Anteromedial subcostosternal defects, also known as a diaphragmatic hernia of Morgagni (MH), allow potentially life-threatening herniation of the abdominal organs into the thorax. Constituting only a small fraction of all types of congenital diaphragmatic hernias, correct diagnosis of MH is often delayed, owing in large part to nonspecific associated respiratory and gastrointestinal complaints. Once identified, the primary management for both symptomatic and incidentally discovered asymptomatic cases of MH are surgical correction because the herniated contents present increasing risk for strangulation. Various thoracic and abdominal surgical approaches have been described without a clear consensus on preference for operative repair technique. In this article, the literature regarding management of MH within the past decade is reviewed, and an illustrative case of laparoscopic repair of a MH with novel reinforcement using a Falciform ligament onlay flap is presented.

CorrespondenceEarly results with the Lichtenstein tension-free hernia repair. Letter 1 SirWe read with interest the report on use of the Lichtenstein patch hernia repair by Mr Davies et al. (Br J Surg 1994; 81: 1478-9).We have recently evaluated the use of this technique in 85 patients, 42 day cases (41 men and 1 woman; median age 50 years, range 16-65) and 43 inpatients (41 men and two women; median age 60.5 years, range 20-85). All cases were performed under general anaesthesia, day cases using propofol infusion allowing general anaesthesia with rapid recovery and minimal sedative effects after operation. Regional blockade was provided using bupivacaine 0.5 per cent with adrenaline 1 : 200 000. Patients were given co-dydramol for 5 days as take-home analgesia, and were reviewed in outpatients at 4 weeks.Median (range) operating time was 30 (20-45)min for day cases and 35 (20-75) min for inpatients. Median postoperative stay for inpatients was 1 day (1-6), and postoperative opiate analgesia was required in 11 of 43 (26 per cent). All day cases were discharged on the day of operation, apart from two (4.8 per cent). One needed bilateral repair; one lived alone in poor home circumstances. A single dose of opiate analgesia was required in three day cases (7.1 per cent), in no case preventing discharge on the same day.Complications occurred in four day cases (9.5 per cent): serous dischargeone, bleedingtwo, haematomaone. Only the latter was serious and required evacuation. No complications occurred in the inpatient group. No early hernia recurrence has been detected.At 1 month follow-up assessment, no day cases regarded themselves as back to full activity including heavy lifting, although 22 (52 per cent) felt comfortable with general day-today activities. The oral analgesia prescribed was required by 28 day cases (67 per cent), and 15 of these (36 per cent) required more analgesia from their own doctor. Three day cases (7.1 per cent) called their GP, one requiring a visit to arrange readmission. The other two were dealt with by a visit from a practice nurse. Of the day cases 39 (93 per cent) were happy with day-case care in spite of any discomfort suffered at home. All of these would be happy to undergo further day-case repair if required.Of the patients undergoing inpatient repair, none were back to full activity at one month, although 21 (49 per cent) were back to general activities. All 43 of these patients were happy with their care.Recent Royal College of Surgeons of England' guidelines Kingsnorth AN, Gray MR, Nott DM. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1992; 79: Wyatt JP. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia. Br J Surg 1993; 80: 403 (Letter). Carter A. Prospective randomized trial comparing the Shouldice technique and plication darn for inguinal hernia Br J Surg 1993; 80: 536 (Letter). Manson WG, Reed MWR. Prospective randomized trial comparing the Shouldice technique a...

This is a review of cases of congenital posterolateral diaphragmatic hernia encountered at the Adelaide Children's Hospital in the period 1950 to 1969, which stresses particularly the causes of the high mortality in this condition in those cases presenting within 24 hours of birth.