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.
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.