morgagni foramen is a para - retrosternal defect resulting from an incomplete fusion of the septum transversum and sternum with the anterior ribs .
surgical treatment consists of direct closure of the diaphragmatic defect , suturing by transabdominal or transthoracic access .
we report a patient with hernia of morgagni who underwent a laparoscopic reduction and diaphragmatic defect closure .
a formerly healthy , 69-year - old woman was seen at our department in february 1995 because of epigastric pain and subocclusive symptoms for nine months .
a computed tomography showed a gross diaphragmatic anterior hernia with partial right and transverse colon migration ( figure 1 ) .
the diagnosis of hernia of morgagni was made , and the patient was considered for repair of the diaphragmatic defect by the laparoscopic approach .
the herniated bowel was gently pulled down with grasping forceps and placed entirely into the abdominal cavity ( figures 2 , 3 and 4 ) .
the defect was ovoid and was closed with interrupted polyester stitches ( ethibond - ethicon ) using the external knot - tying technique .
trocars were retrieved under direct endoscopic vision , and the fascial incision was closed with glycolic acid ( vicryl - ethicon ) . a chest xray showed the successful laparoscopic closure of the diaphragmatic defect ( figure 6 ) .
laparoscopic view of hernia of the foramen of morgagni containing colon and omentum . colon and omentum
chest x - ray done after operation , showing no evidence of morgagni 's hernia .
after 12 , 24 , 36 and 48 months follow - up , the patient was symptom - free , without recurrence of her morgagni 's hernia ( figure 7 ) .
chest x - ray done four years after the laparoscopic repair , showing no evidence of hernial recurrence .
a formerly healthy , 69-year - old woman was seen at our department in february 1995 because of epigastric pain and subocclusive symptoms for nine months .
a computed tomography showed a gross diaphragmatic anterior hernia with partial right and transverse colon migration ( figure 1 ) .
the diagnosis of hernia of morgagni was made , and the patient was considered for repair of the diaphragmatic defect by the laparoscopic approach .
the herniated bowel was gently pulled down with grasping forceps and placed entirely into the abdominal cavity ( figures 2 , 3 and 4 ) .
the defect was ovoid and was closed with interrupted polyester stitches ( ethibond - ethicon ) using the external knot - tying technique .
trocars were retrieved under direct endoscopic vision , and the fascial incision was closed with glycolic acid ( vicryl - ethicon ) . a chest xray showed the successful laparoscopic closure of the diaphragmatic defect ( figure 6 ) .
chest x - ray done after operation , showing no evidence of morgagni 's hernia .
after 12 , 24 , 36 and 48 months follow - up , the patient was symptom - free , without recurrence of her morgagni 's hernia ( figure 7 ) .
chest x - ray done four years after the laparoscopic repair , showing no evidence of hernial recurrence .
the defect is usually small and contains a sac with herniated omentum , transverse colon and , more rarely , liver , small bowel and stomach .
acute symptoms are rare and are almost always due to large bowel obstruction . in infants , respiratory distress and cyanosis
plain roentgenograms usually differentiate the hernia of foramen of morgagni from other masses ( lung or mediastinal tumors , pericardial fat pad , pleural , pericardial , mediastinal or diaphragmatic cyst ) or pathologies ( atelectasis , pneumonia ) .
barium enema , computed tomography and magnetic resonance may be required to confirm the diagnosis .
although complications are rare , because of potential strangulation , hernia of morgagni foramen should be repaired .
after viscera reduction into the abdominal cavity , the sac can or can not be excised .
both the laparotomic and thoracotomic approach require a long postoperative recovery period , with significant mortality and a prolonged rehabilitation period .
conversely , the laparoscopic approach for treatment of morgagni hernia results in an immediate return to normal diet and activities . literature review of laparoscopically treated morgagni 's hernia is reported in table 1 . regarding
the technique of defect closure , in a previous report kuster has underlined that the hernial sac does not needed to be removed .
this removal , in fact , may result in massive pneumomediastinum with potential respiratory and circulatory complications . in kuster 's technique , the diaphragmatic defect was closed by a nonabsorbable monofilament with continuous suture joining the subcostal and retrosternal peritoneum to the full thickness of the diaphragmatic edge . then the suture was percutaneously brought back anteriorly to the abdomen .
a 2-cm skin incision was made , through which the two ends of the suture were tied in subcutaneous tissue .
more recently , fernandez - cebrian has described a patient in whom the hernial sac was removed without complications .
also , in this case , the defect was repaired with a continuous suture , but with intra - abdominal knotting . in our own experience ,
the sac was not removed to avoid the unacceptable risk of damage to the pericardium and/or the mediastinic or diaphragmatic pleura .
cases of fatal pneumopericardium have been reported after dissection of the peritoneal sac in children .
we preferred to close the defect with interrupted nonabsorbable suture using an extra - abdominal knot - tying technique .
in fact , in our own experience and in the literature , it has been noted that separate stitches are preferable to avoid tissue tearing .
moreover , extracorporeal knotting has been shown to be easier to perform and is less time consuming than intracorporeal techniques . the drainage is generally left in place of an empty cavity , according to traditional principles of general surgery . probably , it is not useful , but , since we did not have any previous experience with this kind of operation , a prudential approach was preferred .
rau in 1994 , huntington in 1996 , orita in 1997 , and del castillo in 1998 reported a successfully repaired laparoscopic morgagni hernia by stapling a mesh prosthesis .
rau did resect a peritoneal sac , and the prosthesis was covered with a flap of falciform ligament and with ligament teres .
huntington did not resect the sac , and the prosthesis was covered by a peritoneal reflection obtained by a peripherical incision for several centimeters around the defect . in the orita experience also , the sac was not removed , and the operation was conducted by a gas - less approach to facilitate the suturing technique .
vinard , in 1997 , presented a case that allowed satisfactory surgical repair by simple closure of the hernial orifice with a running suture . because of the lack of experience reported in the literature , it is not possible to define whether or not mesh placement is better than a suture for closing the morgagni 's hernia .
it is , however , noteworthy that the classic repair by the laparotomic approach is the direct suture of the linear hernial orifice .
moreover , laparoscopic repair can be successfully associated with other procedures , such as cholecystectomy .
follow - up of operated patients was reported only by some authors and only in one case for 24 months .
it is not known whether or not patients were recurrence free after longer follow - up . in the patient
herein reported , follow - up was done for more than four years and showed the absence of symptoms or recurrence .
incidental ; preop = preoperative ; nr = not reported ; y = yes ; n = non ; rs = running suture ; ss = separate stitches ; a = stapled agraphes ; d = drainage .
independently from the laparoscopic surgical technique used , literature data and our own experience indicate that the therapeutic and rehabilitative advantages that are well proved for cholecystectomy and other videolaparoscopic procedures with respect to a laparotomic approach can be extended to patients with hernia of foramen of morgagni as well .
 the videolaparoscopic repair of a diaphragmatic hernia of morgagni by external knot tying technique is described . a 69-year - old woman with subocclusive symptoms by intrathoracic migration of abdominal viscera 
 had an immediate and complete postoperative recovery . 
 the hernial sac was not excised . 
 a four - year follow - up shows no hernia recurrence . 
 this case indicated that the laparoscopic approach can be considered a suitable and safe procedure for treatment of morgagni 's hernia . 
INTRODUCTION
CASE REPORT
Case History
Laparoscopic Procedure
Follow Up
DISCUSSION
CONCLUSIONS