Robotic transabdominal preperitoneal Morgagni hernia repair: surgical technique

Introduction

Background

A Morgagni hernia is a rare congenital anterior diaphragmatic hernia caused by the failure of the pars tendinalis part of the costochondral arches to fuse with the pars sternalis on the right side (1). It was first described by Giovanni Battista Morgagni, an Italian anatomist and pathologist in 1769, during a postmortem examination of a head injury patient (2). When the hernia occurs on the left side, it is called a Larrey hernia and is much less common due to the pericardial attachments to the diaphragm that provide protection and support on that side. In rare cases, the hernia can be bilateral. Morgagni-Larrey hernias present later in life and are diagnosed either incidentally on imaging or intraoperatively, or when a viscus, such as the omentum, stomach or colon, herniates through the defect causing gastro-intestinal or respiratory symptoms.

Rationale

Repair of Morgagni-Larrey hernias is recommended, even when asymptomatic, to avoid future complications, such as incarceration or strangulation. Surgical treatment options include transabdominal and transthoracic approaches. The laparoscopic technique often consists of hernia defect closure with possible reinforcement with an intraperitoneal mesh that have to be secured circumferentially to the abdominal wall and the diaphragm. Placing the mesh extraperitoneally however may be more advantageous as it allows less suture fixation, better mesh integration and less visceral adhesions; such an approach would be challenging to perform laparoscopically due to the difficult angles for working in the anterior mediastinum and anterior diaphragm, but it is greatly facilitated by the robotic platform.

Objective

This article and accompanying video (Video 1) describe the robotic-assisted laparoscopic transabdominal preperitoneal technique for repair of Morgagni hernia, using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) with standardization of the surgical steps. This article is presented in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-44/rc).

Preoperative preparations and requirements

A chest radiograph may diagnose a Morgagni hernia if bowel herniation is present, showing a radiolucent paracardiac shadow that is retrosternal on lateral images. Preoperative cross-sectional imaging is required to assess the size of the defect and the contents of the hernia. A computerized tomography (CT) scan of the chest and/or abdomen and pelvis (Figure 1) is the preferred imaging modality. In addition, imaging allows to rule out any concomitant pathology. No other specific preoperative testing is needed beside what is required to ensure that the patient is properly medically optimized for surgery.

Figure 1 Representative image of a coronal reconstruction of the CT scan of the abdomen and pelvis of the patient presented here, showing a portion of the transverse colon (white arrow) herniating through an anterior defect in the diaphragm (black arrows). CT, computerized tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Abdominal access and trocar placement

Abdominal access is obtained using an optical entry technique in the left upper quadrant and pneumoperitoneum is established up to 15 mmHg. The trocars are placed across the upper abdomen about 15 cm below the xiphoid (Figure 2). Three 8-mm trocars are utilized, with the middle one placed slightly to the left of the midline and used for the 30-degree scope angled up. The da Vinci Xi surgical system (Intuitive Surgical) is used in this case. An additional assist port may be used if desired. The patient is placed in a reverse Trendelenburg position.

Figure 2 Trocar configuration. Black arrows point to the 8-mm robotic trocars.

Peritoneal flap creation and hernia sac reduction

The hernia contents are first reduced. A peritoneal incision is made transversely 7–8 cm from anterior edge of the hernia defect and coming across the falciform ligament. The preperitoneal space is developed superiorly using sharp and blunt dissection. The hernia sac is then encountered and reduced along with any herniated preperitoneal fat. The preperitoneal dissection continues for 6–7 cm beyond the posterior edge of the defect, dissecting the peritoneum off the diaphragmatic muscle fibers and central tendon. The preperitoneal pocket extends at least 5 cm on each side of the defect. Figure 3 shows the completed dissection.

Figure 3 Completed preperitoneal dissection showing the Morgagni hernia defect and the exposed diaphragmatic muscle fibers and central tendon.

Defect closure

The hernia defect is closed transversely using slowly absorbable barbed sutures (2-0 V-Loc^TM 180 on GS-22 needle, Medtronic, New Haven, CT, USA). Slowly absorbable sutures are preferred for all fascial closures including diaphragm, specially when a mesh is also used. Great care is made to ensure proper bites of muscle and fascia. Starting sutures from each end of the defect and gradually tightening them allows closure of larger defects; the sutures are overlapped in the middle and do not require to be tied together. If needed, the pressure of the pneumoperitoneum may be reduced at this stage to reduce tension and facilitate closure of wider defects.

Mesh placement and flap closure

An appropriately-sized mesh is placed over the repair with 4–5 cm overlap with normal fascia in all directions. The initial size of the defect prior to closure is used to determine the size of the mesh; in the case presented here, the defect measured 3 cm × 7 cm so the mesh was sized at 12 cm × 16 cm. Any non-coated macroporous permanent mesh is adequate but the self-gripping polyester mesh (ProGrip™ Laparoscopic Self-fixating Mesh, Medtronic, New Haven, CT, USA) works best in this location in order to avoid any suturing to the diaphragm. If a standard mesh is used, only a few interrupted absorbable sutures, such as 2-0 polyglactin 910, are used to keep the mesh in place. The peritoneal flap is then closed with a running barbed absorbable suture (3-0 V-Loc^TM 180 on CV-15 needle, Medtronic, New Haven, CT, USA); the peritoneum may need to be trimmed when a very large hernia sac is present. Before starting flap closure, a Veress needle is introduced percutaneously into the developed preperitoneal space in order to aspirate the carbon dioxide from that space once the flap closure is completed and ensure the mesh stays flat and in proper position.

The total operative time for the case presented here was 160 minutes and the blood loss was minimal.

Postoperative considerations and tasks

Most patients are discharged home on the first postoperative day. Some amount of subcutaneous crepitus is expected. No postoperative imaging is required if the patient is asymptomatic. Most patients are able to return to work within a week, unless they have a physically demanding job. Patients are restricted from doing any heavy lifting or strenuous work-outs for 6 weeks after surgery.

Tips and pearls

Developing the peritoneal flap on the anterior abdominal wall is usually straightforward as this area has a significant amount of fatty tissue. The flap development on the diaphragm can be challenging and requires more careful dissection. It is important to always make sure no muscle fibers are coming down with the flap. Small tears in the flap can be closed with absorbable sutures. If there is significant tearing of the flap or if the flap cannot be developed, the procedure can be converted to an intraperitoneal repair with reduction and excision of the hernia sac, defect closure as describe above and placement of a sublay coated mesh sutured circumferentially in place.

Discussion

Surgical highlights

This step-by-step video demonstration highlights the technique of robotic transabdominal preperitoneal Morgagni hernia repair. This approach allows for reduction of the hernia sac, primary repair of the hernia defect and reinforcement with an uncoated mesh. The robotic platform facilitates such repair compared to traditional laparoscopy as it takes advantage of wristed instruments to navigate the technical challenges of working on the anterior diaphragm and mediastinum and accomplishing complex tasks in a confined space.

Strengths and limitations

The transabdominal preperitoneal Morgagni hernia repair obviates the need for circumferential mesh fixation to the diaphragm which carries a risk of iatrogenic injuries. Given the preperitoneal mesh placement, better mesh tissue integration is to be expected while also protecting the intraperitoneal viscera from any mesh adhesions. This technique is obviously limited by the access to the robotic platform and its associated increased cost, as well as the availability of the technical expertise in more complex robotic-assisted procedures.

Comparison with other surgical techniques and researches

There are a number of surgical techniques available to repair Morgagni hernias including open abdominal approach via laparotomy, open thoracic approaches via median sternotomy or thoracotomy and minimally invasive techniques, including laparoscopy and thoracoscopy. The first laparoscopic repair was described by Kuster et al. in 1992 (3). Given the shorter length of stay with similar recurrence rates as compared to laparotomy and thoracotomy (4), the laparoscopic approach became the preferred approach for repair of Morgagni hernias. In the past few years, there has been increasing reports on the feasibility of repairing Morgagni hernias in adults with robotically-assisted laparoscopy (5-13). Although all these reports are retrospective studies, they have consistently shown that such approach is safe and effective along with minimal postoperative pain, minimal length of stay and durable long-term results.

The initial descriptions of laparoscopic repairs recommended against removing the sac due to concern for creating massive pneumomediastinum with potential respiratory and circulatory complications (3). However, it is currently recommended to excise the hernia sac in order to reduce the risk of recurrence or mediastinal cyst formation (14); pneumomediastinum and subcutaneous emphysema are common but are usually inconsequential.

The use of mesh is controversial. One study reported successful repair of 36 Morgagni hernias via laparotomy and thoracotomy without mesh and with no recurrence noted (15). Although repair of a small Morgagni hernia may be done primarily, mesh repair is recommended for larger defects in most modern series given the tension on the primary repair. Laparoscopic repairs (14,16,17) and many robotic repair series (5,6,9,12), use an intraperitoneal sublay mesh to either reinforce the repair closure or as a bridge.

Gergen et al. compared robotic intraperitoneal versus preperitoneal sublay mesh repair of Morgagni hernias in nine patients (10). They found longer operative times in the preperitoneal repair group but shorter length of stay, reduced post-operative pain and reduced time to return to work with no difference in complications, 30-day readmissions or recurrence of hernia between the two groups.

Implications and actions recommended

Robotic trans-abdominal preperitoneal has the potential of becoming the preferred technique for Morgagni hernia repair for the advantages stated here. Large prospective randomized studies comparing various robotic approaches are not possible given the rarity of this condition. However, standardization of the technique will allow better assessment of the short-term and long-term outcomes of the surgical management of this hernia.

Conclusions

The robotic transabdominal preperitoneal repair of Morgagni hernias appear to provide durable repair with the advantage of shorter length stay, reduced operative pain and quicker return to work. The robotic platform facilitates this approach as compared to laparoscopy. Placing the mesh extraperitoneally has the added advantage of allowing minimal to no mesh suture fixation to the diaphragm in addition to minimizing intraperitoneal visceral adhesions.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Raul Caso and John F. Lazar) for the series “Challenging Robotic Foregut and Diaphragm Procedures” published in the Journal of Visualized Surgery. The article has undergone external peer review.

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-44/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-44/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-44/coif). The series “Challenging Robotic Foregut and Diaphragm Procedures” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this study, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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