A 69-year-old female was referred to our clinic for an incidental finding of a large Morgagni hernia found on a recent CT chest scan for lung cancer screening. Patient reported occasional shortness of breath after prolonged ambulation but denied chest pain. She did have remote history of acid reflux symptoms but nothing recently. She denied issues with prematurity or issues with development as an infant, chest trauma, or MVA history. She did complain of occasional right shoulder pain but attributed this to arthritis. Denied history of heart attack, stroke, DVT, or PE. She had a 30-pack-year smoking history but quit a year prior. She was up-to-date on her colonoscopy, current within the past year. She denied hematochezia and melena, bowel habit changes or major body weight changes as well as any current abdominal pain. On examination her vitals were within normal parameters. Heart and lungs were unremarkable. Abdominal examination was soft with normal bowel sounds and nontender. Remainder of examination was unremarkable. Laboratory values included a normal CBC and BMP. A CT chest scan had demonstrated a large retroxyphoid hernia of Morgagni involving several loops of small bowel and transverse colon located in the right inferior hemithorax (Figs and ). No evidence of acute incarceration or strangulation were noted. A detailed discussion was undertaken with the patient regarding her hernia and she was consented for a laparoscopic repair with mesh.\nPatient underwent a laparoscopic approach in lithotomy positioning with the primary surgeon working between the legs. Three working ports were used, a 12 mm port at the umbilicus and two 5 mm ports; one in the LUQ and one in the RUQ. Upon initial laparoscopy multiple loops of small bowel were progressively reduced out of the hernia sac which also included the ascending colon and part of the transverse colon (Figs and ). All the small bowel and the colon appeared viable. The redundant parietal peritoneal hernia sac was excised out of the right inferior hemithorax utilizing a LigaSure (Covidien) (Fig. ). The falciform ligament was also taken down all the way to the diaphragm. The defect in the diaphragm measured to be approximately 9 cm by 4 cm. A section of Pariatex composite mesh was then trimmed to 2 cm in width by 9 cm in length. Three stay sutures of 0 Ethibond were placed laterally and in the middle of the mesh. This was placed into the peritoneal cavity after soaking it in vancomycin with local anesthetic. The sutures were then percutaneously brought through the diaphragm edge that was unattached to the anterior abdominal wall and then subsequently through the anterior abdominal wall. These were then tied thereby re-approximating the unattached edge of the diaphragm to the anterior abdominal wall near the xiphoid (Fig. ). Additional 0 Ethibond sutures were placed in between these initial ones percutaneously with a suture passer.\nAdditionally, another Pariatex composite mesh was then trimmed to 12 cm in width by 9 cm, soaked in vancomycin with local anesthetic and then placed into the abdominal cavity. It was positioned over the area of the repair and fixed into place with absorbable tacks around its caudad edge and centrally. Along the cephalad edge it was fixed with a running V-lock absorbable suture to the diaphragm. Fibrin glue was placed along this same edge (Fig. ). The ports were removed and incisions were closed.\nPatient’s postoperative course progressed well. She was monitored overnight and discharged the following day. She was seen for follow-up in 2 weeks out of surgery and did quite well. She was tolerating a regular diet and having bowel movements. A month after surgery another CT scan was obtained which demonstrated a postoperative seroma in the right inferior hemithorax (Fig. ). Currently, the patient is to be seen in a 6-month follow-up to have another CT scan at that time.
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.