Robotic Assisted Repair of a Morgagni Diaphragmatic Hernia Utilizing a Thoracic Approach

Morgagni hernia is a rare congenital diaphragmatic hernia comprising 2.6% of all diaphragmatic hernias (1). It is a defect between the costal and sternal attachments of the diaphragm muscle anteriorly and is most common on the right but also can be found on the left or on both sides (2). Abdominal contents can herniate into the thoracic cavity.

Morgagni hernia can be asymptomatic and discovered as an incidental finding. Most frequent symptoms include pulmonary, chest or abdominal pain and intestinal obstruction (3). Diagnosis can be made with computed tomography. Surgical treatment is indicated to avoid future complications (4).

Options for repair of the congenital defect include primary repair or placement of mesh. The repair is usually done by open thoracotomy or laparotomy (5). Laparoscopy has been recently shown to offer advantages of shorter length of stay with a similar recurrence rate compared to the open approach (5). Thoracoscopic repair has also been performed (4).

Robotic assistance for repair of the Morgagni hernia has recently been described (6-8). Most commonly the transabdominal approach has been used (6, 7). Robotic assisted transthoracic approach has recently been reported (8). The transthoracic approach offers the advantage of easier dissection of the hernia sac off the thoracic structures with reduced chance of iatrogenic injuries (2,3).

This video demonstrates robotic assisted repair of a Morgagni diaphragmatic hernia using mesh through a thoracic approach. The patient is a 52-year-old woman who was found to have a Morgagni diaphragmatic hernia with incarcerated omentum during a sleeve gastrectomy 4 years earlier. Repair was not done transabdominally due to the proximity to the heart. During the intervening 4 years she had a 100 lb weight loss, but intermittent severe right anterior chest pain at the costal margin. CT scan demonstrated a 2 to 3 cm right anterior diaphragmatic hernia with incarcerated omentum consistent with a Morgagni diaphragmatic hernia. She underwent robotic assisted repair with acellular mesh. The patient was discharged home on the 1st postoperative day. Follow-up demonstrated resolution of her chest pain. The thoracic approach allows dissection and reduction of the hernia with safe mesh repair close to the heart. Robotic assistance offers improved vision and a more stable platform resulting in reduced pain, shortened length of hospital stay, and enhanced recovery.

References

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