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 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.