Treatment of Morgagni Hernia
Definitive Recommendation
Surgery is mandatory for all Morgagni hernias once diagnosed, with laparoscopic repair being the preferred approach in stable patients, using mesh reinforcement to prevent recurrence. 1
Surgical Approach Algorithm
For Stable, Elective Cases:
- Laparoscopic repair is the first-line approach for uncomplicated Morgagni hernias, offering diagnostic advantages, reduced morbidity, shorter hospitalization, and improved postoperative lung function 2, 3, 4, 5
- The minimally invasive approach has an excellent safety profile with reported in-hospital mortality of 0.14% 1
- Laparoscopic technique allows for complete visualization of the defect and assessment of hernia contents 3, 4
For Emergency/Complicated Cases:
- Transabdominal laparotomy is mandatory when strangulation, incarceration, perforation, or peritonitis is present 6
- In unstable patients with complicated diaphragmatic hernias, a laparotomy approach is recommended 1
- Emergency intervention prevents progression to bowel necrosis and multi-organ failure 2, 6
Technical Repair Details
Hernia Sac Management:
- Hernia sacs are present in 92% of Morgagni hernias and should be identified 4
- Excision of the hernia sac is recommended in most cases, though some authors suggest leaving small sacs intact to avoid complications 4, 5
- The omentum and transverse colon are the most commonly herniated organs 4
Defect Closure Strategy:
- Primary repair with non-absorbable sutures should be attempted when possible for small defects 1
- Mesh reinforcement is strongly recommended for defects larger than 3 cm or when tension-free primary closure is difficult 1, 4
- Mesh should overlap the defect edge by 1.5-2.5 cm, or for defects >8 cm or >20 cm² area 1
- Synthetic mesh is the standard in clean surgical fields, associated with significantly lower recurrence rates without increased infection risk 1
Mesh Fixation:
- Intracorporeal suture placement or transfascial sutures are preferred for secure mesh fixation 1, 3
- Tackers can be used but must be avoided near the pericardium due to risk of cardiac complications 1
- Metal staples require particular care given proximity to cardiac structures 5
Location-Specific Considerations
- 90% of Morgagni hernias are right-sided, 70% occur in females 4
- Right-sided hernias may require modified approach due to liver position 1
- Left-sided hernias (10% of cases) follow the same surgical principles 4, 6
Antimicrobial Prophylaxis
Clean Cases (CDC Class I):
- Short-term prophylaxis for uncomplicated hernias without bowel compromise 1
Clean-Contaminated (CDC Class II):
- 48-hour antimicrobial prophylaxis when intestinal strangulation or bowel resection is performed without gross spillage 1
Contaminated/Dirty (CDC Classes III-IV):
- Full antimicrobial therapy for peritonitis or gross contamination 1
Expected Outcomes
Benefits of Surgical Repair:
- Improvement in basic spirometric values and lung function following elective repair 2
- Resolution of dyspnea (the most prominent symptom) 2, 4
- Prevention of life-threatening complications including strangulation and perforation 2, 6
Complications to Monitor:
- Postoperative pericarditis (can occur with anterior diaphragmatic repairs) 5
- Pulmonary complications including atelectasis 1
- Septic complications in emergency cases 6
- Recurrence (rare with proper mesh repair) 4
Critical Pitfalls to Avoid
- Never delay surgery once diagnosis is confirmed - the risk of progression to incarceration and strangulation makes early surgical treatment warranted 2, 6
- Do not use tackers near the pericardium - this can cause cardiac injury 1
- Avoid inadequate mesh overlap - ensure at least 1.5-2.5 cm overlap to prevent recurrence 1
- Do not miss the diagnosis - maintain high clinical suspicion as these hernias are often asymptomatic until complications develop 2, 4
- In emergency presentations with peritonitis, recognize that delayed diagnosis significantly increases mortality risk 2, 6