A 75-year-old woman with vague epigastric pain from one year prior was admitted to the Emam Khomeyni hospital. Her epigastric pain worsened with large meals and was associated with nausea, vomiting, and constipation. Symptoms were exacerbated since one month prior to admission. No sweating, palpitation, dyspnea, anorexia, early satiety, weight loss, dysphagia, and odynophagia were detected. The patient had a history of hypertension and hyperlipidemia for which she was under treatment with antihypertensive drugs and lipid lowering agents. A chest X-ray (CXR) revealed the presence of a hypodense mass in the proximity of the right lung base. Consequently, thoracic CT scan was performed. After complete clinical and imaging evaluations, the patient was sent for surgical repair of the Morgagni hernia. Preoperative risk assessments that included an ECG, echocardiography, cardiologist consult, routine laboratory analyses, ABG, PFT, and anesthesiologist consult were performed. She had an Left Ventricular Ejection Fraction(LVEF) of 55% and mild Mitral Regurgitation(MR).\nThe second patient was an 80-year-old woman who suffered from dyspnea at rest and orthopnea since two weeks before admission that was associated with vomiting after heavy meals, generalized vague abdominal pain, dysphagia, regurgitation, epigastric fullness, constipation, sweating, and cough. Clinical and diagnostic imaging that included CXR and a spiral thoraco-abdominal CT scan was indicative of a Morgagni hernia.\nFor the laparoscopies, both patients were placed in the supine position with their arms at their sides. A Foley catheter was inserted under general anesthesia. CO2 insufflations were performed by Veress needle. One, 10-mm trocar port was inserted above the umbilicus and a camera (30o angulated optic) was introduced into the abdominal cavity through this port. After primary evaluation in both patients, the Morgagni hernia was located and a segment of transverse colon and omentum was seen in the hernia sac. After insertion of two 10-mm and 5-mm trocar ports from the right and left upper abdominal quadrants (RUQ, LUQ), respectively, the colon and omentum were reduced back into the abdominal cavity. Subsequently, patients’ positions were changed to perform a reverse Trendelenburg; the anesthesiologist manually inflated the lungs to ensure positive pressure in order to facilitate the reduction of the sac contents. The hernia sac was excised( ) and the falciform ligament was divided by LigaSure. The size of the defect was 6 x 7 cm in the first patient and 5 x 6 cm in the second patient.\nDual-sided mesh (15 x 20 cm) was inserted into the abdominal cavity through the 10 mm port in the LUQ. Mesh was expanded over the defect( ) and fixed to the anterior abdominal wall and edge of the diaphragmatic defect in the posterior part with spiral tacks (Protack®, Covidien, Mansfield, MA, USA)\n( ).\nApplication of spiral tacks at the diaphragm carries the risk of life-threatening complications such as cardiac tamponade.\nAfter removal of the trocars under direct visualization, the fascia at the 10 mm trocar sites were closed and incisions repaired. Patients were admitted to the SICU for the first postoperative day and discharged 72 hours after surgery. Both were discharged ambulatory and were on soft diets.\nThere was no complication or recurrence during 18 months of follow up for either patient.
A 55-year-old female of Aryan ethnicity had a history of vague epigastric pain more after taking meals for last 1 year. An ultrasound of the abdomen showed the presence of cholelithiasis. She was planned electively for a laparoscopic cholecystectomy at first. Preoperative workup was done, and no other abnormalities were found except in the chest X-ray, which revealed the presence of a right paracardiac shadow (Figure ). Consequently, she was subjected to CT (computed tomography) scan of the thorax and upper abdomen, which showed the presence of omentum herniating through a retrosternal defect to lie in the right side of the heart in the thorax (Figure ). After complete clinical and imaging evaluations, the patient was considered for a laparoscopic cholecystectomy and laparoscopic repair of the Morgagni hernia (Figure ).\nAnother 44-year-old female of Aryan ethnicity had complaints of retrosternal chest pain and heaviness, who was worked up as a cardiac case in other hospital. On further workup, she was found to have cholelithiasis on ultrasound of the abdomen, and was referred to our hospital for laparoscopic cholecystectomy. A chest X-ray was done, which showed a similar right paracardiac shadow; she was then subjected to a spiral thoraco-abdominal CT scan, which proved the diagnosis of Morgagni hernia (Figure ).\nFor laparoscopic repair, general anesthesia was given, both patients were placed in the supine lithotomy position with their arms at their sides, Foley’s catheter was inserted. A 10-mm trocar port was inserted above the umbilicus via the open technique, and a 0° camera was introduced into the abdominal cavity through this port, and CO2 pneumoperitoneum was created. Operating surgeon was positioned between the legs of the patients, and assistant surgeon at the left side. After primary evaluation in both patients, the Morgagni hernia was located: a segment of omentum from the transverse colon was seen herniating into the hernial sac (Figure ). After insertion of two 5 mm trocar ports on the right and one 5 mm port on left upper abdominal quadrants respectively, patients’ position was changed to a reverse Trendelenburg; there were some adhesions of the omentum to the neck of the sac, and after division of these, the omentum was reduced back into the abdominal cavity. The falciform ligament was divided, and the edge of the defect was approximated with no. 1 polypropylene interrupted sutures (Figure ). Next, the gallbladder was taken care of, after inserting a 10 mm epigastric port, and changing the position of the surgeon to left side of the patient. A polypropylene mesh of size 15 × 15 cm was inserted into the abdominal cavity through the epigastric 10 mm port; it was expanded over the defect and fixed to the anterior abdominal wall and edge of the diaphragmatic defect with a series of two rounds of intracorporeal prolene knots; care being taken not to take deep bites at the diaphragm and avoiding at the left cranial region (the region of the heart) (Figure ). Altogether, for both procedures, total five ports were needed. Patients were admitted to the surgical intensive care unit for the first postoperative day and discharged 72 h after surgery; no postoperative complications were noted; both patients were discharged after proper ambulation and were on soft diets. Postoperative radiograph was satisfactory (Figure ). Follow-up has been done for 12 months postoperatively; there has been no recurrence till date.