Anesthetic Management for Laparoscopic Repair of Morgagni Hernia in a Child with Down Syndrome

Case Report

Austin J Anesthesia and Analgesia. 2016; 4(1): 1043.

Anesthetic Management for Laparoscopic Repair of Morgagni Hernia in a Child with Down Syndrome

Dwivedi D¹*, Arora S¹, Batra YK¹ and Menon P²

¹Department of Anaesthesia & Intensive Care, Post Graduate Institute of Medical Education & Research, India

²Department of Pediatric Surgery, Post Graduate Institute of Medical Education &Research, India

*Corresponding author: Deepak Dwivedi, Assistant Professor, Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS ASVINI, Colaba, Mumbai, India

Received: February 19, 2016; Accepted: March 29, 2016; Published: April 01, 2016


We report a successful management of a 10 year old, overweight female child of down syndrome with Morgagni hernia. Anesthesia concerns are numerous with association of gastro oesophageal reflux disease, pulmonary hypolplasia, susceptibility to respiratory infections, atlantoaxial instability and sensitivity to anesthetic agents which demand modifications. Desflurane, a less potent inhalational agent, and the minimally invasive surgery technique resulted into favorable outcome with limited pulmonary morbidity and postoperative complications.

Keywords: Morgagni hernia; Down syndrome; Anesthesia; Minimal invasive surgery


ABG: Arterial Blood Gas; IV: Intravenous Venous; EMLA: Eutectic Mixture of Local Anaesthesia; ECG: Echocardiography; EtCO2: End tidal Carbon Dioxide; SpO2: Pulse Oximetery; FiO2: Fraction of inspired Oxygen; MAC: Monitored Anaesthesia Care; NIBP: Non Invasive Blood Pressure

Case Presentation

A 10 year old girl with a weight of 67 kg and BMI of 27.8, a known case of Down syndrome with right sided Morgagni hernia was posted for laparoscopic repair. The child, since birth had a history of repeated respiratory tract infections which used to subside in 15 days more than its usual course. One year back she developed respiratory distress following an episode of upper respiratory tract infection and fever which needed hospitalization with mechanical ventilation for 18 days and was diagnosed as a case of Morgagni hernia (right). There was no history of abdominal pain, vomiting. Barium studies (Figure 1) had shown transverse, ascending colon and caecum at high position on right side of abdomen with anterior diaphragmatic hernia. CT scan chest (Figure 2) showed right central and anterior hemi diaphragmatic hernia with mass effect seen on lung parenchyma, Thyroid function test and echocardiography both were normal and pulmonary function test had shown moderate restriction. Chest radiograph revealed widening of the mediastinum with raised right hemi diaphragm. Patient had clinical features of Down syndrome (mental impairment, flat facial features, low set ears, simian crease and mongoloid slant). Mouth opening was adequate without macroglossia and airway was Mallampati class II. Air entry was decreased on right lower zone. Preoperative ABG was normal. Intravenous Venous (IV) access (20G) was secured preoperatively at the dorsum of left hand after the application of EMLA cream followed by administration of 1mg IV midazolam to allay the anxiety. In an operation theatre, all essential monitors were connected (ECG, NIBP, Temperature, ETCO2, SpO2). Inj fentanyl 80 μg, dexamethasone 4mg were administered IV and induced with propofol Intubation achieved with succinylcholine 100mg IV and airway was secured with 6.0mm cuffed endotracheal tube. Anesthesia was maintained with oxygen (FiO2-0.4), air and desflurane (MAC 1.2%) and positive end expiratory pressure of 4 mmHg was added to adjust normocapnia. Intravenous paracetamol, fentanyl 30μg, ondansetron 4mg and intermittent boluses of vecuronium were administered intraoperatively. Continuous Invasive BP (120/60- 100/68 mmHg) and EtCO2 (35-40 mmHg) were monitored along with intraperitoneal insufflation pressure which were kept between 9-10mmHg. Intraoperative ABG was normal. Surgery included the insertion of a 10 mm umbilical and two 5 mm working ports on both sides of the midline in the upper abdomen. Hernial contents, i.e. transverse colon and a very heavy fat laden omentum were easily reduced. The sac was excised using ultrasonic scalpel without injuring pleura or pericardium. Due to obesity and the thickness of the abdominal wall intracorporeal tissue approximation of defect failed. It was closed by passing conventional 2 inch needle threaded with double 0 silk through the abdominal wall lower lip of defect, and then back to the abdominal wall under endoscopic vision. Multiple such sutures were placed and tied externally under the skin. Surgery lasted for four hours and anaesthesia was reversed with IV neostigmine (50μ and glycopyrrolate (10μ Extubation was successful and recovery was complete and patient was shifted to ICU on 4litres of oxygen, with an uneventful postoperative period.

Citation: Dwivedi D, Arora S, Batra YK and Menon P. Anesthetic Management for Laparoscopic Repair of Morgagni Hernia in a Child with Down Syndrome. Austin J Anesthesia and Analgesia. 2016; 4(1): 1043. ISSN: 2381-893X