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Laparoscopic Repair of Larrey (Left-Sided Morgagni) Hernia: Technical Considerations
Abstract
In 1769, Morgagni described the diaphragmatic hernia carrying his name, whist doing a post mortem on a head injury patient. Independently, Larrey had described a left-sided “anterior sternoscostal” hernia, and so left-sided Morgagni hernia is also known as a Larrey hernia. It is a very rare type of congenital diaphragmatic hernia with an incidence of 1–3%. It is caused by failure of fusion in the anterior portion of the pleuroperitoneal membrane resulting in retrosternal defect in the diaphragm. Although infants present with recurrent respiratory infections, they can often go unnoticed for several decades. In this case report, we present a 48-year-old male, diagnosed with Larrey hernia who underwent successful total laparoscopic suture repair and Meshplasty. The sac contents were reduced, and the sac was not excised. The edges were approximated, and the mesh was placed to widely cover the defect and suture to the abdominal wall all around. Relevant literature and technical considerations are discussed in this article.
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Background:
The mesh fixation technique used in repair of hiatal hernias and subxiphoid ventral and incisional hernias must meet strenuous requirements. In the literature, there are reports of life-threatening complications with cardiac tamponade and a high mortality rate on using tacks. The continuing practice of tack deployment for mesh fixation to the diaphragm and esophageal hiatus should be critically reviewed.
Methods:
In a systematic search of the available literature in May 2017, 23 cases of severe penetrating cardiac complications were identified. The authors became aware of two other cases in which they acted as medical experts. Furthermore, the instructions for use issued by the manufacturers of the tacks were reviewed with regard to their deployment in the diaphragm.
Results:
Twenty-three of 25 cases (92%) with severe cardiac injuries and subsequent cardiac tamponade were triggered by the use of tacks in the diaphragm. In six cases (24%), these related to ventral and incisional hernias with extension to the subxiphoid area, and in 19 cases (76%) to mesh-augmented hiatoplasty. Twelve of 25 (48%) patients died as a result of pericardial and/or heart muscle injury with cardiac tamponade despite heart surgery intervention. In the tack manufacturers' instructions for use, their deployment in the diaphragm, in particular in the vicinity of the heart, is contraindicated. Likewise, the existing guidelines urgently advise against the use of tacks in the diaphragm, recommending instead alternative fixation techniques.
Conclusions:
Tacks should not be used for mesh fixation in the diaphragm above the costal arch.
With a prevalence of 0.3-0.5/1000 births, congenital diaphragmatic hernia (CDH) remains a serious, poorly understood abnormality with a high mortality rate that cannot always be effectively managed. Its reported frequency in Spain is 0.69%oo with a yearly decreasing trend of 0.10%oo during the period 1980-2006. Up to 5% of cases are incidentally identified in adults undergoing studies for other reasons. We report the case of a 74-year-old woman with vomiting for three months due to parasternal diaphragmatic hernia of Morgagni-Larrey (retrochondrosternal, retrocostoxyphoid, retrosternal, subcostal, substernal or subcostosternal hernia), which allowed us to report an update on this condition in the adult, and on thoracoabdominal diaphragm morphogenesis. It is in the embryology of the diaphragm where an explanation may be found for some morphological changes and clinical manifestations, even though a number of uncertainties remain. We also analyze the extent of controversy persisting on some aspects of surgical treatment (access routes, mesh use, hernial sac reduction). Overall, minimally invasive techniques predominate. We consider laparoscopy the approach of choice for adult patients with parasternal hernia eligible for surgery.
With a prevalence of 0.3-0.5/1000 births, congenital diaphragmatic hernia (CDH) remains a serious, poorly understood abnormality with a high mortality rate that cannot always be effectively managed. Its reported frequency in Spain is 0.69%00 with a yearly decreasing trend of 0.10%00 during the period 1980-2006. Up to 5% of cases are incidentally identified in adults undergoing studies for other reasons.We report the case of a 74-year-old woman with vomiting for three months due to parasternal diaphragmatic hernia of Morgagni-Larrey (retrochondrosternal, retrocostoxyphoid, retrosternal, subcostal, substernal or subcostosternal hernia), which allowed us to report an update on this condition in the adult, and on thoracoabdominal diaphragm morphogenesis. It is in the embryology of the diaphragm where an explanation may be found for some morphological changes and clinical manifestations, even though a number of uncertainties remain. We also analyze the extent of controversy persisting on some aspects of surgical treatment (access routes, mesh use, hernial sac reduction). Overall, minimally invasive techniques predominate. We consider laparoscopy the approach of choice for adult patients with parasternal hernia eligible for surgery.
Morgagni-Larrey hernia is an uncommon entity. The majority of the literature describes hernia occurring mostly on the right side, a few on the left side and rarely bilateral. Retrospective chart review was done for the patients with the diagnosis of adult diaphragmatic hernia from January 1997 to December 2010. Post-operative course was evaluated for outcome, morbidity and mortality. Out of 20 patients, 13 (65 %) were males and 7 (35 %) were females. Their age ranged from 17 to 50 years (mean = 29.6). Abdominal discomfort was the most common presentation. Eight patients (40 %) were asymptomatic at presentation. Plain X-Ray chest was done for all. Ten patients (50 %) underwent suture repair, 6 (30 %) had mesh placement and the other 4 (25 %) underwent both: suture repair buttressed with mesh. Volvulus of stomach was noted in 5 (25 %) cases. All patients had left sided hernia. There was insignificant morbidity and no mortality. There was no recurrence in 16 patients followed up for a mean duration of 20 months (range = 8 to 32 months). In Morgagni-Larrey hernia, abdominal approach gives good accessibility to reduce the hernia and to undertake repair. When complicated with incarceration, perforation, gangrene or volvulus of the herniated bowel; this can be dealt with ease. Plain X Ray of the chest is fairly accurate in suggesting the diagnosis of Morgagni-Larrey hernia.
Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.
Posterior cruroplasty repair of a large paraesophageal hiatus hernia has a higher than desirable rate of recurrence attributable to the inexorable cyclic negative intrathoracic pressure of respiration and positive intraabdominal pressure produced by straining, physical exertion, and coughing. To reduce the risk of recurrence after repair of a large hiatus hernia and intrathoracic stomach, we have used posterior cruroplasty reinforced with an onlay polypropylene mesh prosthesis. This paper reviews the feasibility of this technique.
We did a retrospective review of 44 patients with large hiatus hernia and intrathoracic stomach who had posterior cruroplasty and onlay of polypropylene mesh prosthesis applied to the crura and adjacent diaphragm to repair the hiatal defect.
Preoperative symptoms (mean duration, 26 months) included pain (33 patients), vomiting (21), dysphagia (19) and anemia (8). The typical patient (28 men and 16 women, mean age, 60) had two-thirds or more of the stomach above the diaphragm. Organoaxial gastric volvulus and herniated large or small bowel were present in 10 and 9 patients, respectively. A gastrostomy was performed for temporary drainage in 38 patients in addition to the hernia repair; 11 patients underwent a concomitant Nissen fundoplication. Postoperative complications included pleural effusion (four patients), atrial dysrhythmia (three patients), and superficial wound infection (two patients). Mean followup for 43 patients was 52 months. There have been no clinical recurrences.
Mesh prosthesis reinforced hiatus hernia repair is effective, appears to have a low clinical recurrence rate, and should be an option in the treatment of a large hiatus hernia with intrathoracic stomach.