Robotic transabdominal preperitoneal Morgagni hernia repair: surgical technique

A Morgagni hernia is a rare congenital anterior diaphragmatic hernia that is often diagnosed in adults and requires surgical repair in order to avoid complications. A preoperative computerized tomography (CT) scan is recommended to assess the size of the defect and the contents of the hernia. There are various transabdominal and transthoracic surgical options for repairing these hernias but minimally invasive transabdominal approaches are usually recommended, with robotic surgery gaining popularity. The wristed instruments of the robotic platform facilitate the surgery, by allowing increased dexterity for working in the anterior mediastinum and suturing to the anterior portion of the diaphragm. The article describes in detail the technical steps of robotic transabdominal preperitoneal surgical repair including peritoneal flap creation, hernia sac reduction, defect closure and mesh placement. The self-gripping polyester mesh is advantageous in this location. Placing the mesh extraperitoneally has the added advantage of allowing minimal to no suture fixation of the mesh to the diaphragm in addition to minimizing intraperitoneal visceral adhesions. This approach is associated with reduced length of stay, faster recovery and quicker return to work. Standardization of the technique will allow better assessment of the short-term and long-term outcomes of the surgical management of this uncommon condition.