title: Transthoracic repair of Morgagni's hernia: a 20-year experience from open to video-assisted approach.
abstract: BACKGROUND
  Foramen of Morgagni's hernia is an uncommon congenital diaphragmatic hernia. Repair is mostly performed through laparotomy. We prefer the transthoracic approach, which allows better and safer control during thoracic dissection, although it is considered more painful and related to greater morbidity. In recent years we introduced the transxiphoid hand-assisted videothoracoscopic approach, which combines the advantages of the thoracic route with a mini-invasive procedure facilitated by one hand inside the chest.
  
  
  METHODS
  A retrospective review was performed over a 20-year period (1985-2005). Twenty-two patients who had a foramen of Morgagni's hernia repaired were identified and relevant data were collected. Average age was 57 +/- 10 years and one half of the patients were asymptomatic. Chest roentgenograms, chest computerized tomography, and barium enema were used as diagnostic utilities. Posterolateral thoracotomy was performed in 17 (15 right-sided) patients, whereas in 5 (all right-sided) the defect was repaired by transxiphoid hand-assisted videothoracoscopy. Operative time, pain scored by visual analog scale, hospital stay, and cosmetic results by acceptance score were reviewed for every patient.
  
  
  RESULTS
  Hernial sac was present in all cases and contained only omentum (n = 13), omentum plus transverse colon (n = 7), omentum plus transverse colon and small bowel (n = 2). In 6 patients (2 videothoracoscopy) we repaired the large defects with polypropylene mesh. Videothoracoscopy achieved significant good results compared to thoracotomy in operative time (85 +/- 7.9 versus 110 +/- 11.3 min, p < 0.01), 24-h visual analog scale (3.5 +/- 1.1 versus 6.7 +/- 3.9, p < 0.01), hospital stay (2.6 +/- 0.5 versus 6.4 +/- 1.2 days, p < 0.01), and acceptance score (4.3 +/- 0.5 versus 3.1 +/- 0.8, p < 0.05). Postoperative course was always uneventful. Patients were followed for an average period of 58.6 +/- 14.7 and 109.7 +/- 43.5 months, respectively: no recurrences were found in any group.
  
  
  CONCLUSIONS
  We believe that the transthoracic approach is a safe and effective method for repairing Morgagni's hernia. The videothoracoscopic approach is a promising alternative and it may be facilitated by introducing a hand inside the chest.
authors.affiliation: Department of Thoracic Surgery, Tor Vergata University, Viale Oxford 81, 00133, Rome, Italy. ambrogi@med.uniroma2.it
authors.forename: V
authors.initials: V
authors.lastname: Ambrogi
authors.forename: D
authors.initials: D
authors.lastname: Forcella
authors.forename: A
authors.initials: A
authors.lastname: Gatti
authors.forename: G
authors.initials: G
authors.lastname: Vanni
authors.forename: T C
authors.initials: TC
authors.lastname: Mineo
mesh_terms: D000328:Adult; D000368:Aged; D017558:Elective Surgical Procedures / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006548:Hernia, Diaphragmatic / Q000175:diagnosis / Q000601:surgery*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011183:Postoperative Complications / Q000503:physiopathology; D011336:Probability; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects / Q000379:methods*; D013906:Thoracoscopy / Q000379:methods; D013908:Thoracotomy / Q000379:methods*; D016896:Treatment Outcome