Robotic-Assisted Repair of a Morgagni Diaphragmatic Hernia Utilizing a Thoracic Approach

Morgagni hernia is a rare congenital diaphragmatic hernia comprising 2.6% of all diaphragmatic hernias (1). It is a defect between the costal and sternal attachments of the diaphragm muscle anteriorly and is most common on the right, but also can be found on the left or on both sides (2). Abdominal contents can herniate into the thoracic cavity.

Morgagni hernia can be asymptomatic and discovered as an incidental finding. Most frequent symptoms include pulmonary, chest, or abdominal pain and intestinal obstruction (3). Diagnosis can be made with computed tomography. Surgical treatment is indicated to avoid future complications (4).

Options for repair of the congenital defect include primary repair or placement of mesh. The repair is usually done by open thoracotomy or laparotomy (5). Laparoscopy has been recently shown to offer advantages of shorter length of stay, with a similar recurrence rate compared to the open approach (5). Thoracoscopic repair has also been performed (4).

Robotic assistance for repair of the Morgagni hernia has recently been described (6-8). Most commonly the transabdominal approach has been used (6, 7). Robotic-assisted transthoracic approach has recently been reported (8). The transthoracic approach offers the advantage of easier dissection of the hernia sac off the thoracic structures with reduced chance of iatrogenic injuries (2,3).

This video demonstrates robotic-assisted repair of a Morgagni diaphragmatic hernia using mesh through a thoracic approach. The patient was a 52-year-old woman who was found to have a Morgagni diaphragmatic hernia with incarcerated omentum during a sleeve gastrectomy 4 years earlier. Repair was not done transabdominally due to the proximity to the heart. During the intervening 4 years she had a 100 lb weight loss, but intermittent severe right anterior chest pain at the costal margin. CT scan demonstrated a 2 to 3 cm right anterior diaphragmatic hernia with incarcerated omentum consistent with a Morgagni diaphragmatic hernia. She underwent robotic-assisted repair with acellular mesh. The patient was discharged home on the 1st postoperative day. Follow-up demonstrated resolution of her chest pain.

The thoracic approach allows dissection and reduction of the hernia with safe mesh repair close to the heart. Robotic assistance offers improved vision and a more stable platform resulting in reduced pain, shortened length of hospital stay, and enhanced recovery.

References

1. Saltzstein HC, Linkner LM, Scheinberg SR. Subcostosternal (Morgagni) diaphragmatic hernia: report of a case of hernia containing stomach, transverse colon, and omentum, with review of the literature. Arch Surg 1951; 63:750-65.
2. Kilic E, Nadir A, Doner E, et al. Transthoracic approach in surgical management of Morgagni hernia. Eur J Cardiovasc Surg 2001; 20:1016-9.
3. Horton JD, Hofman LJ, Hertz SP. Presentation and management Morgagni hernias in adults: A review of 298 cases. Surge Endosc 2008; 22:1413-20.
4. Hussong RL Jr, Landreneau RJ, Cole FH Jr. Diagnosis and repair of a Morgagni hernia with video-assisted thoracic surgery. Ann Thorac Surg 1997; 63:1474-5
5. Young MC, Saddoughi SA, Aho JM, et al. Comparison of laparoscopic versus open surgical management of Morgagni hernia. Ann Thorac Surg 2019; 107:257-61
6. Wei B, Pittman BC. Robotic Morgagni hernia repair: an emerging approach to a congenital defect. J Robotic Surg 2019; 13: 309-313
7. Krueger A, Reznik S. Repair of hernia of Morgagni. July 2020. doi:10.25373/ctsnet.12597104.
8. Amore D, Bergaminelli C, Natale DD, et al. Morgagni hernia repair an adult obese patient by hybrid robotic thoracic surgery. J Thorac Dis 2018; 10:E555-E559.

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