AbstractIntroductionMorgagni’s or Larrey’s diaphragmatic hernias are relatively uncommon. If the defect is too large for primary closure, the use of a mesh is inevitable. Although primary closure is adaptable for relatively small defects, it is difficult to suture the hernial orifice in which the anterior rim is absent. Herein, we present the case of a patient with Larrey’s diaphragmatic hernia that was easily and securely repaired using the recently developed laparoscopic extra-abdominal suturing technique via the port closure needle (Endo Close®; Medtronic, Minneapolis, USA).Presentation of caseAn 89-year-old woman complaining of vomiting was transferred to our hospital. Computed tomography scan showed Larrey’s diaphragmatic hernia. Laparoscopic repair was performed after gastric decompression. We diagnosed Larrey’s hernia on the left side of the falciform ligament. The transverse colon was herniated through the defect. Since the hernial defect was located below the substernal space, there was no tissue to stitch at the anterior rim of the hernial orifice. We performed the extra-abdominal suturing technique, suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall using the port closure needle (Endo Close®) without the need for a mesh. The patient was discharged on the 8th postoperative day. There was no evidence of recurrence at 8 months postoperatively.DiscussionThe recently developed extra-abdominal suturing technique using Endo Close® to suture the full thickness of the anterior abdominal wall achieved secure mattress suture and easy extra-abdominal tying.ConclusionThis method may be useful in terms of easiness and security of suture

Adachi, Tomohiro

Fujikuni, Nobuaki

Hotta, Ryuichi

Misumi, Toshihiro

Ohdan, Hideki

Saeki, Yoshihiro

Takehara, Hiroki

Tanabe, Kazuaki

Yamamoto, Yuji

International Journal of Surgery Case Reports

Elsevier - Publisher Connector 

Laparoscopic extra-abdominal suturing technique for the repair of Larrey’s diaphragmatic hernia using the port closure needle (Endo Close®): A case report 

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cCASE  REPORT  –  OPEN  ACCESS
International Journal of Surgery Case Reports 28 (2016) 34–37
Contents lists available at ScienceDirect
International  Journal  of  Surgery  Case  Reports
j ourna l h om epage: www.caserepor ts .com
aparoscopic  extra-abdominal  suturing  technique  for  the  repair  of
arrey’s  diaphragmatic  hernia  using  the  port  closure  needle  (Endo
lose®):  A  case  report
uji  Yamamoto,  Kazuaki  Tanabe ∗,  Ryuichi  Hotta,  Nobuaki  Fujikuni,  Tomohiro  Adachi,
oshihiro  Misumi,  Yoshihiro  Saeki,  Hiroki  Takehara,  Hideki  Ohdan
epartment of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical & Health Sciences, Hiroshima University, 1-2-3,
asumi, Minami-ku, Hiroshima 734-8551, Japan
 r  t  i  c  l e  i  n  f  o
rticle history:
eceived 22 July 2016
eceived in revised form
1 September 2016
ccepted 11 September 2016
vailable online 21 September 2016
eywords:
arrey’s hernia
orgagni’s hernia
iaphragmatic hernia
aparoscopic repair
xtra-abdominal suturing technique
a  b  s  t  r  a  c  t
INTRODUCTION:  Morgagni’s  or Larrey’s  diaphragmatic  hernias  are  relatively  uncommon.  If the  defect  is
too  large  for  primary  closure,  the  use of  a mesh  is  inevitable.  Although  primary  closure  is  adaptable  for
relatively  small  defects,  it is  difﬁcult  to  suture  the  hernial  oriﬁce  in which  the  anterior  rim is  absent.
Herein,  we present  the case  of  a patient  with  Larrey’s  diaphragmatic  hernia  that  was  easily  and  securely
repaired  using  the  recently  developed  laparoscopic  extra-abdominal  suturing  technique  via the  port
closure  needle  (Endo  Close®; Medtronic,  Minneapolis,  USA).
PRESENTATION  OF  CASE:  An  89-year-old  woman  complaining  of  vomiting  was  transferred  to our hospital.
Computed  tomography  scan  showed  Larrey’s  diaphragmatic  hernia.  Laparoscopic  repair  was  performed
after gastric  decompression.  We  diagnosed  Larrey’s  hernia  on  the  left  side  of  the falciform  ligament.
The  transverse  colon  was  herniated  through  the  defect.  Since  the  hernial  defect  was  located  below  the
substernal  space,  there  was  no  tissue  to  stitch  at the anterior  rim  of the  hernial  oriﬁce.  We  performed  the
extra-abdominal  suturing  technique,  suturing  the  posterior  rim  of  the  hernia  to  the full  thickness  of the
anterior  abdominal  wall  using  the port  closure  needle  (Endo  Close®) without  the  need  for a mesh.  The
patient  was  discharged  on  the  8th postoperative  day. There  was  no evidence  of  recurrence  at  8  months
postoperatively.
DISCUSSION:  The  recently  developed  extra-abdominal  suturing  technique  using  Endo  Close® to  suture  the
full thickness  of  the  anterior  abdominal  wall  achieved  secure  mattress  suture  and  easy  extra-abdominal
tying.
CONCLUSION:  This  method  may  be  useful  in  terms  of easiness  and  security  of suture.
©  2016  The  Authors.  Published  by Elsevier  Ltd  on  behalf  of IJS  Publishing  Group  Ltd.  This  is an  open
he CCaccess  article  under  t
. Introduction
Morgagni’s or Larrey’s diaphragmatic hernias are relatively
ncommon. Surgical repair is indicated in symptomatic patients,
nd asymptomatic patients who are at risk of incarceration or stran-
ulation. If the defect is too large for primary closure, the use of a
esh is inevitable. Although primary closure is adaptable for rela-ively small defects, it is technically difﬁcult to suture the hernial
riﬁce in which the anterior rim is absent. A variety of repairing
echniques have been described to address this problem. Herein,
∗ Corresponding author.
E-mail addresses: ktanabe2@hiroshima-u.ac.jp (K. Tanabe),
otta.kuma@gmail.com (R. Hotta), bfxfw264@yahoo.co.jp (N. Fujikuni),
dachitomohiro@hotmail.com (T. Adachi), lupinn3sei@yahoo.co.jp (T. Misumi),
twtwxaslikexth@ybb.ne.jp (Y. Saeki), turimeijinn82@yahoo.co.jp (H. Takehara),
ohdan@hiroshima-u.ac.jp (H. Ohdan).
ttp://dx.doi.org/10.1016/j.ijscr.2016.09.010
210-2612/© 2016 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing G
reativecommons.org/licenses/by-nc-nd/4.0/). BY-NC-ND  license  (http://creativecommons.org/licenses/by-nc-nd/4.0/).
we present the case of a patient with Larrey’s diaphragmatic her-
nia that was  laparoscopically repaired by the recently developed
extra-abdominal suturing technique using Endo Close® to suture
the full thickness of the anterior abdominal wall.
2. Presentation of case
An 89-year-old woman  complaining of vomiting was trans-
ferred to our hospital. She had no other associated symptoms, no
past surgical history, and no traumatic rupture of the diaphragm.
She was in a good general condition, and clinical examination was
unremarkable. No abnormalities were detected in the laboratory
investigations. Chest radiography (Fig. 1A) and computed tomog-
raphy (Fig. 1B) scan showed Larrey’s diaphragmatic hernia. Hernial
contents were transverse colon and stomach, and they showed
no ischemic changes. A few days after computed tomography and
gastric decompression, the contrast medium passed slowly to the
roup Ltd. This is an open access article under the CC BY-NC-ND license (http://
CASE  REPORT  –  OPEN  ACCESS
Y. Yamamoto et al. / International Journal of Surgery Case Reports 28 (2016) 34–37 35
Fig. 1. (A) Chest radiograph showing colonic gas above the left diaphragm in the left m
transverse colon, greater omentum, and stomach incarcerated in the left pleural cavity.
Fig. 2. (A) Laparoscopic view showing the transverse colon herniating through the
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risk of incarceration or strangulation. However, Loong et al. sug-efect on the left side of the falciform ligament. (B) The hernia content reduced into
he abdominal cavity.
mall intestine due to gastric decompression. Vomiting occurred
ecause of incarceration of the stomach in the left pleural cavity,
nd was unresponsive to conservative therapy. Therefore, laparo-
copic repair was planned.
Under endotracheal general anesthesia, the patient was  posi-
ioned in the supine position. The ﬁrst port was  inserted at the
mbilicus using an open technique. Five millimeter and 12 mm
orking ports were introduced under direct vision from the right
nd left upper quadrants at the mid  clavicular lines, respectively.
We diagnosed Larrey’s hernia based on the intraoperative
ndings of an anterior diaphragmatic defect of approximately
.0 × 4.0 cm located in the left side of the falciform ligament. The
ransverse colon was found herniating through the defect (Fig. 2A)
nd was reduced into the peritoneal cavity (Fig. 2B). The mesocolon
as adhering to the posterior rim of the defect, and was  separated
y laparoscopic coagulating shears. The stomach was not herniat-
ng through the defect intraoperatively, as it probably returned to
he abdominal cavity due to preoperative gastric decompression.
ince the hernia was located between the substernal space and the
osterior border of the diaphragm, there was no tissue to stitch at
he anterior rim of the hernial oriﬁce. Primary closure of the hernial
riﬁce was not possible; hence, we decided to suture the posterior
im of the hernia to the full thickness of the anterior abdominal wall
sing the extra-abdominal suturing technique. First, a 2-0 Proleneiddle and lower lung zones. (B) Chest computed tomography scan showing the
suture attached to a curved needle was inserted into the abdomi-
nal cavity. A horizontal mattress suture was taken at the posterior
rim of the hernia and the needle was removed from the abdom-
inal cavity. A 2-cm incision was made at the epigastrium above
the anterior border of the hernia. The port closure needle (Endo
Close®) was  inserted into the abdominal cavity, taking one end of
the Prolene suture to the outside of the abdominal cavity (Fig. 3A).
The other end was similarly removed. Following the same steps,
4 more sutures were placed and held (Fig. 3B). All 5 sutures were
tied without tension. The knots were laid in the subcutaneous tis-
sue. Closure of the hernial oriﬁce was observed (Fig. 4). No hernia
sac was removed, and using a mesh was not necessary. The oper-
ative time was  89 min. The postoperative course was uneventful.
The patient underwent rehabilitation postoperatively because of
her old age, and was discharged on the 8th postoperative day. There
was no evidence of recurrence at 8 months postoperatively.
3. Discussion
Herniation through the subcostosternal space or Morgagni-
Larry’s hernia is quite uncommon, representing only about 1% to
6% of all surgically repaired diaphragmatic hernias [1]. Morgagni’s
hernia was  ﬁrst described by Morgagni GB, an Italian anatomist, in
1761, being located through a defect in the diaphragm just behind
the sternum [2].
The hernial defect results from the failure of fusion of septum
transversum of the diaphragm and the costal arches. According to
its laterality, it is known as “Morgagni’s” or “Larrey’s” hernia for
left or right sided defects, respectively [3]. Right, left, and bilateral
hernias have incidences of 91%, 5%, and 4%, respectively [4]. Hav-
ing similar anatomical origin, they are collectively referred to as
“anterior diaphragmatic hernia of Morgagni-Larrey” [5].
Horton et al. reviewed 298 adult cases with Morgagni-Larrey’s
hernia, and reported that 28% of these patients were asymptomatic
[4]. In the same study, symptoms reported included pulmonary
symptoms (dyspnea, cough, and shortness of breath) (36%), chest
or abdominal discomfort not related to bowel obstruction (37%),
symptoms due to obstruction (20%), and dysphagia (3%). The omen-
tum (31%), colon and omentum (29%), stomach (15%), small bowel
(11%), and liver (4%) were found within the hernia.
Traditional indications for surgical repair of this hernia are
symptomatic patients, and asymptomatic patients who are at agested that if the hernia is small or contains omentum only, then
surgical repair is indicated when symptoms are recurrent and both-
ersome [7]. Surgical repair of the hernia has been accomplished
CASE  REPORT  –  OPEN  ACCESS
36 Y. Yamamoto et al. / International Journal of Surgery Case Reports 28 (2016) 34–37
Fig. 3. (A) The defect closed by the extra-abdominal suturing technique, suturing the po
Endo  Close® . (B) Placement of all 5 sutures.
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ReferencesFig. 4. Laparoscopic view showing closure of the hernial oriﬁce.
rimarily through 4 procedures: laparotomy, thoracotomy, thora-
oscopy, or laparoscopy. The review of 298 cases during 1951 to
006 reported the ratios of the 4 procedures as thoracotomy (49%),
aparotomy (30%), laparoscopy (17%), and thoracoscopy (0.7%) [4].
owever, in recent reports, laparoscopic repair has been gaining
ncreased popularity given its advantages, such as reduced pain,
horter recovery time, and cosmetic beneﬁts [8]. The defect may  be
losed either by primary sutured closure, primary placement of a
esh, or by a combination of both. Kristel De Vogelaere suggested
hat if the defect is too large for primary closure, a mesh is to be
sed [9]. Thoman et al. recommended using a mesh to avoid ten-
ion if the defect is larger than 20–30 cm2 [3], and that primary
losure is adaptable for relatively small defects. In our patient, the
efect was relatively small (16 cm2), so primary sutured closure
as adaptable. Nevertheless, the anterior rim of the hernial oriﬁce
as absent making primary closure difﬁcult. Mario Lima reported
he efﬁcacy of suturing the muscles of the abdominal wall to the
osterior rim of the hernial oriﬁce intracorporeally [10], but this
ethod requires a highly skilled surgeon. On the other hand, Kuster
11] reported an extra-abdominal suturing technique not requiring
ntracorporeal suturing, followed by reports on other related sutur-
ng techniques [9]. Akkoyun Ibrahim reported a suturing technique
or a child using an 18-gauge epidural needle [12]. In this report,
he needle was introduced into the abdominal cavity and passed
nto the posterior rim. Both ends of a 2-0 silk suture were passed
hrough this needle. This method does not require intraperitoneal
uturing, but may  be difﬁcult for adults or large hernias. In con-
rast, our extra-abdominal suturing technique using Endo Close®
chieved secure mattress suture and easy extra-abdominal tying.
his technique may  be adaptable to most cases, for example paras-
omal hernia [13], and may  be useful for other procedures such as
aparoscopic gastrostomy or gastropexy.sterior rim of the hernia to the full thickness of the anterior abdominal wall using
4. Conclusion
We  reported a case of Larrey’s diaphragmatic hernia successfully
repaired laparoscopically using Endo Close®. This technique may  be
useful in terms of easiness and security of the suture.
Conﬂicts of interest
None.
Funding
None.
Ethical approval
All procedures used in this research were approved by the Eth-
ical Committee of Hiroshima University Hospital.
Consent
Written informed consent was obtained from the patient for the
publication of this case report and any accompanying images.
Author contributions
YY and KT wrote the manuscript. KT, RH, NF and TA treated the
patient. TM,  YS, HT helped with writing the manuscript. HO was
involved in the ﬁnal editing. All authors read and approved the
manuscript.
Guarantor
Kazuaki Tanabe has accepted full responsibility for this work
and the decision to publish it.
Acknowledgement
The artwork was drawn by a special medical illustrator, Mr.
Yoshihiko Tsuda.[1] T.P. Comer, O.T. Clagett, Surgical treatment of hernia of the foramen of
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[2] G.B. Morgagni, Seats and Causes of Diseases, in: A. Millar, C. Thomas (Eds.),
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[3] D.S. Thoman, T. Hui, E.H. Phillips, Laparoscopic diaphragmatic hernia repair,
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[4] J.D. Horton, L.J. Hofmann, S.P. Hetz, Presentation and management of
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Laparoscopic extra-abdominal suturing technique for the repair of Larrey’s diaphragmatic hernia using the port closure needle (Endo Close®): A case report

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