Inguinal hernia--which method leads to the goal? Endoscopic and open surgical procedures are available

In recent years, the methods available for repair of inguinal hernia have greatly expanding, resulting in confusion as to what constitutes a suitable choice. Is it to be laparoscopy or open surgery, plastic mesh yes or no, general anesthesia or local anesthesia? Bassini's operation has now been ousted by the Shouldice procedure, which is suitable for all primary forms of hernia. The Lichtenstein procedure is readily and rapidly carried out under local anesthesia, making it suitable for use in multimorbid and old patients; the recurrence rate is low. The laparoscopic approach can be recommended for patients who, for private or occupational reasons need to be up and about again as soon as possible. It is also particularly suitable for the treatment of recurrent hernias or for the simultaneous repair of bilateral hernias. Disadvantages are the high costs, a lack of long-term results and unusual complications that are not seen in open surgery.     

From Bassini to tension-free mesh hernia repair. Review of 1409 consecutive cases

The short and long-term results of traditional and tension-free inguinal hernia repairs have been assessed in three surgical units. In order to standardise the results, hernias were classified according with Nyhus. There were 109 type I, 311 type II, 854 type III, and 125 type IV hernias. Follow-up was possible in 1201 patients (1249 hernia repairs). Postoperative course, postoperative pain, and recurrences were analysed. Recurrences ranged from 0.7% up to 9.3%. The tension-free methods of repair provided the most important advantages in term of low recurrence rate and early return to work even if, in our series, recurrences resulted mainly related to the type of hernia than to the type of repair. The Authors conclude that any hernia repair should be sized to the type of hernia defect in order to avoid over-treatment and abusive placing of a foreign body such as polypropylene mesh.     

The medical demands of the special athlete

BACKGROUND AND AIMS: Before choosing between open and laparoscopic preperitoneal tension-free repair, a study comparing their safety and short-term outcome was needed. No randomised studies comparing the two hernia repair techniques have hitherto been published. MATERIAL AND METHODS: A prospective randomised study was carried out comparing laparoscopic transabdominal preperitoneal mesh herniorrhaphy (n = 24) to open preperitoneal mesh herniorrhaphy (n = 25). RESULTS: When comparing unilateral repairs, the mean operation time was significantly (P < 0.01) shorter in the open group (55 min) than in the laparoscopic group (66 min). Pain on movement (P < 0.05) and pain on coughing (P < 0.01) receded more rapidly in the laparoscopic group. The median time before return to work or normal activity was 7 days (range 1-60) in laparoscopic and 5 days (1-30) in open repair. There were five (21%) complications associated with the laparoscopic procedure, while the open procedure resulted in two (8%) complications. After a median follow-up of 18 months the recurrence rate in the laparoscopic group was 13% and in the open group 8%. CONCLUSIONS: In this study the open method was associated with fewer complications and recurrences than the laparoscopic technique. Despite the decreased postoperative discomfort after laparoscopic repair, there was no significant difference in median time before return to work or normal activity. These results together with the higher cost of the laparoscopic procedure suggest that the open method is more suitable at least for unilateral hernias.     

Laparoscopic repair and groin hernia surgery

Over the past 15 years, laparoscopic herniorrhaphy has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills in the surgical community, many surgeons are now faced with the question of when to recommend laparoscopic herniorrhaphy to their patients. A surgeon's best hernia repair is the one with which they have had the greatest experience. This results in the lowest recurrence and complication rate in his or her hands. Certainly, simple, unilateral hernias and bilateral hernias can be repaired with either anterior or laparoscopic techniques. Many times, laparoscopic herniorrhaphy is too much surgery for a young patient with a unilateral hernia. In such a case, repair is best performed with the patient under local anesthesia. Also, young patients in whom it is advantageous to avoid mesh should not undergo laparoscopic herniorrhaphy. The authors prefer laparoscopic TEP herniorrhaphy in patients with recurrent hernias, bilateral hernias, and unilateral hernias with a suspected contralateral hernia. There is also a consensus that patients with multiple recurrent hernias in whom a preperitoneal repair is appropriate are best served with a laparoscopic repair. Surgeons without advanced laparoscopic skills or without the time to develop the skills necessary to perform laparoscopic herniorrhaphy should consider referring patients with recurrent hernias to surgeons with experience in TEP. TEP is preferable to TAPP because of its lower complication and recurrence rates and in the authors' hands is the "best repair." TAPP should be reserved for patients with prior lower abdominal wall incisions that make the dissection of the peritoneum from the underside of the incision impossible. Patients who cannot tolerate general anesthesia or who have had extensive lower abdominal surgery should not undergo laparoscopic herniorrhaphy. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are adequately trained and proctored, laparoscopic herniorrhaphy can be performed with acceptably low incidences of recurrence and complications.     

Laparoscopic repair of recurrent ventral hernias

Break down after repair of recurrent ventral hernias can exceed 50 per cent. Laparoscopic techniques offer an alternative. This study evaluated the efficacy of the laparoscopic approach for recurrent ventral hernias. A retrospective review on all patients with a recurrent ventral hernia who underwent laparoscopic repair at our institution from August 1995 to June 1997 was performed. Demographic, operative, postoperative, and follow-up data were collected. Thirty-one patients underwent an attempted laparoscopic ventral hernia repair. Sixteen were for recurrent hernias; 15 were successfully repaired laparoscopically. The patients were typically obese (mean body mass index, 30 kg/m2), had an average of 2.4 previous open repairs (range, 1-7), and six patients had previously placed intra-abdominal mesh. An average of 3.5 (range, 1-16) defects were found per patient with a mean total hernia size of 130 cm2 (6-480 cm2). In all cases, expanded polytetrafluoroethylene mesh (average, 299 cm2) was secured with transabdominal sutures. Postoperatively patients required an average of 19 mg of narcotics (MSO4 equivalent). Bowel function returned in 1.7 days. Length of stay averaged 2.0 days (1-4 days). There were two complications: cellulitis, which resolved with antibiotics, and skin break-down, which required mesh removal. With follow-up averaging 18 months (7-29 months), there is one recurrence; the case in which the mesh was removed. Laparoscopic repair of recurrent ventral hernia seems promising. Decreased hospital stays, postoperative pain, wound complications, and a low rate of recurrence are benefits of this technique.     

Postoperative incisional hernias: intra- or extraperitoneal prosthesis implantation?

STUDY AIM: The aim of this retrospective study concerning the repair of postoperative incisional hernia using Dacron mesh was to compare results according to the extra- or intraperitoneal mesh position in order to assess the respective indications of each option. MATERIALS AND METHODS: From January 1985 to December 1996, 172 patients (mean age: 61.3 years) were operated on using Dacron mesh extraperitoneally (n = 99) or intraperitoneally located (n = 73). For statistical analysis, both groups were compared using Chi square test or Fisher's test. RESULTS: There were no postoperative deaths in the group with extraperitoneal mesh and two postoperative deaths in the group with intraperitoneal mesh. There were no significant differences when results comparing parietal complications (sepsis: 2% vs 2.7%, pain: 9.1% vs 16.9%), secondary intestinal disorders (2% vs 4.2%) and recurrence rate (4% vs 5.6%) were assessed between extraperitoneal and intraperitoneal mesh. Recurrences were related to pareital infection treated by partial removal of the mesh (n = 2) or to the lateral detachment of the mesh (n = 6). CONCLUSIONS: In the group of patients receiving extraperitoneal mesh there were no postoperative deaths and morbidity was low (this technique is generally used in the treatment of large incisional hernia). In the group of patients receiving intraperitoneal mesh, similar parietal and general complications were observed. But the risk of serious complications and postoperative death is higher; this technique must be limited to the most serious incisional hernia and to high risk patients.     

Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia

BACKGROUND: Controversy exists over the relative advantages of open mesh repair compared with open stitching methods and the laparoscopic approach. STUDY DESIGN: Two thousand nine hundred six (2,906) consecutive unselected adult patients underwent 3,175 primary inguinal hernia repairs using polypropylene mesh, under local anesthesia on an ambulatory basis. The age range was 15-92 years. The study specifically investigated the postoperative course with regard to pain, complications, and time of return to work. RESULTS: There were no postoperative deaths and no cases of urinary retention. Two percent of patients developed a hematoma. The incidence of deep infection was 0.3%. No case of testicular atrophy occurred. Postoperatively 19% of patients used no analgesia at all; 60% used oral analgesics for up to 7 days. There was a gradual decrease in time of return to work over four successive 1-year periods. Manual workers returned to work in 15 days (median) in the first year, reducing to 9 days in the fourth year. The overall median time of return to work across the whole group was 9 days. There were eight recurrences with an 18-month to 5-year followup. CONCLUSIONS: Open mesh repair under local anesthesia is an effective day case technique, particularly in the elderly and medically unfit. The economic benefits are enhanced by low morbidity, early return to normal activities and low recurrence rates.     

Complications of laparoscopic paraesophageal hernia repair

The complications of laparoscopic paraesophageal hernia repair at two institutions were reviewed to determine the rate and type of complications. A total of 76 patients underwent laparoscopic paraesophageal hernia repair between December 1992 and April 1996. Seventy-one of them had fundoplication (6 required a Collis-Nissen procedure). Five patients underwent hernia reduction and gastropexy only. There was one conversion to laparotomy. Traumatic visceral injury occurred in eight patients (11%) (gastric lacerations in 3, esophageal lacerations in 2, and bougie dilator perforations in 3). All lacerations were repaired intraoperatively except for one that was not recognized until postoperative day 2. Vagus nerve injuries occurred in at least three patients. Three delayed perforations occurred in the postoperative period (4%) (2 gastric and 1 esophageal). Two patients had pulmonary complications, two had gastroparesis, and one had fever of unknown origin. Seven patients required reoperation for gastroparesis (n = 2), dysphagia after mesh hiatal closure of the hiatus (n = 1), or recurrent herniation (n = 4). There were two deaths (3%): one from septic complications and one from myocardial infarction. Paraesophageal hernia repair took significantly longer (3.7 hours) than standard fundoplication (2.5 hours) in a concurrent series (P <0.05). Laparoscopic paraesophageal hernia repair is feasible but challenging. The overall complication rate, although significant, is lower than that for nonsurgically managed paraesophageal hernia.     

Mesh hernioplasty using a stapler

BACKGROUND: The recent development of laparoscopic hernioplasty has evoked extensive re-examination of the safety and effectiveness of using synthetic mesh materials in hernia surgery. We have investigated the efficacy of anterior stapling mesh repair in the treatment of inguinal hernia. METHODS: From July 1993 to June 1994, a modified open mesh hernioplasty using staples for anchorage has been performed in 127 patients. RESULTS: The mean age of patients was 61.4 +/- 13.0 years. Over 90% of them were operated on under local anaesthesia. The operation time ranged from 30 to 95 min with a median of 39 min. Only sixteen patients (12.6%) required postoperative parenteral analgesics and the median time for resuming daily activities was 7 days. Apart from two patients with reactionary haemorrhage, there was no other significant complication observed. Only one recurrence was encountered over the 26-month median follow-up period. CONCLUSIONS: We conclude that the modified mesh hernia repair with a stapling device is a feasible, inexpensive and safe procedure that is well tolerated under local anaesthesia by most patients.     

Management of complicated incisional hernias with underlay-technique implanted polypropylene mesh. An effective technique in French hernia surgery

Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30-50%. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. METHOD: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. RESULTS: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 +/- 12.92 years). Local complications occurred in four patients (12%): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3%). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6-17 months). To date no recurrent hernias have been observed. There were only minor complaints like "a feeling of tension" in the abdominal wall (n = 3) and slight pain under physical stress (n = 6). CONCLUSIONS: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

OBJECTIVE: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN: A randomised controlled trial of 403 patients with inguinal hernias. SETTING: Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.     

Femoral hernia: the dire consequences of a missed diagnosis

Femoral hernia has always presented more difficulty in diagnosis than other external abdominal hernias. The incidence of incarceration and strangulation is higher in our series than the published literature would suggest. A retrospective study was performed at our institution from February 1990 to June 1995. In that period, 22 patients were operated on for femoral hernia. There were 16 women and 6 men, average ages 51 and 48 years, respectively. The men weighed on average 209 lb, and the women, 154 lb. Three of our patients had elective repair of their hernias (16%); 19 were performed urgently or emergently (86%). Of the emergency repairs, 3 had strangulated small bowel requiring resection (16%), 1 had a strangulated vermiform appendix with abscess formation (5%), 3 had strangulated omentum requiring excision (16%), giving a total of 7 patients with strangulation and necrosis of the hernial contents (36%). The remainder had viable contents in the hernia sac. The time from the onset of symptoms to presentation at the hospital varied from 1 day to 3 years. The time from strangulation to presentation was between a few hours and 4 days. Surgery was performed on the day of admission (within 24 hours) on all but 2 of our patients. Procedures performed were McVay repair, 13; Bassini, 4; laparoscopic with Marlex mesh, 1 patient; drainage of a groin abscess in 2 patients with later repair; and on 2 patients the type of repair was not specified. One of the patients died. Postoperative wound infection occurred in 2 heavily contaminated patients, and 3 had pneumonia. Patients with no regular physician and no routine physical examinations are at higher risk for developing strangulation of femoral hernias. Emergency physicians and general practitioners are in the best position to diagnose these hernias early, when treatment can be elective.     

Controlled multicenter trial of laparoscopic transabdominal preperitoneal hernioplasty vs Shouldice herniorrhaphy. Early results

BACKGROUND: In February 1993 a prospective randomized multicenter trial was initiated to compare laparoscopic transabdominal preperitoneal hernioplasty to Shouldice herniorrhaphy as performed by surgeons of nonspecialized clinics. METHODS: Until January 1994, 87 patients with 108 hernias took part in the trial (43 Shouldice and 44 laparoscopic repairs). RESULTS: The laparoscopic procedure took significantly longer than did the open operation but caused less pain as measured by pain analogue score and consumption of paracetamol and narcotics. The postoperative complication rate was 26% in the open and 16% in the laparoscopic group. The patients in the laparoscopic group were discharged earlier and their convalescence was shorter than after open hernia repair. There has been one early recurrence in the laparoscopic and two in the open group to date with a mean follow-up of 201 days. CONCLUSIONS: Laparoscopic hernia repair causes less pain than the conventional operation and enables the patient to return to full work and usual activities earlier. The recurrence rate will not be known for 5 years.     

Late mesh rejection as a complication to transabdominal preperitoneal laparoscopic hernia repair

BACKGROUND: The use of a mesh in transabdominal preperitoneal laparoscopic hernia repair (TAPP) caries the risk of late rejection or infectious complications related to the mesh. The aim of this study was to describe the extent of these complications. METHODS: We performed a retrospective study of 500 consecutive patients with TAPP for inguinal hernia. Results: Late mesh rejection was observed in three patients at 5-19 months after surgery. The mesh was removed via a suprapubic midline incision. At 3-4 month's follow-up, none of the patients had recurrence of the hernia, even though no hernia repair had been done. CONCLUSION: Late mesh rejection is a potential complication of TAPP and has to be considered when choosing the surgical method of hernia repair.     

Prospective randomized comparative study of laparoscopic hernioplasty and Lichtenstein tension-free hernioplasty]

To compare the laparoscopic transabdominal preperitoneal inguinal hernioplasty (TAPP) and the open Lichtenstein technique, in 1992 a prospective randomized trial was initiated. Until 1995 108 patients with 130 hernias took part in the trial: 64 TAPP (group A) and 66 Lichtenstein (group B). 22 patients had simultaneous bilateral repairs. Laparoscopic approach (group A) was able to expose otherwise-occult controlateral hernias in 3 cases and discovered a complex hernia (a hernia with more than one defect in the wall) in 2 patient in whom a direct hernia had been diagnosed before the operation. Mean operating time for monolateral operations was significantly longer in group A (p < 0.05). The corresponding figures for bilateral operations were longer in group B (p < 0.01). No intraoperative complications, conversions from TAPP to open repair, postoperative deaths. There were not less pain quicker mobility and shorter period of disability in the laparoscopic group (group A). Ten (15.6%) postoperative complications occurred in group A: local hematoma (6 cases, 9.3%), neuralgias (3 cases, 4.7%), urinary retention (1 case, 1.6%). Eight (12.1%) postoperative complications: hematomas (3 cases, 4.5%), urinary retention (3 cases, 4.5%), neuralgias (2 cases, 3%) occurred in group B. Differences were not significant. The current follow-up period is 36 months (15-54) in median. In both groups no recurrences occurred, but 3 patients in group B who were operated on for monolateral hernia (6.5%) discovered to be affected by contralateral hernia. The results of the present report suggest that TAPP does not appear to be associated with better results in terms of complications, pain or period of disability as compared to open tension free hernia repair, but the ability of the laparoscopic approach to expose otherwise-occult defects eliminated the risk of recurrences due to missed hernias.     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision. Minihernia repair

BACKGROUND: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. METHODS: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. RESULTS: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17-83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25-74). Mean hospital stay was 1.2 days (0-3 days). The mean return to normal activity was 8 days (2-10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1-22 months). CONCLUSION: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma.     

Day-case laparoscopic hernia repair

Some 114 patients (median age 52 years) underwent laparoscopic hernia repair as a day-case procedure. Twenty-one patients had bilateral and 11 recurrent hernias. Some 113 patients underwent transabdominal preperitoneal mesh repair but one required conversion to open operation. Mean operating time was 24 min for unilateral and 38 min for bilateral repair. In an operating session of 3.5 h, up to five patients (mean 4.4) underwent surgery and as many as seven hernias were repaired. More than 10 per cent of patients were found to have a previously undiagnosed hernia on the opposite side. A total of 111 patients were discharged home on the day of surgery. Major complications included one omental bleed and one small bowel obstruction. Seroma was the commonest minor complication and occurred in 7 per cent of patients. More than 35 per cent of patients needed no postoperative analgesia. To date there has been one recurrence (follow-up range 2-18 months).     

New possibility in inguino-femoral hernia repair: laparoscopic herniaplasty

The development of minimally invasive surgery brought up the challenge: to repair the frequent inguino-femoral hernias laparoscopically. The authors performed 65 laparoscopic hernioplasties in one year: "transabdominal preperitoneal" technique was used in 61 cases und "intraperitoneal onlay mesh" in 4 cases. Fifty-three patients were operated on, 12 of them had bilateral hernias. Recurrent hernia was the indication in 22 patients (34%). The average operating time was 102 and 144 minutes in the unilateral and the bilateral cases, respectively. There was no wound infection, or general complication. Spontaneously dissolving seroma/hematoma of the spermatic cord was noticed and detected by ultrasound in 5 patients (7.7%). The neuralgia caused by the irritation of the nerves of the region in 4 patients (6.1%) disappeared without sequels after treatment with vitamins B. The 2 early recurrences (3.2%), considered to be caused by technical inexperience, these patients were treated successfully with the "intraperitoneal onlay mesh" technique. In the authors' opinion there are definite advantages of laparoscopic hernioplasty, namely the minimal postoperative pain, early mobilization, shorter hospital stay and early restoration of full physical activity (in 1-2 weeks) as well as the known disadvantages of this technique (narcosis, longer operative time, intraperitoneal procedure, higher costs).     

Measurement of DNA in intervertebral disc and other autofluorescent cartilages using the dye hoechst 33258

BACKGROUND AND OBJECTIVES: Morgagni hernias are unusual congenital diaphragmatic hernias that are generally asymptomatic and discovered incidentally. Surgical treatment is indicated once the diagnosis is made. These hernias have traditionally been repaired by the open abdominal or thoracic approaches. We report a case of Morgagni hernia repaired successfully via the laparoscopic approach. METHODS AND RESULTS: The patient was noted to have a large anteromedial diaphragmatic hernia by chest radiograph and CT imaging. He underwent laparoscopy, during which the hernia was reduced and the defect repaired with mesh placement. We used intracorporeal suture placement to anchor the mesh. The patient recovered uneventfully after a short hospitalization. CONCLUSIONS: The laparoscopic approach for repair of Morgagni hernias offers diagnostic advantages as well as the potential for reduced morbidity when compared to laparotomy. We report intracorporeal knot-tying for fixation of the mesh to be a secure and satisfactory means to achieve the laparoscopic repair.