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Laparoscopic repair of Morgagni-Larrey hernia in a child
Laparoscopic Repair of Morgagni-Larrey Hernia in a Child By Mario Lima, Marcello Do`mini, Michele Libri, Antonino Morabito, Giovanni Tani, and Remigio Do`mini Bologna, Italy
Primary laparoscopic repair of Morgagni-Larrey hernia has been described in adult patients but not in children. This is the first report of primary laparoscopic correction in the pediatric age group without using a prosthesis. A MorgagniLarrey hernia was found incidentally in a 3-year-old-girl. Laparoscopic correction of the defect was performed. After 6 months the patient is doing well. The chest radiograph shows complete resolution of the hernia. The laparoscopic ap-
proach allowed repair the hernia with minimal invasiveness. Laparoscopic correction is not difficult except for those hernias in which dense adhesions are present. J Pediatr Surg 35:1266-1268. Copyright r 2000 by W.B. Saunders Company.
A
the right side, thus assuming the picture of a true Morgagni-Larrey hernia (MLH; Fig 2A). Three other 5-mm trocars were inserted. The patient was put in reverse Trendelenburg position, with the surgeon positioned between her legs (this is our preferred position). The herniated transverse colon was retracted from the defect into the
NOMALIES of the sternal insertions of the diaphragmatic bundles result in congenital retro-costalxyphoid openings. When bowel herniates into one of these, a Morgagni hernia (MH) occurs. It is the rarest form of diaphragmatic hernia (DH). It accounts, according to world literature, for less than 6% of all diaphragmatic hernias. However, according to our personal experience, it is 4.5% of all congenital diaphragmatic abnormalities operated on in our department over a period of 29 years. The hernia usually is discovered incidentally because most are asymptomatic and can be discovered in adult life or on a chest radiograph obtained for other reasons. Surgical treatment is mandatory even though incarceration is extremely unusual.1 Laparoscopy has been advocated on few occasions, generally on adult patients, often using a prosthesis (mesh). This is the third report of primary laparoscopic closure in the pediatric age group with interrupted suture and without prosthesis.
INDEX WORDS: Morgagni hernia, space of Larrey, diaphragmatic hernia, laparoscopic repair.
CASE REPORT A chest radiograph was performed on a 3-year-old girl because of purulent otitis media. A Morgagni-Larrey hernia (MH) was discovered incidentally (Fig 1A). A barium swallow confirmed the diagnosis of MH (Fig 1B). The girl was completely asymptomatic. The patient was admitted to our department for the surgical correction. We performed a laparoscopic repair of the hernia. The pneumoperitoneum (flow, 1 L/min; pressure, 10 mm Hg) was done by ‘‘open laparoscopy’’ with a supraumbilical skin incision and insertion of a 10-mm trocar for insertion of the telescope. The exploration of the peritoneal cavity showed a wide diaphragmatic defect (10 ⫻ 5 cm) on the left side of the falciform ligament, that extended to
From the Clinica Chirurgica Pediatrica, Radiologia Pediatrica, Universita` degli Studi di Bologna, Bologna, Italy. Address reprint requests to Mario Lima, MD, Clinica Chirurgica Pediatrica, Universita` degli Studi di Bologna, Via Massarenti 11, 40138 Bologna, Italy. Copyright r 2000 by W.B. Saunders Company 0022-3468/00/3508-0027$03.00/0 doi:10.1053/jpsu.2000.8770 1266
Fig 1. (A) Lateral view of the chest x-ray with the air filling the bowel herniated through the defect in the retrosternal space. (B) The colon is visualized by the contrast medium in the retrosternal space.
Journal of Pediatric Surgery, Vol 35, No 8 (August), 2000: pp 1266-1268
LAPAROSCOPIC REPAIR OF MORGAGNI-LARREY HERNIA
1267
Over a period of 29 years, between 1970 and 1999, in the Department of Pediatric Surgery of the University of Bologna, 179 congenital abnormalities of the diaphragm were surgically corrected. This included 118 Bochdalek hernias, 27 hiatal hernias (without gastroesophageal reflux), 22 instances of congenital diaphragmatic eventration, 8 Morgagni-Larrey hernias, and 5 phrenic centre aplasias. The frequency of the Morgagni-Larrey hernias is 4.5% of all the congenital diaphragmatic hernias (DH) operated on in our department and 0.03% of all the surgical procedures performed. Morgagni-Larrey hernia is the rarest form of diaphragmatic hernia, and frequency in the world literature is between 1% and 6% of all surgically corrected DH.1,3,4 Larrey hernias are particularly rare.5 MH usually are diagnosed during the first decade of life, but most of them are asymptomatic and may be discovered in adult life or because of acquired conditions (eg obesity or pregnancies) that increase abdominal pressure enlarging the hernia with age.5 Diagnosis usually is made by frontal and lateral chest radiographs, and a barium enema or a barium swallow test can
Fig 2. (A) Laparoscopic image of the true Morgagni-Larrey hernia, with the defect extending on both sides of the falciform ligament. (B) The aspect of the defect once the falciform ligament was excised.
peritoneal cavity, and the falciform ligament was divided and ligated, allowing downward displacement of the liver and exposing the defect (Fig 2B). A primary closure appeared to be feasible without the need of a prosthesis. The sac was not removed, and the defect was closed by suturing the muscles of the abdominal wall to the anterior edge of the diaphragmatic defect (8 interrupted nonabsorbable 2-0 stitches tied extracorporeally; Fig 3). No drains were left in place. The postoperative course was uneventful. She spent the first 24 hours in the intensive care unit and was discharged on the fourth postoperative day. After 6 months, the patient is doing well. A chest radiograph shows an intact repair (Fig 4).
DISCUSSION
Anomalies of the sternal insertions of the diaphragmatic bundles result in congenital retro-costal-xyphoid openings. They can be defined as Morgagni hernias when occurring in the right sternocostal hiatus, or as Larrey hernias when located in the left sternocostal hiatus.2 If the opening is so wide that it includes both hiatus, the defect is called Morgagni-Larrey hernia (Fig 2A). Usually there is no clinical distinction between the 2 defects; therefore, most of time they are referred to as Morgagni hernias.
Fig 3. (A) The first stitch is positioned in the middle point of the defect. (B) The defect appears completely repaired at the end of the suture.
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Fig 4. (A) Chest x-ray of the postoperative control taken 6 months after the operation. (B) Lateral view of the postoperative chest x-ray showing the complete return to normal anatomy.
confirm the diagnosis. Computed tomography and magnetic resonance imaging may be performed in difficult cases to achieve diagnosis and clarify relationship of the defect to adjacent organs.6 Surgical correction is the treatment of choice.1,5 Conventional open repair includes hernia reduction, resection of the sac (when possible), and suture of the defect. The repair can easily be performed by laparoscopy. Laparoscopic repair has been performed on a few adult patients. We believe this is the first case of laparoscopic primary closure of the MH defect without using a prosthesis in the pediatric age group. The laparoscopic reduction of the hernia is not difficult except in those cases in which dense adhesions are present. Some investigators recommend the excision of the hernia sac,1 whereas others prefer to leave it.3,5 In the current case, we did not resect the sac because of the potential risk of pericardial or pleural injury. Moreover, it has been shown that spontaneous obliteration of the residual cavity can occur.5 Some investigators emphasize the risk of the formation of a cystic space, because of the fluid produced by the sac, and recommend draining the residual cavity.3 The method of closure of the defect still is debatable. Some investigators choose to close it primarily with a continuous suture1; others prefer to use interrupted nonabsorbable sutures, and those who prefer to use mesh are still debating whether to anchor it with suture or use a stapler device.5-7 Our patient seems to be the third case report8 of direct laparoscopic closure of diaphragmatic defects in children without using prosthesis. We believe that in children, repair of a congenital Morgagni-Larrey hernia can be performed easily using the laparoscopic approach without using prosthesis.
REFERENCES 1. Fernandez-Cebrian JM, Perez De Oteyza J: Laparoscopic repair of hernia of foramen of Morgagni: A new case report. J Laparoendosc Adv Surg Techn 6:61-64, 1996 2. Do`mini R: Conformazione Anatomica del Diaframma, in Do`mini R: Chirurgia delle Ernie Diaframmatiche e del Reflusso GastroEsofageo. Piccin Editore, 1972, p 30 3. Contini S, Dalla Valle R, Bonati L, et al: Laparoscopic repair of a Morgagni hernia: Report of the case and review of the literature. J Laparoendosc Adv Surg Techn 9:93-99, 1999 4. Stolar CJH, Dillon PW: Congenital diaphragmatic hernia and reduction, in O’Neill JA, Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery (ed 5). St Louis, MO, Mosby 1998, p 832
5. Bortul M, Calligaris L, Gheller P: Laparoscopic repair of a MorgagniLarrey hernia. J Laparoendosc Adv Surg Techn 8:309-313, 1998 6. Del Castillo D, Sanchez J, Hernandez M, et al: Morgagni’s hernia resolved by laparoscopic surgery. J Laparoendosc Adv Surg Techn 8:105108, 1998 7. Georgacopulo P, Franchella A, Mandrioli G, et al: Morgagni-Larrey hernia correction by laparoscopic surgery. Eur J Pediatr Surg 7:241-242, 1997 8. van der Zee DC, Bax NMA, Valla J-S: Laparoscopic repair of diaphragmatic conditions in infants and children, in Bax NMA, Georgesson GE, Najmaldin AS, et al (eds): Endoscopic Surgery in Children, New York, NY, Springer 327-328, 1999
Primary laparoscopic repair of Morgagni-Larrey hernia has been described in adult patients but not in children. This is the first report of primary laparoscopic correction in the pediatric age group without using a prosthesis. A MorgagniLarrey hernia was found incidentally in a 3-year-old-girl. Laparoscopic correction of the defect was performed. After 6 months the patient is doing well. The chest radiograph shows complete resolution of the hernia. The laparoscopic ap-
proach allowed repair the hernia with minimal invasiveness. Laparoscopic correction is not difficult except for those hernias in which dense adhesions are present. J Pediatr Surg 35:1266-1268. Copyright r 2000 by W.B. Saunders Company.
A
the right side, thus assuming the picture of a true Morgagni-Larrey hernia (MLH; Fig 2A). Three other 5-mm trocars were inserted. The patient was put in reverse Trendelenburg position, with the surgeon positioned between her legs (this is our preferred position). The herniated transverse colon was retracted from the defect into the
NOMALIES of the sternal insertions of the diaphragmatic bundles result in congenital retro-costalxyphoid openings. When bowel herniates into one of these, a Morgagni hernia (MH) occurs. It is the rarest form of diaphragmatic hernia (DH). It accounts, according to world literature, for less than 6% of all diaphragmatic hernias. However, according to our personal experience, it is 4.5% of all congenital diaphragmatic abnormalities operated on in our department over a period of 29 years. The hernia usually is discovered incidentally because most are asymptomatic and can be discovered in adult life or on a chest radiograph obtained for other reasons. Surgical treatment is mandatory even though incarceration is extremely unusual.1 Laparoscopy has been advocated on few occasions, generally on adult patients, often using a prosthesis (mesh). This is the third report of primary laparoscopic closure in the pediatric age group with interrupted suture and without prosthesis.
INDEX WORDS: Morgagni hernia, space of Larrey, diaphragmatic hernia, laparoscopic repair.
CASE REPORT A chest radiograph was performed on a 3-year-old girl because of purulent otitis media. A Morgagni-Larrey hernia (MH) was discovered incidentally (Fig 1A). A barium swallow confirmed the diagnosis of MH (Fig 1B). The girl was completely asymptomatic. The patient was admitted to our department for the surgical correction. We performed a laparoscopic repair of the hernia. The pneumoperitoneum (flow, 1 L/min; pressure, 10 mm Hg) was done by ‘‘open laparoscopy’’ with a supraumbilical skin incision and insertion of a 10-mm trocar for insertion of the telescope. The exploration of the peritoneal cavity showed a wide diaphragmatic defect (10 ⫻ 5 cm) on the left side of the falciform ligament, that extended to
From the Clinica Chirurgica Pediatrica, Radiologia Pediatrica, Universita` degli Studi di Bologna, Bologna, Italy. Address reprint requests to Mario Lima, MD, Clinica Chirurgica Pediatrica, Universita` degli Studi di Bologna, Via Massarenti 11, 40138 Bologna, Italy. Copyright r 2000 by W.B. Saunders Company 0022-3468/00/3508-0027$03.00/0 doi:10.1053/jpsu.2000.8770 1266
Fig 1. (A) Lateral view of the chest x-ray with the air filling the bowel herniated through the defect in the retrosternal space. (B) The colon is visualized by the contrast medium in the retrosternal space.
Journal of Pediatric Surgery, Vol 35, No 8 (August), 2000: pp 1266-1268
LAPAROSCOPIC REPAIR OF MORGAGNI-LARREY HERNIA
1267
Over a period of 29 years, between 1970 and 1999, in the Department of Pediatric Surgery of the University of Bologna, 179 congenital abnormalities of the diaphragm were surgically corrected. This included 118 Bochdalek hernias, 27 hiatal hernias (without gastroesophageal reflux), 22 instances of congenital diaphragmatic eventration, 8 Morgagni-Larrey hernias, and 5 phrenic centre aplasias. The frequency of the Morgagni-Larrey hernias is 4.5% of all the congenital diaphragmatic hernias (DH) operated on in our department and 0.03% of all the surgical procedures performed. Morgagni-Larrey hernia is the rarest form of diaphragmatic hernia, and frequency in the world literature is between 1% and 6% of all surgically corrected DH.1,3,4 Larrey hernias are particularly rare.5 MH usually are diagnosed during the first decade of life, but most of them are asymptomatic and may be discovered in adult life or because of acquired conditions (eg obesity or pregnancies) that increase abdominal pressure enlarging the hernia with age.5 Diagnosis usually is made by frontal and lateral chest radiographs, and a barium enema or a barium swallow test can
Fig 2. (A) Laparoscopic image of the true Morgagni-Larrey hernia, with the defect extending on both sides of the falciform ligament. (B) The aspect of the defect once the falciform ligament was excised.
peritoneal cavity, and the falciform ligament was divided and ligated, allowing downward displacement of the liver and exposing the defect (Fig 2B). A primary closure appeared to be feasible without the need of a prosthesis. The sac was not removed, and the defect was closed by suturing the muscles of the abdominal wall to the anterior edge of the diaphragmatic defect (8 interrupted nonabsorbable 2-0 stitches tied extracorporeally; Fig 3). No drains were left in place. The postoperative course was uneventful. She spent the first 24 hours in the intensive care unit and was discharged on the fourth postoperative day. After 6 months, the patient is doing well. A chest radiograph shows an intact repair (Fig 4).
DISCUSSION
Anomalies of the sternal insertions of the diaphragmatic bundles result in congenital retro-costal-xyphoid openings. They can be defined as Morgagni hernias when occurring in the right sternocostal hiatus, or as Larrey hernias when located in the left sternocostal hiatus.2 If the opening is so wide that it includes both hiatus, the defect is called Morgagni-Larrey hernia (Fig 2A). Usually there is no clinical distinction between the 2 defects; therefore, most of time they are referred to as Morgagni hernias.
Fig 3. (A) The first stitch is positioned in the middle point of the defect. (B) The defect appears completely repaired at the end of the suture.
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Fig 4. (A) Chest x-ray of the postoperative control taken 6 months after the operation. (B) Lateral view of the postoperative chest x-ray showing the complete return to normal anatomy.
confirm the diagnosis. Computed tomography and magnetic resonance imaging may be performed in difficult cases to achieve diagnosis and clarify relationship of the defect to adjacent organs.6 Surgical correction is the treatment of choice.1,5 Conventional open repair includes hernia reduction, resection of the sac (when possible), and suture of the defect. The repair can easily be performed by laparoscopy. Laparoscopic repair has been performed on a few adult patients. We believe this is the first case of laparoscopic primary closure of the MH defect without using a prosthesis in the pediatric age group. The laparoscopic reduction of the hernia is not difficult except in those cases in which dense adhesions are present. Some investigators recommend the excision of the hernia sac,1 whereas others prefer to leave it.3,5 In the current case, we did not resect the sac because of the potential risk of pericardial or pleural injury. Moreover, it has been shown that spontaneous obliteration of the residual cavity can occur.5 Some investigators emphasize the risk of the formation of a cystic space, because of the fluid produced by the sac, and recommend draining the residual cavity.3 The method of closure of the defect still is debatable. Some investigators choose to close it primarily with a continuous suture1; others prefer to use interrupted nonabsorbable sutures, and those who prefer to use mesh are still debating whether to anchor it with suture or use a stapler device.5-7 Our patient seems to be the third case report8 of direct laparoscopic closure of diaphragmatic defects in children without using prosthesis. We believe that in children, repair of a congenital Morgagni-Larrey hernia can be performed easily using the laparoscopic approach without using prosthesis.
REFERENCES 1. Fernandez-Cebrian JM, Perez De Oteyza J: Laparoscopic repair of hernia of foramen of Morgagni: A new case report. J Laparoendosc Adv Surg Techn 6:61-64, 1996 2. Do`mini R: Conformazione Anatomica del Diaframma, in Do`mini R: Chirurgia delle Ernie Diaframmatiche e del Reflusso GastroEsofageo. Piccin Editore, 1972, p 30 3. Contini S, Dalla Valle R, Bonati L, et al: Laparoscopic repair of a Morgagni hernia: Report of the case and review of the literature. J Laparoendosc Adv Surg Techn 9:93-99, 1999 4. Stolar CJH, Dillon PW: Congenital diaphragmatic hernia and reduction, in O’Neill JA, Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery (ed 5). St Louis, MO, Mosby 1998, p 832
5. Bortul M, Calligaris L, Gheller P: Laparoscopic repair of a MorgagniLarrey hernia. J Laparoendosc Adv Surg Techn 8:309-313, 1998 6. Del Castillo D, Sanchez J, Hernandez M, et al: Morgagni’s hernia resolved by laparoscopic surgery. J Laparoendosc Adv Surg Techn 8:105108, 1998 7. Georgacopulo P, Franchella A, Mandrioli G, et al: Morgagni-Larrey hernia correction by laparoscopic surgery. Eur J Pediatr Surg 7:241-242, 1997 8. van der Zee DC, Bax NMA, Valla J-S: Laparoscopic repair of diaphragmatic conditions in infants and children, in Bax NMA, Georgesson GE, Najmaldin AS, et al (eds): Endoscopic Surgery in Children, New York, NY, Springer 327-328, 1999