Laparoscopic mesh repair of Morgagni hernia in an octogenarian patient

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The estimated incidence of congenital diaphragmatic hernia (CDH) is 1 in 2000–5000 live births. They are the rarest of CDH, making up 2–3% of all the diaphragmatic hernia cases.1 The aetiology of CDH is unknown, however, 2% of cases have been noted to be familial and another 15% of patients have associated chromosomal abnormalities. Presentation may vary from non-specific gastrointestinal symptoms to bowel obstruction and strangulation.2 More than half of patients can be diagnosed incidentally while investigating unrelated problems and most symptomatic cases tend to present acutely.3 We are reporting an eighty years old male patient with Morgagni hernia, who presented with features of GOO and underwent successful laparoscopic reduction of hernia followed by mesh and intracorporeal suture repair of the diaphragmatic defect Figs. 1 and 2. Fig. 1 (a) Radiograph chest – blunting of right CP angle (yellow arrow); obscuration of cardiac silhouette on right side; right dome of diaphragm is poorly delineated with areas of increased density and multiple air lucencies (red arrow head). (b) Post ... Fig. 2 Intra op (a) 10 × 8 cm sized defect clearly visible after reduction of the hernial contents. (b) Anchoring of dual mesh (PTFE side towards the abdomen); intracorporeal suturing with silk 2-O in progress, tackers already in place ... Case report An eighty-years-old patient was admitted under gastroenterology medicine (GE) with chief complaints of heart burn (10 days), post meal vomiting (2 days) and pain upper central abdomen (2 days). There was no history of lump abdomen, hemetemesis, malaena or jaundice. In the past history patient was a known case of coronary artery disease (CAD) and cerebro-vascular disease and was on regular follow up. General physical examination was normal. On abdominal examination there was fullness and deep tenderness in the epigastrium; but no signs of peritoneal irritation were present. The rest of abdominal examination was essentially normal. The respiratory system examination revealed reduced air entry in the right basal area and occasional crepts bilaterally. Routine blood tests; including liver function tests were within normal range. In the chest radiograph there was blunting of right cardio-phrenic (CP) angle and areas of increased density with multiple air lucencies were seen along right hemidiaphragm outline (Fig. 1a). Ultrasonography (USG) abdomen showed dilated stomach and pylorus with abrupt cut off at the junction of pylorus with first part of duodenum (D1). Contrast enhanced computed tomography (CECT) abdomen revealed distended stomach and a large defect in right hemidiaphragm. The body of stomach, pylorus and transverse colon along with omentum were found herniating into right hemithorax (Fig. 1b–d). Evaluation with upper gastrointestinal endoscopy showed stasis oesophagitis, food residue in the stomach, scope could not be negotiated beyond pylorus. A surgical review was requested and he was planned for surgery on next day. In the pre anaesthetic checkup there was mild restriction of pulmonary function and echocardiography was suggestive of early diastolic dysfunction. Considering the advanced age of patient, multiple comorbidities and morbidity of large sub costal incision; patient was considered for laparoscopic reduction and mesh repair. Intra operatively there was large Morgagni hernia anterior to right lobe of liver and the defect measuring 10 × 8 cm in size was present (Fig. 2a). Distal part of stomach, transverse colon and the omentum were found herniating through the defect. Laparoscopic reduction of the contents was done. The margins of hernia sac were dissected and defined; the sac was not removed. As primary closure was not possible, 15 × 12 cm dual mesh (Prolene+PTFE) was placed over the hernia defect and secured to the margins with 5 mm and 10 mm tackers. Intracorporeal silk 2-0 sutures on medial side were taken because of close proximity to the pericardium and heart; tackers were avoided on this side (Fig. 2b). Post operative recovery was uneventful. Patient was started on oral diet on first post operative day (POD) and was discharged on second POD. Patient is asymptomatic and there is no evidence of recurrence after six months of follow up.