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.
An 82-year-old woman came to our hospital with chief complaint of nausea and vomiting that worsened after taking meal from 2 weeks ago. She had no epigastric pain or dysphagia or odynophagia and no weight loss was detected. She had no history of blunt trauma prior to this problem. A chest X-ray was done and showed round opacity with air-fluid level at right hemithorax on the dome of the diaphragm (). Biochemical marker was normal. On further workup, thoracic CT scan was performed and revealed part of the colon, omentum, and stomach herniated into the thorax. When the diagnosis is confirmed, the patient was prepared for laparoscopic surgery.\nAfter preoperative risk assessments including ECG, echocardiography, cardiologist consult, routine laboratory tests, and pulmonary function test, patients were prepared for surgical repair of the Morgagni hernia.\nPatients were placed in the supine position. A Foley catheter was inserted after general anesthesia. Pneumoperitoneum with carbonic dioxide (CO2) was performed by Veress needle. One 10 mm trocar port was inserted above the umbilicus and a camera (30° angulated optic) was inserted into the abdominal cavity. Two additional trocars (5 mm) were placed at the right and the left of the abdomen, and one 10 mm trocar was placed at the left flank, respectively. Subsequently, patients were putted on the reverse Trendelenburg positions. The anesthesiologist manually inflated the lungs to ensure positive pressure in order to facilitate the reduction of the sac contents. Intraoperatively, hernial sac content (colon, omentum, and part of stomach) was pulled out and reduced back into the abdominal cavity (). The falciform ligament was divided and the hernia sac was excised at first two cases by LigaSure (), but at operation of the third patient, the hernial sac had not been removed. The size of the defect was 6 × 7 cm in the first patient, 5 × 6 cm in the second patient, and 6 × 6 cm in the third patient. Dual-sided mesh (15 × 20 cm) was inserted into the abdominal cavity through the 10 mm port in all three cases. 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) (). After removal of the trocars under direct visualization, the fascial incision at the 10 mm trocar sites was closed via sutures. All patients were admitted to the SICU for the first postoperative day and discharged within 48 to 72 hours after surgery. All three cases were discharged ambulatorily and putted on normal diets. There was no complication such pneumomediastinum, fluid collection, or recurrence during 20 to 30 months of follow-up for all patient.