What is the treatment for Morgagni's hernia?

Treatment of Morgagni's Hernia

Laparoscopic surgical repair is the recommended treatment for Morgagni's hernia due to lower morbidity rates (5%) compared to open approaches (17%) and shorter hospital stays. 1, 2

Diagnostic Approach

• CT scan of chest and abdomen is the gold standard for diagnosing Morgagni's hernia 1
• Chest X-ray and contrast studies of the upper GI tract may also be used in the diagnostic workup 3
• Most patients present with:
  • Respiratory symptoms (35.7%) 2
  • Gastrointestinal symptoms (28.6%) 2
  • Some patients may be asymptomatic with incidental findings 4

Surgical Management Algorithm

1. Preoperative Considerations

• Surgical repair is indicated once diagnosis is made, even in asymptomatic patients, due to risk of incarceration 5, 3
• Preoperative preparation should include:
  • Fluid resuscitation if needed
  • Broad-spectrum antibiotics if strangulation is suspected
  • NPO status 6

2. Surgical Approach Selection

• Hemodynamically stable patients: Laparoscopic approach preferred

  • Benefits: Lower morbidity (5%), shorter hospital stay, less postoperative pain 1, 2
  • Average operative time: 61 minutes 6

• Hemodynamically unstable patients: Open repair (laparotomy or thoracotomy)

  • Indicated for patients with peritonitis, bowel compromise, or hemodynamic instability 6, 3
  • May be necessary for very large defects or when bowel resection is anticipated 6

3. Repair Technique

• For small defects (<3 cm):

  • Primary tissue repair with non-absorbable sutures 6, 5

• For larger defects (>3 cm or >20 cm²):

  • Mesh repair recommended 1
  • Mesh should overlap defect edges by 1.5-2.5 cm 1
  • Mesh can be fixed using tackers or transfascial sutures (avoid tackers near pericardium) 1

• Additional procedures to consider:

  • Fundoplication if patient has history of gastroesophageal reflux 1
  • Gastropexy if gastric volvulus is present 1

Postoperative Care

• Monitor for at least 24 hours focusing on:

  • Hemodynamic stability
  • Surgical site complications
  • Respiratory function 6

• Pain management:

  • First-line: Acetaminophen 500-1000 mg every 6 hours (max 4000 mg/day)
  • Second-line: Tramadol 50-100 mg every 6-8 hours if needed
  • Avoid NSAIDs due to bleeding risk 6

Outcomes and Complications

• Recurrence rates are low (2.3%) regardless of surgical approach 2

• Potential complications include:

  • Wound infection (4-12%)
  • Incisional/port site hernia
  • Respiratory complications (atelectasis)
  • Bleeding
  • Ileus 1, 6, 2

• Improvement in lung function can be expected postoperatively 3

Follow-up Care

• Monitor for recurrence and complications
• Patient education regarding signs of recurrence or complications
• Gradual return to normal activities as tolerated 6

Clinical Pearls and Pitfalls

• Recurrence risk is increased with:

  • Use of absorbable sutures
  • Suture tension
  • Improper fixation of prosthetic material
  • Prolonged ileus
  • Poor chest toileting
  • Intra-abdominal sepsis 1

• Mesh repair is associated with lower recurrence rates compared to primary repair in larger defects 6

• Early intervention (<6 hours from symptom onset) is associated with better outcomes when strangulation is present 6