it could be an incidental diagnosis in adulthood or could present with obstructive symptoms from the herniated viscera .
surgical treatment consists of direct closure or mesh placement for the diaphragmatic defect , or suturing by transabdominal or transthoracic access .
we report a patient with morgagni hernia who underwent a laparoscopic mesh placement with reduced port surgery ( rps ) .
an 85-year - old female presented in er with a 2-day history of upper abdominal discomfort and loss of appetite .
she had never experienced the same symptoms previously , and she denied any history of abdominal trauma .
physical examination revealed no palpable mass in the upper abdomen , and local tenderness on upper abdomen was shown without any peritoneal inflammatory signs .
serum blood test showed a hyperlipidemia and mild elevation of urea nitrogen ( total cholesterol , 250  mg / dl ; urea nitrogen , 22.5  mg / dl ) .
a ct scan showed a huge diaphragmatic anterior hernia with a segment of transverse colon and fat tissue migration ( fig .
the diagnosis of morgagni hernia was made and the patient was considered for repair of the diaphragmatic defect by the laparoscopic approach . under general anesthesia in the lithotomy position , the sils port ( covidien , tokyo , japan ) was inserted into a 2.5-cm umbilical incision vertically .
after inspection of the visceral space , a second port , 12  mm in size , was inserted into the left lower abdomen .
the herniated bowel and fat tissues were gently pulled down with grasping forceps and placed entirely into the abdominal cavity ( fig .
the defect was ovoid and approximately 5  cm in size , and difficult to close by the suturing technique ; therefore we performed mesh placement with gore - tex dual mesh ( gore inc .
operation time and operative blood loss were 157  min and 5  ml , respectively .
the patient started to eat a soft meal on day 1 after surgery and was discharged from our hospital on day 8 after surgery without any symptoms .
after 6-month , 12-month , and 24-month follow - ups , the patient had no sign of recurrence of the morgagni hernia ( figs . 4 and 5 ) .
giovanni - battista morgagni first described this type of hernia in 1769 . at present ,
it could be an incidental diagnosis in adulthood or could present with obstructive symptoms of the herniated viscera .
surgical treatment is required to relive current symptoms or to prevent possible future complications such as strangulation ileus or incarceration .
originally , direct closure of the hernia site or mesh placement was used as the surgical options by laparotomy or thoracotomy .
recently , the laparoscopic procedure has become available to treat this type of hernia and has bought a number of advantages such as reduced pain , shorter recovery time , and cosmetic benefits .
in addition , recent trends in laparoscopic procedures have been toward minimizing the number of incisions to achieve less invasiveness .
examples of such approaches are single incision laparoscopic surgery ( sils ) and reduced port surgery ( rps ) .
only one report previously described morgagni hernia repair using single port access and closing the hernia site by non - absorbable suturing into extra - abdominal region .
this report was very successful , however postoperative pain might be occurred because of suturing tension by lifting the interrupted sutures to close the hernia site .
some technical problems associated with sils have been reported : restriction of the working field and interference of surgical instrument .
the sils technique does not rely on triangulation , which is one of the core principles of conventional laparoscopic surgery , allowing adequate operative exposure while maintaining an ergonomic position for the surgeon and assistant .
consequently , the inherent technical challenge that arises from the sils technique is that of a compromised view and locomotive field . therefore unfavorite outcomes such as longer operative time and possibly higher complication rate have been reported in early period of sils operation .
a small additional port or a reduced number of ports as with rps are modifications that may overcome these problems . in combination with the sils port and the additional port
enable the performance of dual - port surgery , even for complex operation such as laparoscopic gastrectomy .
this type of repair is technically easy and should have a high probability of success because of the  tension free  condition .
also , less postoperative pain is also expected , compared to the external knot tying technique .
thoracoscopic approach is also other option for this type of hernia as a less invasive treatment , although the benefits over conventional laparoscopic approach have not been cleared .
although the benefits of sils or rps over conventional laparoscopic surgery have not been established , either sils or rps could be the first choice for symptomatic morgagni hernia repair because of the acceptable operation time , blood loss , and clinical outcome .
basically , cosmetic benefits and less operative pain are also expected as advantages of sils or rps originating from fewer incisions . in addition , tissue trauma and port - related complications such as organ damage , adhesions , bleeding , wound infections and hernias could be decreased . for the future direction , additional
this approach is safe and can be the good indication for this kind of hernia .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
 highlightsmorgagni hernia is a rare diaphragmatic hernia and standard therapy has not been established.the laparoscopic repair of a rare diaphragmatic morgagni hernia in an elder patient using the reduced port approach is described.this reduced port approach is a good indication for this type of hernia because of less invasive ness , cosmetics and safety . 