Chapter 1 of 4 · Case-Based Learning
Technique & Case 1
Technique overview and first case: 2-year-old with trisomy 21
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Morgagni hernia appears centrally on anteroposterior chest X-ray and anteriorly on lateral view.
No further imaging beyond AP and lateral chest films is required for diagnosis of Morgagni hernia.
The laparoscopic-assisted repair uses a 5mm umbilical port for camera and stab incisions or 3mm trocars in bilateral upper quadrants.
The epigastric incision is approximately 1.5 to 2 centimeters, placed directly overlying the hernia site.
U-stitches of Prolene are placed between the anterior abdominal wall and posterior rim of the defect using a suture passer.
Peritoneal attachments of the liver to the diaphragm are divided to further release the posterior rim of the defect.
The sutures are tied sequentially in the subcutaneous space to close the defect by bringing the diaphragmatic rim up to the anterior abdominal wall.
The first patient was discharged the following day after repair.
The falciform ligament can tether the liver to the posterior rim of the defect and must be taken down with cautery.
Dissection of the falciform ligament onto the diaphragmatic rim requires awareness of the proximity of the hepatic veins.
When anterior abdominal fascia is extremely weak, sutures can be passed through a small piece of cortex placed in the transverse abdominal incision and tied over the cortex to prevent tearing through the fascia.
A hernia sac, when found to be quite adherent to the mediastinum, can be left in situ.
Large Morgagni defects may require six U-stitches to obtain closure.
Fluid accumulation within the residual sac at one month post-repair may resolve by one year.
When the distance between the anterior abdominal wall and the posterior diaphragmatic rim is quite short, an alternate simpler technique using Ethibond sutures on CTX needles can be used.
In the alternate technique, sutures purposefully overlap to avoid any gaps in closure.
Intermittent tension on the first stitch facilitates the passing of the second stitch.
This laparoscopic-assisted procedure can be used in patients of all ages.
The laparoscopic-assisted Morgagni repair is associated with a low risk of recurrence and excellent cosmetic results.