Chetan V Aher, Assistant Professor of Surgery, Michael D Holzman, Professor of Surgery. Vanderbilt University Medical Center
It is my pleasure to present a case of a large Morgagni hernia requiring pericardotomy and mesh closure
The patient is a 33-year-old man who initially presented with chest pain and new onset hypertension. His chest x-ray shown here shows abnormal lucencies in the chest, and his workup eventually revealed a large Morgagni hernia containing liver, transverse colon and omentum.
His CT revealed cardiac significant cardiac compression. Based on these symptoms and findings, the patient elected to undergo laparoscopic Morgagni hernia repair.
As with all diaphragmatic hernias, we began our dissection to expose the extraperitoneal plane. During this dissection, it became clear that the hernia sac was adherent to the pericardium, which was quite thin. You can see that, despite taking small bites, we enter the pericardium. Watch the right side of the screen as the pericardium insufflates and the hernia sac, previous stuck superiorly, starts to fall.
A few small spreads demonstrate how thin the pericardium is, and how improbable separating those two layers would be. We opened the sac a little more, and with that, the heart comes into full view in the anterior mediastinum.
We then began to circumferentially excise the hernia sac. A grasper placed inside the cavity shows how close to the heart we are working.
During this effort it became clear that, even after reducing the pneumoperitoneum, we would not be able to close this defect primarily. The still image shows the posterior diaphragm free, but immobile.
The defect measured 13 x 8 cm, as shown here. We elected to use a PTFE mesh for closure, which we introduced into the abdomen we sized it appropriately.
It is important to note that we typically repair Morgagni hernias primarily with pledgeted prolene suture, and that the technique shown here is uncommon. Evaluation of diaphragmatic mobility must be ascertained with the pneumoperitoneum reduced or released.
Ethibond sutures placed here in the left inferior aspect of the defect demonstrate the technical difficulty of working in the anterior mediastinum. Notice how we engage the tissue and quickly turn the needle over to avoid injury to the heart. It may be difficult to see, but the heart does hit the back end of the needle in a few of those stitches.
His 4 month post operative chest xray is shown here, and shows no recurrence of his hernia.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87348
Program Number: V038
Presentation Session: Foregut Session
Presentation Type: Video
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