Laparoscopic repair of adult retrosternal morgagnis hernia with interlocking barbed suture

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International Surgery Journal | July-September 2016 | Vol 3 | Issue 3 Page 1697
International Surgery Journal
Mir IS et al. Int Surg J. 2016 Aug;3(3):1697-1699
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Case Report
Laparoscopic repair of adult retrosternal morgagnis hernia with
interlocking barbed suture
Iqbal Saleem Mir*, Mudasir Farooq Hajini, Shiekh Viqar, Tajamul Rashid, Suhail Nazir
INTRODUCTION
Foramen of morgagni hernia in adults are relatively rare.
It was first described in the 1700s and is the least
common type of diaphragmatic hernia, contributing only
1–6% of all diaphragmatic hernias.1,2 Reported here is an
interesting case of a central diaphragmatic hernia which
could be a variant of Morgagni hernia presenting in a
patient with history of shortness of breath and palpitation
increased on lying down.
CASE REPORT
A gentleman aged 40 years presented to surgical OPD
after being evaluated on medical side for palpitation and
shortness of breath. On examination patient was stable
with pulse of 73 blood pressure = 120/80.Chest
examination revealed decreased breath sounds on left
side on lying down. The patient was admitted for
evaluation and further management. Baseline
investigations were normal including pulmonary function
test and ECG.
Oesophagoduodenoscopy was normal. Barium study
showed the evidence of herniation of transverse colon
into the chest. CECT chest confirmed the presence of
diaphragmatic hernia by showing the presence of
transverse colon inside the pleural cavity. Laparoscopic
repair of defect was planned. Umbilical port was created
by direct trocar insertion. Rest of the two ports were
created under vision after achieving pneumoperitoneum
in both upper quadrants. Herniation of left side of
diaphragm was confirmed with a defect of approximately
5 cm. The defect was extending retrosternal also.
Excision of sac was avoided in view of dense adherence
of the same with pericardium. Margins of diaphragm
were approximated using self-retaining interlocking
sutures. This was further strengthened by mobilization of
falciparum ligament and fixing of the same over the
suture line. Postoperative period remained uneventful and
the patient was relieved of the symptoms and was
discharged after 4th post-operative day in a satisfactory
condition. Repeat chest x-ray and CECT chest after one
month was normal.
DISCUSSION
Hernia of Morgagni although an anterior defect in the
diaphragm but usual presentation in adulthood is through
a paramedian defect. It occurs in a central retrosternal
location in children.3 It could be found incidentally in
ABSTRACT
We are reporting a case of 35 year male with history breathlessness and palpitation which increased on lying down. A
Morgagni hernia was diagnosed with a computer tomographic (CT) scan, which later proved out to be a left sided
morgagnis hernia with a defect extending retrosternally. Laparoscopic repair of the same was done using self-
retaining interlocking sutures.
Keywords: Laparoscopic, Adult diaphragmatic hernia
Department of Surgery, Government Medical College and Hospital, Srinagar, Jammu and Kashmir, India
Received: 19 June 2016
Accepted: 15 July 2016
*Correspondence:
Dr. Iqbal Saleem Mir,
E-mail: Iqbalsurg@rediffmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20162780

Mir IS et al. Int Surg J. 2016 Aug;3(3):1697-1699
International Surgery Journal | July-September 2016 | Vol 3 | Issue 3 Page 1698
adulthood or can present with visceral obstructing
hernia.4 Symptoms of these hernias may present
according to the herniated viscera. Morgagni hernias
containing bowel have risk of incarceration and may
require repair on presentation.5
Figure 1: Barium Follow through showing herniation
of colon into the pleural cavity.
Figure 2: Chest x-ray normal.
Figure 3: Laparoscopic view of hernia containing
colon.
Figure 4: laparoscopic view of hernial defect after
reduction of contents.
Figure 5: CECT Chest showing large gut herniation
anteriorly into the pleural cavity.
The conventional 10-12 cm midline laparotomy approach
has long been the standard approach for Morgagni hernia
repair. However, problems related to open surgery like
wound problems, postoperative pain, and cosmesis,
adhesion obstruction, can be major concerns for these
patients. Although laparoscopic repair of the Morgagni
hernia was first described in the mid-1990s, the number
of reported cases has been small because it is a rarity.6
We performed laparoscopic repair using interlocking self-
retaining sutures. A laparoscopic approach was sufficient
for reducing and completing the tension free repair of
hernial defect. Prosthetic patch repair could be used to
reduce recurrence by avoiding the tension on suture line.7
However small defects of 3 to 5cm could be closed
primarily in tension free manner. In our case we felt that
attachment of mesh with an overlap of 4-5cm would not
be feasible. The use of interlocking barbed suture helped

Mir IS et al. Int Surg J. 2016 Aug;3(3):1697-1699
International Surgery Journal | July-September 2016 | Vol 3 | Issue 3 Page 1699
in spreading the strain on the ring throughout the length
of the hernia ring.
Figure 6: Laparoscopic reduction of hernia.
Figure 7: Laparoscopic repair of hernial defect using
interlocking self-retaining sutures.
Surgery should be considered in all cases because
Morgagni hernia is likely to cause or induce
strangulation, spontaneously recovery is rare [8, 9].
Surgery always consists of reduction of the herniated
organs, ligation of the hernia sac, and closure of the
hernia defect.10,11 Prognosis after surgery is good,
recurrence is rare indeed.12
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
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Cite this article as: Mir IS, Hajini MF, Viqar S,
Rashid T, Nazir S. Laparoscopic repair of adult
retrosternal morgagnis hernia with interlocking
barbed suture. Int Surg J 2016;3:1697-9.