in front of the fascia (Fig. 6). The skin was closed with a 4-0 monofilament suture. The patient was dismissed the following day after having a regular breakfast. Subsequently the patient has recovered well and has had no further symptoms. As of March 1992 she remains asymptomatic. Chest x-rays performed 3 and 8 months after surgery showed no abnormalities (Fig. 7). mass
of a
(A) Chest x-ray shows mass in right cardiophrenic angle. (B) Morgagni hernia in highlighted area (arrow).
FIG. 1.
94
Schematic
drawing of chest
x-rays
depicting
DIAPHRAGMATIC HERNIA REPAIR
FIG. 2.
showing
(A) CT scan reveals soft tissue density in lower right anterior mediastinum. (B) Schematic hernia in high-lighted area (arrow).
drawing of CT scan
DISCUSSION
Diaphragmatic hernias form through the esophageal hiatus, traumatic defects, or congenital abnormalities. The diaphragm is derived from the septum transversum ventrally, the pleuroperitoneal membrane and body wall laterally, and the mesoesophagus mediodorsally. The lateral structures may not fuse, causing Bochdalek hernias. Congenital hernias also occur in the retro xiphoid region. These are called hernias of the foramen of Morgagni and nearly all have a sac. Usually found in adults, they commonly extend to the right side.2 The patients are frequently obese.3 Many of these hernias are probably acquired, developing through a weak area of attachment between the diaphragm and the sternum and costal cartilage. The sac usually contains omentum or transverse colon. The '
small bowel and stomach may also be herniated. Morgagni hernias are rarely symptomatic but may produce epigastric discomfort or bloating. Acute symptoms are almost always due to large bowel obstruction,4 although omentum and stomach may also
95
KÜSTER ET AL.
FIG. 3. (A) Laparoscopic view of hernia of the foramen of Morgagni containing transverse colon and omentum. (B) Schematic drawing of laparoscopic view of Morgagni hernia containing the omentum (D: peritoneum covering retrosternal and retrocostal area, M: hernial sac, H: edge of diaphragm, O: omentum).
become incarcerated.' Lateral chest films show an anterior cardiophrenic mass and the diagnosis may be confirmed with barium enema or CT scan."" The differential diagnosis includes lung and mediastinal tumors, pericardial fat pad, atelectasis, pneumonia, and pleural, pericardial, mediastinal, or diaphragmatic cysts. Operative repair is recommended to avoid strangulation, although the frequency of this complication may not be high.3 The standard surgical procedure requires a laparotomy or a thoracotomy, both of which have a long postoperative recovery period and can lead to significant morbidity, especially in high risk patients. The laparoscopic technique described in this patient proved to be a sound approach, technically easy, and, in addition, resulted in immediate return of the patient to normal diet and activities. The hernial sac should not be removed during laparoscopic repair of diaphragmatic hernias,6 as this may result in massive pneumo
96
DIAPHRAGMATIC HERNIA REPAIR
FIG. 4. (A) Laparoscopic view of hernial defect after reducing its contents. (B) Schematic drawing of laparoscopic view of hernial opening and sac (D: peritoneum covering retrosternal and lower retrocostal area, M: cavity lined by hernial sac, H: edge of diaphragm forming the posterior half of the hernial neck, F: falciform ligament).
mediastinum with potential respiratory and circulatory complications. To our knowledge this is the first report of a diaphragmatic hernia of the foramen of Morgagni repaired laparoscopically. Another novelty of this technique is the way the suture is placed. The passage of the suture to be tied in the front of the abdominal fascia allows the best possible anchoring and permanent repair. It also makes the tieing of knots easy, being done outside the abdomen. The most difficult part of the techniques described previously has been the placing of the sutures in the back of the sternum and costal margin, where there is no strong fascia. The suturing concept described in this report may find other applications, particularly in
laparoscopic surgery. 97
KÜSTER ET AL.
FIG. 5. (A) Laparoscopic repair of the Morgagni hernia closing the diaphragmatic defect with continuous suture. (B) Schematic drawing showing the laparoscopic suture of the hernia opening (D: peritoneum covering retrosternal and retrocostal area, A: stitch being placed through peritoneum and periostium of retrosternal area, M: hernial sac, H: edge of diaphragm, F: falciform ligament).
98
DIAPHRAGMATIC HERNIA REPAIR
FIG. 6. Schematic depiction of laparoscopic repair of diaphragmatic hernia. Over-and-over closure of the defect with the loop joining the two ends of the suture, placed outside the rectus fascia.
FIG. 7.
Chest x-ray done
on
December 2, 1991,
showing no evidence of recurrence of Morgagni hernia. 99
KÜSTER ET AL.
CONCLUSIONS
Laparoscopy is an excellent approach to confirm the diagnosis and to repair a noncomplicated diaphragmatic hernia of the foramen of Morgagni. A suturing technique is described, incorporating the abdominal fascia in the repair and securing the knots outside the abdomen. The same technical approach might be useful for other hernia repairs or surgical procedures, especially when done by laparoscopy. This laparoscopic technique is technically easy, safe, and is followed by prompt recovery. REFERENCES TP, Clagett OT: Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-468. 2. Ketonen P, MattilaSP, MattilaT, et al: Surgical treatment of hernia through the foramen of Morgagni. ActaChirScand 1975;141:633-636. 3. Saha SP, Mayo P, Long GA: Surgical treatment of anterior diaphragmatic hernia. South Med J 1982;75:280-281. 1. Comer
4.
Harrington SW: Various types of diaphragmatic hernia treated surgically. Report of 430 cases. Surg Gynecol Obstet 1948;86:735-755.
5. 6.
Fagelman D, Caridi JG: CT diagnosis of hernia of Morgagni. Gastrointest Radiol 1984;9:153. Küster GGR, Gilroy S: Laparoscopic repair of paraesophageal hiatal hernia. Surg Gynecol Obstet. (In press.) Address reprint requests to: Gustavo G. R. Küster, M.D.
Department of Surgery Scripps Clinic and Research Foundation 10666 N. Torrey Pines Road La Jolla, CA 92037
100
Brief Clinical
Report
Diaphragmatic Hernia Through the Foramen of Morgagni: Laparoscopic Repair Case Report GUSTAVO G. R. KÜSTER, M.D., LAWRENCE E. GABRIEL GARZO, M.D.
KLINE, D.O.,
and
ABSTRACT
Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.
INTRODUCTION of Morgagni are congenital hernias of the retroxiphoid region which account for 1-3% of surgically treated diaphragmatic hernias. ' Until now, the surgical treatment of these hernias has consisted of transabdominal or transthoracic suture of the edge of the diaphragm to the retrosternal and retrocostal peritoneum and periosteum.'2 We report a patient with a Morgagni hernia who underwent repair with a technique performed laparoscopically. Prompt recovery and complete resolution of the symptoms were accomplished.
Hernias approximately
of the foramen
CASE REPORT A 67-year old woman had shown, in yearly chest x-rays done since 1987, the presence of a 5 cm mass in the right cardiophrenic angle. She remained asymptomatic until January 1991 when she began to experience nausea, abdominal distention, and irregularity of bowel movements. Chest x-rays at this time showed that the
Departments of Surgery and Medicine, Scripps Clinic and Research Foundation, La Jolla, 93
California.
KÜSTER ET AL. had enlarged to 10 cm in diameter (Fig. 1 ). A CT scan of the chest and abdomen confirmed the presence large fat-density mass in the lower anterior mediastinum bulging into the right chest (Fig. 2). A barium enema showed the mid transverse colon tented up into the diaphragm. The physical examination of the chest and abdomen revealed no abnormalities. To confirm the diagnosis, laparoscopy was performed on March 19, 1991. A 10 mm, 0° angle scope was introduced through the umbilicus. Pneumoperitoneum with C02 was maintained at 8 mmHg. Examination of the upper abdomen showed the presence of a defect measuring 10 cm in diameter in the anterior aspect of the diaphragm, containing almost the entire omentum and part of the transverse colon (Fig. 3). Through two other 5 mm ports placed in both sides of the subcostal areas, the contents of the hernia were gently pulled down with grasping forceps, reducing them entirely into the peritoneal cavity (Fig. 4). Electrocautery was used to separate adhesions encountered at the edge of the hernial sac. The hernial defect could be easily inspected and the exposure was excellent, allowing ideal conditions to repair the defect laparoscopically. The sac was not removed. A No. 1 monofilament polypropilene suture on a curved needle (1-Prolene, Ethicon 8455 H, taper CTX needle) was passed percutaneously through the abdominal wall into the peritoneal cavity just inferior to and left of the xiphoid. Using the instruments introduced through the subcostal accesses, an over-and-over continuous closure was done by suturing the subcostal and retrosternal peritoneum anteriorly to the full thickness of the edge of the diaphragm posteriorly (Fig. 5). At this level the suture was percutaneously brought back outside the abdomen on the right side of the xiphoid. A 2 cm incision in the skin was made, through which the two ends of the suture were tied in the subcutaneous tissue in front of the fascia (Fig. 6). The skin was closed with a 4-0 monofilament suture. The patient was dismissed the following day after having a regular breakfast. Subsequently the patient has recovered well and has had no further symptoms. As of March 1992 she remains asymptomatic. Chest x-rays performed 3 and 8 months after surgery showed no abnormalities (Fig. 7). mass
of a
(A) Chest x-ray shows mass in right cardiophrenic angle. (B) Morgagni hernia in highlighted area (arrow).
FIG. 1.
94
Schematic
drawing of chest
x-rays
depicting
DIAPHRAGMATIC HERNIA REPAIR
FIG. 2.
showing
(A) CT scan reveals soft tissue density in lower right anterior mediastinum. (B) Schematic hernia in high-lighted area (arrow).
drawing of CT scan
DISCUSSION
Diaphragmatic hernias form through the esophageal hiatus, traumatic defects, or congenital abnormalities. The diaphragm is derived from the septum transversum ventrally, the pleuroperitoneal membrane and body wall laterally, and the mesoesophagus mediodorsally. The lateral structures may not fuse, causing Bochdalek hernias. Congenital hernias also occur in the retro xiphoid region. These are called hernias of the foramen of Morgagni and nearly all have a sac. Usually found in adults, they commonly extend to the right side.2 The patients are frequently obese.3 Many of these hernias are probably acquired, developing through a weak area of attachment between the diaphragm and the sternum and costal cartilage. The sac usually contains omentum or transverse colon. The '
small bowel and stomach may also be herniated. Morgagni hernias are rarely symptomatic but may produce epigastric discomfort or bloating. Acute symptoms are almost always due to large bowel obstruction,4 although omentum and stomach may also
95
KÜSTER ET AL.
FIG. 3. (A) Laparoscopic view of hernia of the foramen of Morgagni containing transverse colon and omentum. (B) Schematic drawing of laparoscopic view of Morgagni hernia containing the omentum (D: peritoneum covering retrosternal and retrocostal area, M: hernial sac, H: edge of diaphragm, O: omentum).
become incarcerated.' Lateral chest films show an anterior cardiophrenic mass and the diagnosis may be confirmed with barium enema or CT scan."" The differential diagnosis includes lung and mediastinal tumors, pericardial fat pad, atelectasis, pneumonia, and pleural, pericardial, mediastinal, or diaphragmatic cysts. Operative repair is recommended to avoid strangulation, although the frequency of this complication may not be high.3 The standard surgical procedure requires a laparotomy or a thoracotomy, both of which have a long postoperative recovery period and can lead to significant morbidity, especially in high risk patients. The laparoscopic technique described in this patient proved to be a sound approach, technically easy, and, in addition, resulted in immediate return of the patient to normal diet and activities. The hernial sac should not be removed during laparoscopic repair of diaphragmatic hernias,6 as this may result in massive pneumo
96
DIAPHRAGMATIC HERNIA REPAIR
FIG. 4. (A) Laparoscopic view of hernial defect after reducing its contents. (B) Schematic drawing of laparoscopic view of hernial opening and sac (D: peritoneum covering retrosternal and lower retrocostal area, M: cavity lined by hernial sac, H: edge of diaphragm forming the posterior half of the hernial neck, F: falciform ligament).
mediastinum with potential respiratory and circulatory complications. To our knowledge this is the first report of a diaphragmatic hernia of the foramen of Morgagni repaired laparoscopically. Another novelty of this technique is the way the suture is placed. The passage of the suture to be tied in the front of the abdominal fascia allows the best possible anchoring and permanent repair. It also makes the tieing of knots easy, being done outside the abdomen. The most difficult part of the techniques described previously has been the placing of the sutures in the back of the sternum and costal margin, where there is no strong fascia. The suturing concept described in this report may find other applications, particularly in
laparoscopic surgery. 97
KÜSTER ET AL.
FIG. 5. (A) Laparoscopic repair of the Morgagni hernia closing the diaphragmatic defect with continuous suture. (B) Schematic drawing showing the laparoscopic suture of the hernia opening (D: peritoneum covering retrosternal and retrocostal area, A: stitch being placed through peritoneum and periostium of retrosternal area, M: hernial sac, H: edge of diaphragm, F: falciform ligament).
98
DIAPHRAGMATIC HERNIA REPAIR
FIG. 6. Schematic depiction of laparoscopic repair of diaphragmatic hernia. Over-and-over closure of the defect with the loop joining the two ends of the suture, placed outside the rectus fascia.
FIG. 7.
Chest x-ray done
on
December 2, 1991,
showing no evidence of recurrence of Morgagni hernia. 99
KÜSTER ET AL.
CONCLUSIONS
Laparoscopy is an excellent approach to confirm the diagnosis and to repair a noncomplicated diaphragmatic hernia of the foramen of Morgagni. A suturing technique is described, incorporating the abdominal fascia in the repair and securing the knots outside the abdomen. The same technical approach might be useful for other hernia repairs or surgical procedures, especially when done by laparoscopy. This laparoscopic technique is technically easy, safe, and is followed by prompt recovery. REFERENCES TP, Clagett OT: Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-468. 2. Ketonen P, MattilaSP, MattilaT, et al: Surgical treatment of hernia through the foramen of Morgagni. ActaChirScand 1975;141:633-636. 3. Saha SP, Mayo P, Long GA: Surgical treatment of anterior diaphragmatic hernia. South Med J 1982;75:280-281. 1. Comer
4.
Harrington SW: Various types of diaphragmatic hernia treated surgically. Report of 430 cases. Surg Gynecol Obstet 1948;86:735-755.
5. 6.
Fagelman D, Caridi JG: CT diagnosis of hernia of Morgagni. Gastrointest Radiol 1984;9:153. Küster GGR, Gilroy S: Laparoscopic repair of paraesophageal hiatal hernia. Surg Gynecol Obstet. (In press.) Address reprint requests to: Gustavo G. R. Küster, M.D.
Department of Surgery Scripps Clinic and Research Foundation 10666 N. Torrey Pines Road La Jolla, CA 92037
100
