Treatment of Morgagni Hernia
Surgery is mandatory for all Morgagni hernias once diagnosed, with laparoscopic repair being the preferred approach using mesh reinforcement to prevent recurrence. 1
Surgical Approach Selection
The laparoscopic approach should be your default strategy in stable patients, offering an excellent safety profile with in-hospital mortality of only 0.14%. 2, 1 This minimally invasive technique provides:
- Significantly lower morbidity (5-6%) compared to open repair (17-18%) 2, 1
- Reduced postoperative pain and wound complications 3
- Shorter hospital stays (3-5 days average) 4
For unstable patients with complicated presentations (bowel strangulation, perforation, or septic shock), proceed directly to laparotomy to prevent abdominal compartment syndrome. 2, 1
Technical Repair Strategy
Primary Closure Technique
Always attempt primary closure first using non-absorbable sutures (2-0 or 1-0 monofilament) to approximate the diaphragm to the anterior abdominal wall fascia. 1, 5 This is feasible for small defects (<3 cm). 2, 1
Mesh Reinforcement (Critical)
Mesh reinforcement is strongly recommended for all Morgagni hernias, particularly for defects >3 cm or when tension-free primary closure is difficult. 1, 5 The evidence is compelling:
- Synthetic mesh in clean surgical fields significantly reduces recurrence without increasing infection risk 2, 1
- Primary repair alone carries a 42% recurrence rate 6
- Mesh must overlap the defect edge by 1.5-2.5 cm 2, 1
For defects >8 cm or area >20 cm², mesh interposition is mandatory. 2, 1
Mesh Selection by Contamination Level
- Clean field (CDC Class I): Synthetic mesh is standard 2, 1
- Clean-contaminated/contaminated fields (CDC Class II-III): Biosynthetic or biologic meshes are preferred 2, 1
- Dirty field (CDC Class IV): Consider delayed repair or biologic mesh 2
Fixation Technique
Secure the mesh using either tackers or transfascial sutures. 2 Critical pitfall: Never use tackers near the pericardium due to risk of cardiac injury. 2, 1 This is a potentially fatal complication that is entirely preventable.
Location-Specific Considerations
Right-sided Morgagni hernias (more common) may require modified approach or combined thoracic access due to liver position limiting visualization and repair. 2, 1 Be prepared to convert or add a thoracic approach if laparoscopic exposure is inadequate.
Antimicrobial Prophylaxis Protocol
- Uncomplicated hernia without bowel compromise: Short-term prophylaxis only 2, 1
- Intestinal strangulation or bowel resection without spillage (CDC Class II): 48-hour antimicrobial prophylaxis 2, 1
- Gross enteric spillage or peritonitis (CDC Class III-IV): Full antimicrobial therapy 2
Management of Hernia Sac
The decision to excise or reduce the hernia sac remains controversial. 7 In practice, reduction without excision is acceptable and avoids potential pleural or pericardial injury, which occurred in one reported case. 8
Expected Complications
Be vigilant for:
- Pulmonary complications (most common): Atelectasis is frequent postoperatively 2, 1
- Pleural or pericardial effusion (may require drainage) 8
- Surgical site infection, bleeding, ileus 2
- Recurrence: Primarily due to inadequate mesh overlap, absorbable suture use, or improper fixation 2, 1
Critical Pitfalls to Avoid
- Inadequate mesh overlap (<1.5 cm) leads to recurrence through host-prosthesis interface failure 2, 1
- Using absorbable sutures for primary repair increases recurrence risk 2
- Tacker placement near pericardium risks cardiac complications 2, 1
- Primary repair alone in obese patients has unacceptably high recurrence rates 5
Outcomes
With proper technique, laparoscopic repair achieves excellent results with minimal recurrence when mesh reinforcement is used. 4, 5 The combination of primary closure plus mesh buttressing is particularly effective in obese patients who have higher baseline recurrence risk. 5