Annals of Medicine and Surgery 56 (2020) 7–10

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Annals of Medicine and Surgery

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Laparoscopic repair of Morgagni hernia in children T

ARTICLE INFO ABSTRACT

Keywords: Aim: We aimed to present our laparoscopic treatment experience in Morgagni hernia repair.
Morgagni hernia Methods: The patients who underwent laparoscopic surgery with diagnosis of Morgagni hernia between 2016
Children and 2019 were evaluated retrospectively.
Minimally invasive Results: Their mean age at diagnosis was 4,1 ± 2,6 years (1 year-13 years). All patients were male. The pre-
Laparoscopic
senting complaints were respiratory tract infection in 3 patients and vomiting in 3. Two patients were diagnosed
incidentally. Associated Down's Syndrome was detected in 3 (38%) cases. The defect was left-sided in 7 (87.5%)
patients and bilateral in 1 (12,5%). Omentum was herniated in 2 patients, colon and omentum were in 6 and
colon, omentum and stomach were in one. All patients underwent primary repair extracorporeally by removing
sutures from single incision, without removal of the hernia sac. There were no complications or recurrence in the
mean 19,2 ± 15,8 months (6–42 months) follow-up period.
Conclusions: Minimal invasive repair of Morgagni hernia is efficient and safe. It should be the first choice be-
cause of fast recovery and better cosmetic results. In this series, it was seen that leaving the hernia sac had no
effect on early and late complications. Leaving the hernia sac may prevent potential complications due to un-
necessary dissection.

1. Introduction following information was obtained: age at diagnosis, sex, presenting

symptoms, method of diagnosis, associated anomalies, site of hernia,
The foramen of Morgagni is a retrosternal space that develops when operative repair and outcome.
the fibrotendinous portion of the pars sternalis does not fuse with the All procedures performed were in accordance with the ethical
fibrotendinous tissue arising from the costochondral arches [1]. A pa- standards of the responsible committee on human experimentation
tent foramen of Morgagni offers a path through which the abdominal (institutional and national) and with the Helsinki Declaration of 1964
viscera can herniate into thoracic cavity. It was first described by and later versions. This study has been reported in line with the
Giovani Morgagni in 1769 and has unique features in terms of clinical PROCESS 2018 criteria [12]. Written informed consent was obtained
presentation and associated anomalies [2]. from the patients for the surgery and information to be included in our
Morgagni hernia (MH) is extremely rare, occurring approximately manuscript.
in 1 out of 5000 live births, and accounts for less than 5% of all con-
genital diaphragmatic defects [3,4]. Patients may present with an in- 3. Results
cidental diagnosis or nonspecific respiratory symptoms such as frequent
lung infection, dyspnea or ileus and abdominal pain [5–8]. MH may During the study period, 8 male children with MH were operated.
also be associated with heart defects and Down syndrome [9]. Clinical Their mean age at diagnosis was 4,1 ± 2,6 years (1 year-13 years).
experience with this entity is limited owing to its rare occurrence. The Three patiets (37,5%) were presented with vomitting (Table 1). Three
treatment of MH is surgical repair either conventionally by open ab- (37,5%) had nonspecific upper respiratory tract symptoms at admission
dominal or thoracic approaches, or more recently by minimal invasive and recurrent lung infection history. In two (25%) the hernia was dis-
surgery [10,11]. With this study we aimed to present our experience covered incidentally. Diagnosis was reached by two sided plain chest X-
with the laparoscopic repair of MH. Ray and/or computed tomography (Fig. 2). Down syndrome was noted
in 3 (38%) patients.
2. Material and methods In all cases, the correction was performed using transabdominal
laparoscopic-assisted technique. At the operation, defect and sac of
The medical records of the children operated on from 2016 to June hernia was checked. Seven (87,5%) patients had left-sided and one
2019 with the diagnosis of MH were reviewed retrospectively. Patients (12,5%) patient had bilateral hernia (Table 2). Hernia sacs were present
were included when submitted to laparoscopic-assisted surgical ap- in all of the patients. None of the sacs were removed. The hernial
proach using three ports and when sutures were performed with, se- contents were only omentum in two patients, omentum and colon in six
parated, percutaneous, ‘‘U’’ shaped, stitches, through the full thickness and colon, omentum and stomach in one patient. There were no in-
of the anterior abdominal wall (Fig. 1) and the knots were tied in the traoperative complications. The average discharge time was 2.6 days.
subcutaneous tissue by a single incision. Surgeries were performed by 3 There is only one suture reaction in subcutaneous tissue at post-
pediatric surgeons who experienced between 1 and 5 years. The operative 2 months. There were no complications or recurrence in the

https://doi.org/10.1016/j.amsu.2020.05.012
Received 12 March 2020; Received in revised form 6 May 2020; Accepted 8 May 2020
2049-0801/ © 2020 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/BY/4.0/).
 Annals of Medicine and Surgery 56 (2020) 7–10

Fig. 1. Operative view of the defect and stitches including the sac.

Table 1
Demographics and clinical presentation. CXR - plain chest X-Ray, CT-computed tomography.
Case Gender Age at diagnosis (year) Clinical presentation Diagnosis Chromosomopathy

1 Male 1 Vomiting CXR Down sydrome

2 Male 1 Incidentally CXR No
3 Male 2 Incidentally CXR,CT No
4 Male 2 Vomiting CXR,CT Down sydrome
5 Male 3 Frequent lung infection CXR,CT No
6 Male 4 Frequent lung infection CXR,CT No
7 Male 7 Vomiting CXR No
8 Male 13 Frequent lung infection CXR,CT Down sydrome

Fig. 2. Anteroposterior (A) and lateral (B) chest x-ray showing anterior herniation of bowel loops into the chest and abdominal air fluid levels.

mean 19,2 ± 15,8 months (6–42 months) follow-up period. variety of clinical presentations ranging from severely life-threatening
at the time of birth to remaining asymptomatic until adulthood. It can
4. Discussion be discovered either incidentally or as a result of vague gastrointestinal
complaints; more commonly, it causes respiratory symptoms, which can
Congenital MHs are a rare form of diaphragmatic hernia that make be severe during infancy [8,13]. This was the case in our series as the
up 2–4% of all congenital diaphragmatic hernias [3,4]. MHs have a majority of our patients presented with repeated attacks of chest

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 Annals of Medicine and Surgery 56 (2020) 7–10

Table 2
Perioperative and follow-up details. CXR-plain chest X-Ray.
Case Age at surgery (year) Laterality Hernia contents Suture Length of hospital stay (days) Residual cavity (CXR) Recurrence Follow-up (months)

1 1 Left Stomach, colon, omentum Nonabsorbable 4 No No 42

2 1 Left Omentum Nonabsorbable 2 – No 26
3 2 Left Colon, omentum Nonabsorbable 2 No No 15
4 2 Left Stomach, colon, omentum Nonabsorbable 3 – No 32
5 3 Left Omentum Nonabsorbable 2 No No
6 4 Left Colon, omentum Nonabsorbable 2 No No 13
7 7 Bilateral Colon, omentum Nonabsorbable 2 No No 22
8 13 Left Colon, omentum Nonabsorbable 4 No No 6

infections and with vomiting and abdominal pain in acute situation. and late complications. Leaving the hernia sac may prevent potential
Chromosomal disorders and congenital abnormalities with MH have complications due to unnecessary dissection.
been reported to be around 20% in the literature [7,14]. As in earlier
reports, Down syndrome was a frequent association (38%) [15,16]. In Informed consent
present study, three of our patients (37,5%) had Down syndrome. Two
of the 3 patients with Down syndrome had vomiting and the other had a Informed consents were obtained from the patients.
history of frequent lung infection. MH should be considered as the
differential diagnosis in patients with Down sydrome that admitted Provenance and peer review
with frequent recurrent lung infections or vomiting.
It is generally accepted that surgical repair of Morgagni hernia Not commissioned, externally peer reviewed.
should be performed even in asymptomatic children to prevent major
complications like intestinal obstruction, volvulus or perforation. For
Ethical approval
many years, thoracotomy and specially laparotomy have been the
standard surgical approaches. After the first laparoscopic repair of MH
Authors declared that the research was conducted according to the
by Kuster et al. [17] in 1992, minimally invasive techniques became
principles of the World Medical Association Declaration of Helsinki
rapidly accepted as elected approaches in the repair of MH [18–20].
“Ethical Principles for Medical Research Involving Human Subjects”,
Thoracoscopic approach of thoracic surgeons has not received any
(amended in October 2013).
interest in pediatric surgery because of the necessity of opening hernia
sac, narrowed study area, ineffectiveness in bilateral cases and the risk
Sources of funding
of peroperative complications [21]. As transabdominal approach, a
variety of techniques to repair Morgagni hernia laparoscopically have
The authors declared that this study has received no financial sup-
been described in the literature using either primary closure with a
continuous suture, interrupted suture, or using a mesh [22,23]. Our port.
patients had variable sizes of hernia defects but in none of them there
was a need to use a patch because the defect could be closed without Author contribution
tension.
The laparoscopic interrupted or continuous suture technique to re- Author Contributions: Concept – A.İ.A., G.G.; Design - G.G.;
pair Morgagni hernia is complicated and time consuming. In this study, Supervision- A.İ.A.; Resources - A.İ.A., G.G., O.H.K; Materials – A.İ.A.,
in all cases, the correction was performed using transabdominal la- G.G.,O.H.K; Data Collection and/or Processing – A.İ.A., G.G., O.H.K;
paroscopic-assisted technique using three ports and when sutures were Analysis and/or Interpretation - G.G.; Literature Search – A.İ.A, G.G.;
performed with, separated, percutaneous, ‘‘U’’ shaped, nonabsorbable Writing Manuscript – A.İ.A., G.G.; Critical Review - G.G.
stitches, through the full thickness of the anterior abdominal wall and
the knots were tied in the subcutaneous tissue by a single incision. Registration of research studies
Cosmetic appearance was obtained by removing all sutures from the
same skin incision. Cosmetic appearance could be further improved by 1. Name of the registry: Researchregistry
making it from single-port. The full thickness stitches allows for max- 2. Unique Identifying number or registration ID: 5421
imum strength repair. By contrast, anchoring the sutures in the back of 3. Hyperlink to the registration (must be publicly accessible): https://
the sternum and costal margin is technically challenging and the fascia www.researchregistry.com/browse-the-registry#home/
may not be strong enough. There were no recurrence in this series. We registrationdetails/5e6a931f29050500186e3538/
believe that full thickness stitches is useful for preventing recurrence.
Another controversial issue at the time of repair is whether to excise Guarantor
or leave the associated hernia sac [6,8,24,25]. Excision is suggested in
order to reduce recurrence rate, but it may be potentially dangerous Dr. Ali İhsan Anadolulu.
such as possible injury of the pericardium, pleura, or phrenic nerve that Dr.Gonca Gerçel.
might be associated with the hernia sac excision. In present study,
hernia sac was not removed in any patient and we had no adverse Declaration of competing interest
events leaving the hernia sac in place and no effect on recurrence. And
also there were no residual cavity in chest X-ray in follow up period.
The authors have no conflict of interest to declare.
In conclusion, laparoscopic-assisted repair of MH using sutures in-
cluding the full thickness of anterior abdominal wall and extracorporeal
knots proved to be effective, safe, and reliable in children. It should be Appendix A. Supplementary data
the first choice because of fast recovery and better cosmetic results. In
this series, it was seen that leaving the hernia sac had no effect on early Supplementary data to this article can be found online at https://
doi.org/10.1016/j.amsu.2020.05.012.

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 Annals of Medicine and Surgery 56 (2020) 7–10

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∗
Corresponding author. Şanlıurfa Training and Research Hospital, Department of Pediatric Surgery, Şanlıurfa, Turkey.

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