Morgagni Hernia Repair: Transabdominal Robotic Approach

This video presents a fifty-six-year-old male who was admitted to the hospital with ten days of bilateral upper quadrant pain that was intermittently sharp without radiation with associated decreased appetite and exertional chest pain. 

A routine CT scan of the chest was obtained, which demonstrated a Morgagni hernia with concern for ventricular compression. The patient then underwent a complete cardiac workup, which demonstrated no mass effect on the TTE and a normal CT cardiac study. He had a past medical history of CVA and a DVT, for which he is currently on apixaban with the MTHFR mutation. He has type 1 diabetes, hyperlipidemia, and irritable bowel syndrome. He had previously undergone a lap chole and a right first toe amputation due to diabetes. 

The authors’ operative approach robotically placed three 8 mm trocars adjacent to the midline and 2 cm cranial to the umbilicus, which were in line with the 12 mm trocar 2 cm cranially and 2 cm laterally to the umbilicus. The surgery began by pulling the hernia sac of the defect on the anterior aspect of the diaphragm, then incising using monopolar robotic scissors. A peritoneal layered flap was then created surrounding the hernia sac. Hemostasis was carefully maintained throughout this dissection. 

Next, the rectus muscle was pulled superiorly towards the anterior abdominal wall, and the hernia sac was then pulled out of the Morgagni defect. The preperitoneal layer was then visualized and the peritoneum was dissected to ensure adequate room for the mesh to be placed. Next, a 0-Ethibond suture was placed in the lateral wall of the diaphragmatic defect at the inferior aspect and pulled through to close that space. A second 0-Ethibond suture was placed superiorly to that. The suture was then pulled transfascially through the anterior abdominal wall. 

Next, a pursestring suture was placed with the same mechanism to further tighten the diaphragmatic defect. This pursestring suture was also pulled transfascially through the anterior abdominal wall in the same fashion as the previous sutures and demonstrated that the lateral wall still needed one additional suture to close the defect in its entirety. Once the diaphragmatic defect was completely closed, the peritoneal layer was further dissected to create space for the mesh placement. The mesh was then inserted and placed in the correct anatomical configuration. The mesh was then secured in all four corners in simple interrupted fashion, and the peritoneal flap was closed with a running 3-0 barbed suture. A final look was then performed, which showed that the hernia was adequately closed with mesh in place. 

On postoperative day one, the patient had a slight AKI, which was resolved by postoperative day three when the patient was discharged home. He has been doing well since surgery. 

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