Management of Morris Space (Hepatorenal Recess) Hernia
Surgical repair is the definitive treatment for Morris space hernias, with primary closure using non-absorbable sutures as the first-line approach, and mesh reinforcement required for defects larger than 3 cm to prevent the high 42% recurrence rate associated with suture repair alone. 1
Surgical Approach
Laparoscopic exploration is strongly recommended as the preferred surgical approach for Morris space (hepatorenal recess) hernias, particularly in hemodynamically stable patients, as it allows for comprehensive evaluation of all potential internal hernia sites while offering lower morbidity and faster recovery compared to open surgery. 1
Key Operative Steps
Begin exploration from the ileocecal valve and work proximally, as the bowel distal to the obstruction is less dilated and can be handled more safely during laparoscopic manipulation. 1
Reduce the hernia contents carefully before assessing bowel viability—internal hernias can be more easily reduced from distal to proximal where intestinal loops are less distended. 1
Perform primary closure of the defect using interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers when the defect edges can be approximated without excessive tension. 1
Close all mesenteric defects with non-absorbable sutures after reducing the hernia to prevent recurrence. 1
Mesh Reinforcement Criteria
Mesh reinforcement is mandatory for defects larger than 3 cm or when primary closure would create excessive tension, as primary repair alone carries a very high recurrence rate of 42%. 1, 2
Mesh Selection
Biosynthetic, biologic, or composite meshes are preferred over synthetic meshes due to lower hernia recurrence rates, higher resistance to infections, and lower risk of displacement. 1, 2
In clean-contaminated fields (such as when bowel resection is required), mesh can be safely used with no significant difference in infection rates compared to non-mesh repair. 3
Polytetrafluoroethylene (PTFE) mesh is recommended when synthetic mesh is chosen, as it does not adhere to bowel and reduces the risk of bowel fistulation. 1
Assessment of Bowel Viability
Indocyanine green (ICG) fluorescence angiography should be used to evaluate intestinal perfusion and define resection margins more accurately when bowel viability is questionable. 1
Perform bowel resection with primary anastomosis if vascular compromise or necrosis is identified. 1
Emergency Considerations
Damage control surgery is indicated in patients with intraoperative instability, hypothermia, coagulopathy, significant acidosis, or when the defect cannot be closed definitively. 1
Common Pitfalls
Do not attempt primary closure if the distance between the defect edge and the chest wall/anatomical attachment point exceeds 3-4 cm, as this creates excessive tension and dramatically increases recurrence risk. 1
Avoid delaying surgical exploration in suspected internal hernias, as late diagnosis leads to intestinal vascular compromise and necessitates bowel resection. 1
Do not overlook other potential causes of obstruction (adhesions, intussusception, volvulus) if no internal hernia is found during initial exploration—the entire small intestine should be assessed. 1