a 12-year - old female visited the hospital with the chief complaint of an abnormal finding on a simple chest x - ray .
a discontinuity of the diaphragm was observed in the retrosternal portion by chest ct and mesenteric fat was herniated through this discontinuity ( fig .
the lack of an intestinal hernia was confirmed by barium esophagography , and there was no finding of incarceration .
although the patient was 12 years old , her height was above average for her age at 164 cm .
thus , it was determined to perform a laparoscopic procedure considering that the surgical space for the laparoscopic procedure would be large enough , given her height .
a 10-mm 30 degree laparoscope was inserted through an upper umbilical incision . to insert additional surgical instruments , a 10-mm troca was inserted through the left flank , the right lower rib , and the right flank incision .
the diaphragm injury was observed on the left side of the falciform ligament in the peritoneal cavity ( fig .
the great omentum and fat from the falciform ligament were put in the thoracic cavity .
the great omentum , which was pushed into the thoracic cavity by the diaphragm injury , was recovered .
the falciform ligament was separated from the margin of the thoracic wall to secure space for the operation .
after resection of adipose tissue from the falciform ligament , the hernia sac was closed by tying up the mediastinal pleura and the right diaphragm as is done for plication . to avoid creating a dead space in the pleura cavity , an incision of about 1 cm was made in the mediastinal pleura before tie - up to make the dead space disappear by inflation of the lung .
the right margin of the diaphragm defect was stretched in the lateral direction to adjust the edge of the diaphragm .
a chest tube was inserted to treat a pneumothorax which occurred right after the operation .
the patient was discharged on the third day after the surgery without special complications , and her progress was observed in the outpatient department ( fig .
morgagni hernias , which are the rarest type among the congenital diaphragmatic hernias , comprise 3~5% of all diaphragmatic hernias .
however , other cases are found in adulthood and pregnancy , the latter of which makes abdominal pressure increase because it is usually asymptomatic . according to the research of comer et al .
acute symptoms form in only 14% of cases ; however , surgical treatment should be considered because there is a risk of incarceration by an intestinal hernia .
in addition , this approach has an advantage in case of adhesion between the pericardia and lungs .
on the other hand , disadvantages of this approach are that it is difficult to repair bilateral hernias and to diagnose the obstruction of intestin .
herniated organs can be returned to their original places easily with an approach through the abdomen .
particularly , this approach should be used in case of bilateral and central hernias , and combined abnormalities in the abdomen .
therefore , to prevent excessive pressure on the intestine , the diaphragm injury lesion should be anchored retrosternally .
however , the argument for the minimally invasive surgical technique still stands because this procedure is difficult . to compliment this procedure
, the method in which the diaphragm defect is sutured on the abdominal wall and the suture is fixed to the subcutaneous layer of the abdominal wall has been developed . in the present case ,
a horizontal procedure with laparoscopy to treat a morgagni hernia is not a difficult method .
however , follow up for cases of pregnancy and trauma , which cause an increase in abdominal pressure , is essential .
 a 12-year - old female presented with the abnormal findings on the chest pa . 
 the chest ct revealed a retrosternal defect of the diaphragm and a fatty opacity in the pleural cavity , resulting in a diagnosis of morgagni hernia . 
 it was decided to undergo a laparoscopic surgery . 
 the retrosternal defect of the diaphragm measuring 3.5 cm in diameter was found , through which a portion of the greater omentum and the fatty tissue connected with the falciform ligament were herniated into the pleural cavity . 
 the greater omentum was pushed back into the peritoneal cavity and the fatty tissue connected with falciform ligament was excised . 
 the mediastinal pleura was plicated and the defect of the diaphragm was repaired primarily . immediately after the operation , the patient developed a right pneumothorax for which a chest tube was inserted . 
 she was discharged at the post - operative third day without any further complications . 
CASE REPORT
DISCUSSION