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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 9  |  Page : 1517-1522

A novel scarless laparoscopic method for morgagni hernia repair


Department of Pediatric Surgery, Faculty of Medicine, Dicle University, Diyarbakir, Turkey

Date of Submission16-Jan-2022
Date of Acceptance06-Jun-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Dr. M H Okur
Department of Pediatric Surgery, Faculty of Medicine, Dicle University, Diyarbakir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_36_22

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   Abstract 


Background: Morgagni hernia (MH) is a rare congenital defect of the diaphragm. Although the various surgical method has been proposed, there is no surgical consensus. Aim: In this study, we aimed to report the outcome of the patients that underwent surgery which is completed using a single port laparoscopic-assisted transabdominal closure of MH. Patients and Methods: This is a retrospective analysis of 18 pediatric patients who underwent novel laparoscopic MH repair at a single tertiary pediatric hospital between March 2018 and December 2020. Results: Of the 18 patients, 72% (n = 13) were male and 28% (n = 5) were female. The symptoms at admission included repeated chest infection (39%), dyspnea (33%), vomiting (17%), and abdominal pain (22%). The colon (78%) was the most frequently herniated organ. Hernias were bilateral, on the left, and on the right in seven, four, and seven cases, respectively. All surgical interventions were completed within 25–50 min. All patients started enteral feeding within 24 hours. All patients were discharged within 1–3 days without any complications. The mean follow-up period was 27 months. Conclusions: In conclusion, our method is characterized by a shorter operation time, early return to feeding, early discharge, excellent cosmetic results, low cost, and low recurrence rate. Further prospective trials are needed to compare our novel scarless technique to other methods.

Keywords: Laparoscopic, morgagni hernia, scarless


How to cite this article:
Okur M H, Aydogdu B, Azizoglu M, Arslan S, Basuguy E. A novel scarless laparoscopic method for morgagni hernia repair. Niger J Clin Pract 2022;25:1517-22

How to cite this URL:
Okur M H, Aydogdu B, Azizoglu M, Arslan S, Basuguy E. A novel scarless laparoscopic method for morgagni hernia repair. Niger J Clin Pract [serial online] 2022 [cited 2022 Sep 28];25:1517-22. Available from: https://www.njcponline.com/text.asp?2022/25/9/1517/356677




   Introduction Top


Morgagni hernia (MH), a defect in the anteromedial portion of diaphragm, was first described by Giovanni Morgagni.[1] MHs are rare compared to Bochdalek hernias,[2],[3],[4] occurring in 1 of every 4,800--5,000 live births and accounting for <4% of all diaphragmatic defects.[2],[3],[4] Although the colon is one of the most frequently herniated organs in the thoracic cavity, herniation also occurs in the omentum, stomach, liver, and small intestines.[5],[6] Congenital heart disease, chest wall deformities, intestinal malrotation, omphalocele, chromosomal anomalies, and Down syndrome are associated with MH.[6],[7] Patients with MH are typically asymptomatic but are sometimes referred to the pneumology department due to respiratory system complaints such as fever, cough, and wheezing.[8],[9] Various surgical approaches to thoracic repair have been reported, via median sternotomy, thoracotomy, and thoracoscopy, as well as abdominal approaches via laparotomy and laparoscopy. However, there is no surgical consensus, and thoracoscopic repair outcomes among laparoscopic approaches are variable and controversial.[10] Both surgeons and patients have raised concerns over the surgical options for MH, including regarding cosmetic outcomes, surgery time, cost, and length of stay at the hospital. This study evaluated medium-term surgical and clinical outcomes in pediatric patients following application of a novel, minimally invasive approach for MH correction.


   Material and Method Top


We retrospectively analyzed the records of 18 patients who underwent surgery for MH between March 2018 and December 2020 at Dicle University Medical School, Department of Pediatric Surgery. Demographic characteristics were evaluated, including age, gender, symptoms, associated anomalies, radiological studies, operation and hospitalization times, complication and recurrence rates, and side of herniation.

Evaluations of associated anomalies were based on physical examination, radiological imaging, surgical intervention, and, if necessary, echocardiography and chromosomal analysis.

All patients underwent surgical repair via laparoscopy using our novel scarless technique. The surgical intervention and postoperative follow-up were performed by the same surgeon.

Surgical technique

In this study, a novel scarless laparoscopic method for MH repair is described. This method is similar to the percutaneous internal ring suturing technique of inguinal hernia for children. General anesthesia is induced and the patient is stabilized in a supine reverse Trendelenburg position. The intervention is started by inserting only one port through the umbilicus via an open technique; no additional ports are inserted into the abdominal cavity. This port is used only for imaging the hernia sac. Although we usually find no herniated organs in the cavity during surgery due to the relaxing effect of the anesthesia and the position of the patient, herniated abdominal contents are sometimes seen. However, these organs can be easily cleared from the hernia sac by maneuvering the endoscope.

We entered the abdominal cavity around the xiphoid with a 20-gauge catheter needle and a nonabsorbable 2-0 prolene suture made into a loop [Figure 1]. The needle entered the abdominal cavity through the abdominal wall and preperitoneal tissue, and approached the rim of the diaphragm. The loop was pushed forward through the opening” of the needle. After creating a sufficiently large loop, the needle was withdrawn so that the loop remained in the abdominal cavity. Then, another needle with prolene suture was inserted through the previous needle point on the skin but passed through the subcut and anterior abdominal wall muscles away from the previous needle tract pushed forward through the first loop after reaching the rim of the diaphragm. The second needle was also removed, and the second Prolene suture was held while withdrawing the first loop. With this maneuver, the second Prolene suture was turned out of the abdominal cavity, forming a “U” suture in the abdomen [Figure 2]. Finally, the Prolene sutures were tied extracorporeally, leaving the knots under subcutaneous tissue [Figure 3]. Although the number of loops depends on the size of the defect, about one centimeter apart was preferred. We did not perform any skin incisions for the knots.
Figure 1: (a). Entrance of the Needle around the xiphoid (b). Needle drawing (c). 20-gauge catheter needle nonabsorbable 2-0 prolene suture.

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Figure 2: (a). Pushed needle, (b). Created loops (c). A View of the sutures extracorporeally (d). View intracorporeally after tied sutures.

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Figure 3: View of the abdominal wall (a). during surgery after tied sutures (b). The end of surgery.

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   Results Top


[Table 1] summarizes the patient demographic data. Of the 18 patients, 72% (n = 13) were male and 28% (n = 5) were female. The mean ages at diagnosis and at operation were 21 months (range: 4--43 months) and 22 months (range: 5--54 months), respectively. Eleven patients (61%) were older than 1 year of age. The symptoms at admission included repeated chest infection (RCI) (39%), dyspnea (33%), vomiting (17%), and abdominal pain (22%) there were no symptoms in 28% of cases.
Table 1: Clinical data of patients

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Laboratory analyses and X-rays were performed in all patients, while computed tomography was performed in only two patients [Figure 4].
Figure 4: (a). Chest radiograph of a Morgagni hernia (paracardiac opacity), (b). Computed tomography image of a Morgagni hernia

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All patients underwent surgery using our novel scarless technique. In all cases, prolene sutures were used to repair the hernia defect without hernia sac excision. The colon (78%) was the most frequently herniated organ.

Hernias were bilateral, on the left, and on the right in seven, four, and seven cases, respectively. Nine patients had at least one associated congenital anomaly, and four had multiple associated anomalies. Down syndrome was found in four patients. Cardiac anomalies were found in eight patients, and three patients were operated on due to major cardiac anomaly.

All surgical interventions were completed within 25--50 min (mean, 37 min). All patients started enteral feeding within 24 hours (mean, 6 hours; range: 5--24 hours). All patients were discharged within 1--3 days (mean, 1.6 days) with no complications.

The follow-up period was 12--45 months (mean, 27 months), and all patients were asymptomatic, except one who experienced recurrence; this patient had multiple associated anomalies including Down syndrome, atrial septal defect (ASD), ventricular septal defect (VSD), right arcus aorta, hypothyroidism, and prematurity. The patient had also undergone laparoscopic MH repair and had been operated on due to major cardiac anomaly before admission to our institute.


   Discussion Top


Although MH may be diagnosed incidentally in childhood, patients present with symptoms ranging from slight abdominal pain to severe respiratory symptoms.[11],[12] Based on 15 years of experience with MH repair, Jetley et al.[8] reported that RCI was the most common presenting symptom, most admissions to our center were due to RCIs.

Previous studies have found genetic mutations associated with Bochdalek hernia.[13],[14] Associations between MH and chromosomopathies, such as Down's syndrome, suggest that MH is an inheritable defect, but evidence is lacking.[13],[14] However, four of our patients had Down syndrome. Further investigations should confirm this potential relationship.

Diagnosis of MH is made by physical examination, chest radiograph (CXR), or computed tomography (CT). Pinheiro et al.[15] performed CT in 69% of patients, while Jetley et al.[8] used CT in 36% of cases. Although CT is the gold standard for diagnosis, we used CXR for the initial radiological study due to concerns about radiation exposure and the stability of the patient; CT was performed in only two patients (11%). A careful assessment using CXR is sufficient in most cases.

Before 1990, thoracotomy and especially laparotomy were the standard surgical approaches for MH. After the first laparoscopic repair of MH in 1992 by Kuster et al.,[10] minimally invasive techniques became the gold standard in both children and adults.[9],[10],[16],[17],[18] Many laparoscopic techniques have been proposed but the optimal approach is still controversial. Laparoscopic-assisted repair of MH (LARMH) with extracorporeal knots under the subcutaneous tissue is widely used.[2],[19] Ergun et al.[20] and Pinheiro et al.[15] used LARMH with three and four ports, respectively. We used only one port for imaging the hernia sac through the umbilical area and repaired the defect using prolene sutures without sac excision, resulting in fewer complications, a lower recurrence rate, shorter operative time, shorter length of stay, and excellent cosmetic results compared toother repair methods.

Garriboli et al.[21] suggested that the use of absorbable sutures may be associated with recurrence of MH. Pinheiro et al.[15] reported one recurrence in a case that had been repaired with an absorbable suture. Therefore, we used nonabsorbable sutures in all of our patients.

Although volvulus, obstruction, and perforation are serious, MH repair generally prevents these intestinal complications.[22]

Lamas-Pinheiro et al.[15] used a minimally invasive repair technique for MH and reported a mean operative time of 95 min. Ergun et al.[20] reported a mean of operative time of 40 min. Although 39% of our cases had bilateral MH, the mean operation time was only 37 min. The lower number of ports used and shorter operative time highlight how efficient and simple this method is.

The decision to excise the hernia sac remains controversial. Excision has been suggested to reduce the recurrence rate.[23],[24] Ergun et al.[20] recently reported their experience with laparoscopic MH repair using a loop suture removal technique; they removed the hernia sac using two working trocars and reported no recurrence or complications. However, additional port usage increases the financial burden and cosmetic concerns. Pinheiro et al.[15] reported a recurrence rate of 18% when using three working trocars without excising the sac. Al-Salem et al.[7] reported an overall recurrence rate of 7%, and there were no recurrences in the LARMH group despite no excision of the sac. Although we did not excise the sac in the present study, there was only one recurrence during the follow-up period (mean, 27 months) in a patient with Down syndrome. Down syndrome is associated with muscular deficiency of the body wall and diaphragm[25] so may be a risk factor for recurrence.

Ergun et al.[20] reported a mean enteral feeding time of 7 hours (range: 6--24 hours), which is comparable to the mean feeding time of 6 hours (range: 5--24 hours) in the present study. Ergun et al.,[20] Pinheiro et al.,[15] and Al-Salem et al.[7] used three, four, and four ports, respectively, for imaging the hernia sac, whereas we used only one port. This enhances trust in patients due to the satisfactory cosmetic results compared to laparotomy, thoracotomy, and minimally invasive techniques with multiple ports. Although we used only one port for imaging and did not excise the hernia sac, we encountered no complications and the recurrence rate was superior to those reported in the literature.

In conclusion, our method is superior to techniques such as open repair and laparoscopic methods (i.e., methods using multiple ports and internal suturing) because it is characterized by a shorter operation time, early return to feeding, early discharge, excellent cosmetic results (i.e., it is scarless), low cost, and low recurrence rate. Further prospective trials are needed to compare our novel scarless technique to other methods.

Acknowledgements

  • The English in this document has been checked by at least two Professional editors, both native speakers of English (Reference No: 21042405).
  • The study was approved by the Ethics Committee of Dicle University (June 03, 2021; approval number: 306).


Type of Study: Retrospective, Clinical Study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Morgagni M. Seats and Causes of Diseases. Vol 3. London: Millar A and Cardell T; 1769. p. 205-7.  Back to cited text no. 1
    
2.
Van De Winkel N, De Vogelaere K, De Backer A, Delvaux G. Laparoscopic repair of diaphragmatic Morgagni hernia in children: Review of 3 cases. J Pediatr Surg 2011;46:e23-6.  Back to cited text no. 2
    
3.
Simson JN, Eckstein HB. Congenital diaphragmatic hernia: A 20 year experience. Br J Surg 1985;72:733-6.  Back to cited text no. 3
    
4.
Comer TP, Clagett OT. Surgical treatment of hernia of the foramen of Morgagni. J Thorac Cardiovasc Surg 1966;52:461-8.  Back to cited text no. 4
    
5.
Golden J, Barry WE, Jang G, Nguyen N, Bliss D. Pediatric Morgagni diaphragmatic hernia: A descriptive study. Pediatr Surg Int 2017;33:771-5.  Back to cited text no. 5
    
6.
Cigdem MK, Onen A, Okur H, Otcu S. Associated malformations in Morgagni hernia. Pediatr Surg Int 2007;23:1101-3.  Back to cited text no. 6
    
7.
Al-Salem AH, Zamakhshary M, Al Mohaidly M, Al-Qahtani A, Abdulla MR, Naga MI. Congenital Morgagni's hernia: A national multicenter study. J Pediatr Surg 2014;49:503-7.  Back to cited text no. 7
    
8.
Jetley NK, Al-Assiri AH, Al-Helal AS, Al-Bin Ali AM. Down's syndrome as a factor in the diagnosis, management, and outcome in patients of Morgagni hernia. J Pediatr Surg 2011;46:636-9.  Back to cited text no. 8
    
9.
Danielson PD, Chandler NM. Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a pediatric patient: Advancement in single-port technology allows effective intracorporeal suturing. J Pediatr Surg 2010;45:E21-4.  Back to cited text no. 9
    
10.
Kuster GG, Kline LE, Garzo G. Diaphragmatic hernia through the foramen of Morgagni: Laparoscopic repair case report. J Laparoendosc Surg 1992;2:93-100.  Back to cited text no. 10
    
11.
Al-Salem AH, Nawaz A, Matta H, Jacobs A. Herniation through the foramen of Morgagni: Early diagnosis and treatment. Pediatr Surg Int 2002;18:93-7.  Back to cited text no. 11
    
12.
Minneci PC, Deans JK, Kim P, Mattisen DJ. Foramen of Morgagni hernia: Changes in diagnosis and treatment. Ann Thorac Surg 2004;77:1956-9.  Back to cited text no. 12
    
13.
Enns GM, Cox VA, Goldstein RB. Congenital diaphragmatic defects and associated syndromes, malformations, and chromosome anomalies: A retrospective study of 60 patients and literature review. Am J Med Genet 1998;79:215-25.  Back to cited text no. 13
    
14.
Slavotinec AM. The genetics of congenital diaphragmatic hernia. Semin Perinatol 2005;29:77-85.  Back to cited text no. 14
    
15.
Lamas-Pinheiro R, Pereira J, Carvalho F, Horta P, Ochoa A, Knoblich M, et al. Minimally invasive repair of Morgagni hernia---A multicenter case series. Rev Port Pneumol (2006) 2016;22:273-8.  Back to cited text no. 15
    
16.
Al-Salem AH, Khawaher HA. Delayed presentation of bilateral Morgagni's hernia in a child with Down's syndrome. Saudi Med J 2002;23:237-9.  Back to cited text no. 16
    
17.
Laituri CA, Garey CL, Ostlie DJ, Holcomb GW 3rd, St Peter SD. Morgagni hernia repair in children: Comparison of laparoscopic and open results. J Laparoendosc Adv Surg Tech A 2011;21:89-91.  Back to cited text no. 17
    
18.
Sherigar JM, Dalal AD, Patel JR. Laparoscopic repair of a Morgagni hernia. J Minim Access Surg 2005;1:76-8.  Back to cited text no. 18
    
19.
Mallick MS, Alqahtani A. Laparoscopic-assisted repair of Morgagni hernia in children. J Pediatr Surg 2009;44:1621-4.  Back to cited text no. 19
    
20.
Ergun E, Gollu G, Ates U, Sozduyar S, Jafarov A, Bahadir K, et al. Laparoscopic assisted anterior transabdominal wall closure using loop suture removing technique in Morgagni hernia: Safe and easy method. Pediatr Surg Int 2020;36:679-85.  Back to cited text no. 20
    
21.
Garriboli M, Bishay M, Kiely EM, Drake DP, Curry JI, Cross KM, et al. Recurrence rate of Morgagni diaphragmatic hernia following laparoscopic repair. Pediatr Surg Int 2013;29:185-9.  Back to cited text no. 21
    
22.
Sartelli M, Coccolini F, van Ramshorst GH, Campanelli G, Mandalà V, Ansaloni L, et al. WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg 2013;8:50. doi: 10.1186/1749-7922-8-50.  Back to cited text no. 22
    
23.
Azzie G, Maoate K, Beasley S, Retief W, Bensoussan A. A simple technique of laparoscopic full-thickness anterior abdominal wall repair of retrosternal (Morgagni) hernias. J Pediatr Surg 2003;38:768-70.  Back to cited text no. 23
    
24.
Fernandez-Cebrian JM, De Oteyza JP. Laparoscopic repair of hernia of foramen of Morgagni: A new case report. J Laparoendosc Surg 1996;6:61-4.  Back to cited text no. 24
    
25.
Honore LH, Torfs CP, Curry CJ. Possible association between the hernia of Morgagni and trisomy 21. Am J Med Genet 1993;47:255-6.  Back to cited text no. 25
    


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