International Journal of Surgery Case Reports 114 (2024) 109149

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Incidental finding and successful management of Larrey's hernia during

laparoscopic cholecystectomy: Case report
Racem Trigui a, *, Anis Hasnaoui a, b, Anis Kerkeni c, Sihem Heni a
a
Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebal Lakhdar, 1006, Tunis, Tunisia
b
Faculty of Medicine of Tunis, Tunis el Manar University, Tunisia
c
Faculty of Medicine of Sousse, Tunisia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Larrey hernias (LH) are birth defects causing abdominal viscera to protrude into the thoracic cavity.
Adult Larrey's hernia With an incidence of 2–4 %, they are exceptional in adults.
Laparoscopic hernia repair Case presentation: A 65-year-old female patient was admitted for an elective laparoscopic cholecystectomy.
Congenital diaphragmatic hernia
During history intake, besides biliary colic, no additional symptoms were reported. Physical examination yielded
normal results. Chest-X ray did not reveal any anomalies. Intraoperatively, an inspection of the diaphragm
revealed a 3 cm defect in the left-sided sternocostal triangle, with the omentum protruding through the thorax.
After performing cholecystectomy, the content of the LH was cautiously reduced. The hernia sac was not
resected, to prevent potential injury to the neighboring anatomical structures. The defect was closed using non-
resorbable interrupted sutures. The postoperative course was uneventful. No recurrence was detected during
follow-up.
Clinical discussion: LH diagnosis is challenging due to its unspecific symptoms. Only 10 % of patients are
asymptomatic. CT imaging establishes a positive diagnosis and identifies acute complications requiring emer­
gency management.
Conclusion: Asymptomatic LH cases mandate surgery. Laparoscopic management is safe and efficient. The trans-
abdominal approach offers easier access to hernia content. Hernia sac resection is still debatable. The selection of
defect closure technique hinges on the quality and elasticity of the tissue, as well as the size of the defect, all
under the unwavering banner of the tension-free principle. Literature remains conflicting on mesh use.

1. Introduction underscore the significance of maintaining a heightened level of suspi­

cion among young surgeons, even in routine laparoscopic surgeries.
LH, commonly referred to as Morgagni-Larrey hernias, is a dia­ Additionally, we expose the surgical key steps involved in the laparo­
phragmatic birth defect in the left central part of the diaphragm, that scopic management of this exceptional condition. This case report ad­
causes protrusion of the abdominal viscera into the thoracic cavity [1]. As heres to the SCARE Criteria [3].
the evidence on LH primarily stems from case reports and retrospective
studies, reliance on these low evidence and biased sources impacts inci­ 2. Case presentation
dence findings [2]. Most published papers report an incidence of just 2 to
4 % of all congenital diaphragmatic hernias, emphasizing the rarity of A 65-year-old female patient, without a history of medical disease or
this entity in adults [2]. Due to the restricted number of adult patients prior abdominal surgeries, presented to our surgery ward for a planned
with LH, our understanding of this condition's symptoms, optimal diag­ laparoscopic cholecystectomy.
nostic approach, and effective management options is rather limited. Over the past eight months, the patient has complained of typical
In our paper, we highlight a very rare incidental discovery of biliary colic without fever or jaundice. Further history intake did not
congenital LH during a routine laparoscopic cholecystectomy. We aim to reveal any additional symptoms.

Abbreviations: LH, Larrey's hernia.

* Corresponding author at: Department of General Surgery, Menzel Bourguiba Hospital, Rue Djebal Lakhdar, 1006 Tunis, Tunisia.
E-mail address: [email protected] (R. Trigui).

https://doi.org/10.1016/j.ijscr.2023.109149
Received 30 October 2023; Received in revised form 18 November 2023; Accepted 1 December 2023
Available online 12 December 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
R. Trigui et al. International Journal of Surgery Case Reports 114 (2024) 109149

On examination, the patient had a BMI of 32 kg/m2. A comprehen­ abdominal pressure [7]. On the other hand, patients are protected from
sive physical assessment, encompassing respiratory, hemodynamic, and LH by the anatomical predisposition of the pericardium, as it prevents
abdominal examinations, revealed normal findings. abdominal viscera from herniating through the left diaphragm [8]. LH
An abdominal ultrasound showed a distended, thin-walled gall­ mostly affects women in their fifth to sixth decades [9]. This entity
bladder containing infra-centimetric gallstones. Laboratory findings and presents with a diverse range of symptoms, making it challenging to
chest X-rays were within normal limits. establish clear associations. This plethora of clinical features, from res­
The surgical procedure was conducted under general anesthesia with piratory to digestive symptoms, adds a layer of complexity to fully un­
the patient in a French position. After establishing pneumoperitoneum derstanding this condition [9]. While retrospective studies can introduce
and introducing trocars, inspection of the diaphragm revealed a 3 cm recall bias and limit the accuracy of evaluating clinical features, Katsaros
defect in the left-sided sternocostal triangle. The greater omentum was et al. [10] findings published in 2021 suggested that LH was more
protruding through the thorax (Fig. 1a and b). associated with digestive than respiratory symptoms. Recent scientific
Initially, we performed a cholecystectomy after reaching the critical papers have reported that while most patients are symptomatic, only 10
view of safety. Then the falciform ligament was taken down, exposing % were asymptomatic and discovered incidentally on imagery or during
the whole defect (Fig. 1c). After carefully reducing the content of the surgery [11]. Even though retrospective studies severely impede accu­
hernia, we opted not to resect the hernia sac due to the proximity of the rate evaluation of clinical features, patients' symptoms are inevitably
inferior lobe of the left lung, and the mediastinal structures. The defect based on the hernia contents, and they outline as follows: the small or
was closed via tension-free herniorrhaphy using non-resorbable sutures large intestine leads to bowel obstruction, the stomach leads to
(Video clip 1 highlights intraoperative findings, showing the hernia abdominal discomfort and reflux, and the omentum leads to abdominal
defect and the inferior lobe of the left lung). The postoperative course pain [12]. Respiratory symptoms are mainly due to hernia size [12]. In
was uneventful, and the patient was discharged three days later. Post- this paper, our patient suffered from obesity. LH was discovered inci­
operative follow-up did not show signs of recurrence. dentally during laparoscopic cholecystectomy. Besides the biliary colic
attached to gallstones, our patient was completely asymptomatic, with
3. Discussion no history of abdominal pain or discomfort although the hernia sac
contained the omentum. Given the diversity of the patient's symptoms,
LH manifests as the protrusion of abdominal viscera through the left confirmation of the diagnosis relies on imaging. However, the lack of
anterior retrosternal defect in the diaphragm [4]. well-defined guidelines for LH diagnosis introduces variability in the
While congenital diaphragmatic hernias are frequently diagnosed in diagnostic approach, subject to varying interpretations. In the era of
the pediatric population, their persistence and recognition in adults are advanced CT imaging, more incidental LH is diagnosed in adults [13]. A
quite rare [5]. Therefore, the entire evidence pertaining to LH is drawn positive diagnosis is established by identifying a retrosternal fat-density
only from case reports, small case series, and limited retrospective re­ mass or a hollow viscera [14]. Besides providing information on
views [5]. This limited scientific evidence underscores the distinctive anatomical characteristics and hernia contents, CT imaging can confirm
nature of this condition. The origin of this entity traces back to the un­ the presence of complications requiring emergency management [15].
successful fusion of the diaphragm and costal arches progenitors during The currently available literature lacks both prospective trials and large
embryological development [6]. Although there have been significant retrospective studies that can provide long-term follow-up and quality-
advancements in recent years, scientific knowledge is still limited about of-life checks on patients following LH repair. As a result, no clear
the exact insults occurring during embryonic development and how they guidelines for management have been issued for LH, and treatment
contribute to LH [6]. Despite being a birth defect, LH was more modalities are entirely based on the surgeon's past experiences [16].
commonly found in pregnant women, and patients with chronic con­ Given the rarity of LH, optimal surgical management is yet to be defined.
stipation, chronic cough, and obesity [7]. While their exact mechanism Facing the potential risk of acute incarceration, surgery is mandatory for
remains unclear, these conditions have in common the increase of intra- all patients, including incidentally discovered LH [13].
While most patients in ancient retrospective studies were operated
on via laparotomy or thoracotomy [17], emerging case series favor the
laparoscopic approach because it is associated with shorter hospital
stays, a similar recurrence rate, and lower postoperative complications
[5]. The trans-abdominal approach is better suited for incarcerated LH,
as it offers improved access and a better overview of the anatomy during
hernia repair [18]. The trans-thoracic approach is more useful in ancient
non-complicated hernias to provide a better view of pleural, medias­
tinal, and pulmonary structures while performing dissection [17]. The
debate over hernia sac resection remains unresolved. On one hand, some
authors believe that the risks of hernia sac resection outweigh the
benefits, as radical sac excision is associated with a high risk of injury to
anatomical structures such as the pleura, lung, pericardium, phrenic
nerve, and epigastric vessels [12]. On the other hand, leaving the hernia
sac unresected was associated with higher rates of seroma, hematoma,
and recurrence [12]. In our reported case, due to the proximity of the left
inferior pulmonary lobe, the pleura, and the pericardium, we decided to
leave the sac in situ. Active drainage was placed, and no effusion or
hematoma was detected in the postoperative course. Mesh use is
dictated by the possibility of ensuring a tension-free repair and hernia
size [19]. To this day, the literature is still conflicted between reports
confirming perfect defect closure by sutures, and others insisting on
mesh use where there is tissue loss in the diaphragm [19]. As for hernia
Fig. 1. Intraoperative findings. (a) showing a Larrey's hernia containing the size, although a literature review published in 2002 suggested that a
omentum (black star) and the transverse colon (black square) exhibiting defect larger than 2–3 cm requires mesh use [20], until today there is no
adhesion to the anterior abdominal wall. (b) and (c) showing the hernia defect. high-level scientific evidence on the cutoff size of hernia defect

2
R. Trigui et al. International Journal of Surgery Case Reports 114 (2024) 109149

regarding mesh implantation [19]. Acknowledgments

To successfully manage LH, a series of technical steps must be per­
formed with the utmost diligence. First, to fully expose the hernia defect Not applicable.
and to provide space for eventual mesh placement, the falciform liga­
ment must be taken down [13]. If hernia sac resection is to be per­ References
formed, this step requires thorough dissection, dreading the risk of
injury to the left pleural cavity, left lung, mediastinal structures, and left [1] S. Foutzitzi, S. Deftereos, Morgagni’s hernia in adult, Pan Afr. Med. J. 44 (2023)
26, https://doi.org/10.11604/pamj.2023.44.26.38571.
epigastric vessels. If defect closure without mesh application is decided, [2] V. Dumpa, P. Chandrasekharan, Congenital Diaphragmatic Hernia, in: StatPearls,
non-resorbable sutures must be employed [13]. StatPearls Publishing, Treasure Island (FL), 2023. http://www.ncbi.nlm.nih.
gov/books/NBK556076/ (accessed October 26, 2023).
[3] R.A. Agha, T. Franchi, C. Sohrabi, G. Mathew, A. Kerwan, A. Thoma, A.J. Beamish,
4. Conclusion A. Noureldin, A. Rao, B. Vasudevan, B. Challacombe, B. Perakath, B. Kirshtein,
B. Ekser, C.S. Pramesh, D.M. Laskin, D. Machado-Aranda, D. Miguel, D. Pagano, F.
Surgical management is the mainstay of treatment, even in cases of H. Millham, G. Roy, H. Kadioglu, I.J. Nixon, I. Mukherjee, J.A. McCaul, J. Chi-Yong
Ngu, J. Albrecht, J.G. Rivas, K. Raveendran, L. Derbyshire, M.H. Ather, M.
asymptomatic LH. Laparoscopy is a safe and feasible approach in elec­ A. Thorat, M. Valmasoni, M. Bashashati, M. Chalkoo, N.Z. Teo, N. Raison, O.
tive cases with the appropriate expertise. The trans-abdominal approach J. Muensterer, P.J. Bradley, P. Goel, P.S. Pai, R.Y. Afifi, R.D. Rosin, R. Coppola,
offers easier access to hernia content with a clear view of anatomical R. Klappenbach, R. Wynn, R.L. De Wilde, S. Surani, S. Giordano, S. Massarut, S.
G. Raja, S. Basu, S.A. Enam, T.G. Manning, T. Cross, V.K.L. Karanth,
structures. Hernia sac management is still controversial, but most au­
V. Kasivisvanathan, Z. Mei, S.C.A.R.E. The, Guideline: updating consensus surgical
thors advocate its conservation as the risk outweighs the benefit. Hernia CAse REport (SCARE) guidelines, Int. J. Surg. 84 (2020) (2020) 226–230, https://
defect closure by non-resorbable sutures vs. mesh application is still a doi.org/10.1016/j.ijsu.2020.10.034.
debatable subject with no clear guidelines, depending on tissue elasticity [4] M. Marshall-Webb, S.K. Thompson, Morgagni hernia in an adult: a forgotten cause
of epigastric pain, J. Gastrointest. Surg. 27 (2023) 628–630, https://doi.org/
and defect size. 10.1007/s11605-022-05542-3.
Supplementary data to this article can be found online at https://doi. [5] M.C. Young, S.A. Saddoughi, J.M. Aho, W.S. Harmsen, M.S. Allen, S.H. Blackmon,
org/10.1016/j.ijscr.2023.109149. S.D. Cassivi, F.C. Nichols, K.R. Shen, D.A. Wigle, Comparison of laparoscopic
versus open surgical Management of Morgagni Hernia, Ann. Thorac. Surg. 107
(2019) 257–261, https://doi.org/10.1016/j.athoracsur.2018.08.021.
Consent of publication [6] N. De Leon, W.H. Tse, D. Ameis, R. Keijzer, Embryology and anatomy of congenital
diaphragmatic hernia, Semin. Pediatr. Surg. 31 (2022), 151229, https://doi.org/
10.1016/j.sempedsurg.2022.151229.
A written consent was obtained from the patient to publish this case [7] A.B. Ulaş, Y. Aydın, A. Eroğlu, Laparoscopic approach in the treatment of Morgagni
report. hernia, Turk. Gogus Kalp Damar Cerrahisi Derg. 28 (2020) 514–520, https://doi.
org/10.5606/tgkdc.dergisi.2020.19209.
[8] X. Wang, H. Chen, L. Yang, C. Lu, Adult congenital diaphragmatic hernia with
Ethical approval absent pericardium and liver heterotopia, Eur. J. Cardiothorac. Surg. 58 (2020)
867–869, https://doi.org/10.1093/ejcts/ezaa111.
Published with the consent and approval of the patient. [9] E. Târcoveanu, A. Ștefan Georgescu, D. Vasilescu, N. Andronic, C. Dănilă, C.
Bradea Lupaşcu, Laparoscopic Management in Morgagni Hernia - Short Series and
Personal Data have been respected.
Review of Literature, Chirurgia (Bucur) 113, 2018, pp. 551–557, https://doi.org/
Written informed consent was obtained from the patient to publish 10.21614/chirurgia.113.4.551.
this report in accordance with the journal's patient consent policy. [10] I. Katsaros, S. Katelani, S. Giannopoulos, N. Machairas, S. Kykalos, N. Koliakos, E.
Ethical approval was not needed, because no study dealing with I. Kapetanakis, A. Bakopoulos, D. Schizas, Management of Morgagni’s hernia in the
adult population: a systematic review of the literature, World J. Surg. 45 (2021)
human or animal data was submitted in our case report. 3065–3072, https://doi.org/10.1007/s00268-021-06203-3.
Ethical Approval was waived by the Ethical Committee NAC of [11] Z. Sanford, A.S. Weltz, J. Brown, N. Shockcor, N. Wu, A.E. Park, Morgagni hernia
Menzel Bourguiba Hospital, Bizerte, Tunisia. repair: a review, Surg. Innov. 25 (2018) 389–399, https://doi.org/10.1177/
1553350618777053.
[12] P.U. Oppelt, I. Askevold, F. Bender, J. Liese, W. Padberg, A. Hecker, M. Reichert,
Funding Morgagni− Larrey diaphragmatic hernia repair in adult patients: a retrospective
single-center experience, Hernia 25 (2021) 479–489, https://doi.org/10.1007/
s10029-020-02147-0.
None. [13] A.M. Kao, S.A. Ayuso, C.R. Huntington, W.C. Sherrill, L.N. Cetrulo, P.D. Colavita,
B.T. Heniford, Technique and outcomes in laparoscopic repair of Morgagni hernia
Author contribution in adults, J. Laparoendosc. Adv. Surg. Tech. 31 (2021) 814–819, https://doi.org/
10.1089/lap.2021.0038.
[14] D.M. Gunia, D.J. Porter, A. Alijani, P. Patil, A tale of two unconventional adult
Racem Trigui: writing-Original draft preparation. Anis Hasnaoui: diaphragmatic hernias, Ann. R. Coll. Surg. Engl. 105 (2023) 484–488, https://doi.
Conceptualization, Writing-Reviewing and Editing. Anis Kerkeni: Data org/10.1308/rcsann.2022.0107.
[15] A.T. Abdelhamid, Non-traumatic left-sided diaphragmatic hernia causing volvulus
curation. Sihem Heni: Data curation. All authors read and approved the
in an adult, Radiol. Case Rep. 18 (2023) 899–902, https://doi.org/10.1016/j.
final manuscript. radcr.2022.10.106.
[16] E. Leeflang, J. Madden, A. Ibele, R. Glasgow, E. Morrow, Laparoscopic
Guarantor management of symptomatic congenital diaphragmatic hernia of Morgagni in the
adult, Surg. Endosc. 36 (2022) 216–221, https://doi.org/10.1007/s00464-020-
08259-z.
Dr Hasnaoui Anis [17] J.D. Horton, L.J. Hofmann, S.P. Hetz, Presentation and management of Morgagni
Dr Trigui Racem hernias in adults: a review of 298 cases, Surg. Endosc. 22 (2008) 1413–1420,
https://doi.org/10.1007/s00464-008-9754-x.
[18] S. Misimi, A. Shurlani, A. Nikolovski, Incidentally diagnosed large asymptomatic
Research registration number Morgagni hernia in adult male patient, Eur. J. Case Rep. Intern. Med. 10 (2023),
004047, https://doi.org/10.12890/2023_004047.
[19] S. Kuikel, S. Shrestha, S. Thapa, N. Maharjan, B.P. Kandel, P.J. Lakhey, Morgagni
1.Name of the registry: None hernia in adult: a case report, Int. J. Surg. Case Rep. 85 (2021), 106286, https://
2.Unique identifying number or registration ID: NONE doi.org/10.1016/j.ijscr.2021.106286.
3.Hyperlink to your specific registration (must be publicly accessible [20] D.S. Thoman, T. Hui, E.H. Phillips, Laparoscopic diaphragmatic hernia repair, Surg.
Endosc. 16 (2002) 1345–1349, https://doi.org/10.1007/s00464-001-8162-2.
and will be checked): NONE

Conflict of interest statement

Authors do not declare any conflict of interest.