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Congenital chest wall deformities occurred in roughly 1% of children and if asymptomatic are often overlooked and taken lightly. This results in a progressive deformity of the chest and delays in diagnosis of the underlying causes. Complications can also develop from the underlying condition. Chest wall deformities are associated with a number of syndromes and other anomalies including abnormalities of the diaphragm. Congenital Diaphragmatic Hernia (CDH) is one of the underlying causes of chest deformity. Congenital Morgagni Hernia (CMH) is a rare form of CDH and consists of 3-5% in all CDH. Many cases were delayed in diagnosis due to the subtle presentation or were incidental findings. The consequence of delay in diagnosis can lead to the onset of complications which carries morbidities and even mortality. We report a case of a child with missed diagnosis of a rare condition Morgagni Diaphragmatic Hernia presenting with chest deformity.

Single-incision laparoscopic repair of a congenital Morgagni diaphragmatic hernia using a suture-assisting needle was performed in a 1-year-old boy. Three ports were inserted through a single umbilical incision to repair the 2.5 × 2.3-cm defect. The full-thickness muscle layer of the anterior abdominal wall and the posterior rim of the defect were penetrated with the suture-assisting needle holding a thread, which was then released. The needle tip was pulled back over the muscle layer, shifted laterally, and again passed through the muscle layer and the posterior rim. The thread was then captured by the needle and pulled out through the anterior abdominal wall. Five mattress sutures were placed in this way and tied subcutaneously. The postoperative course was uneventful, and the cosmetic outcome was favorable. A suture-assisting needle is useful for completing full-thickness anterior abdominal wall repair, which is important for preventing the recurrence of a congenital Morgagni diaphragmatic hernia.

Differential diagnosis of seizures and convulsive syncope may be challenging in clinical practice. Furthermore, a misleading diagnosis of epilepsy may be detrimental for the patient as it often implies an over-prescription and an over-use of antiepileptic drugs which can cause adverse reactions. Moreover, a wrong diagnosis also causes distress to the patient with the risk of performing plenty of investigations without any benefits on the symptoms. In this case, we present a 57-year-old patient suffering from recurrent convulsive syncope over the last 7 years for which he underwent several cardiological and neurological tests and took plenty of antiepileptic drugs without any benefits on his convulsive episodes with loss of consciousness. During hospitalization, a chest X-ray was performed revealing an unknown diaphragmatic hernia with eventration of the transverse colon in the right hemitorax and mild cardiac compression. The patient underwent laparotomic surgery and diaphragmatic reconstruction with complete recovery. After 6-month follow-up, the patient no longer had episodes of convulsive syncope.

Acquired anterior diaphragmatic hernia (ADH) is usually the result of thoracic trauma. Acquired Morgagni-type anterior diaphragmatic hernia is a rare complication after cardiac surgery, especially with associated pericardial hernia. We will present a patient with acquired Morgagni-type hernia and pericardial hernia presumably after previous cardiac surgery successfully treated with laparoscopic Morgagni hernia reduction and repair with mesh onlay as well as prophylactic laparoscopic appendectomy, open epigastric hernia repair, and open umbilical hernia repair.

Acute Budd–Chiari syndrome is a rare condition characterised by obstruction of hepatic venous outflow. We describe the case of a 52-year-old man, with a congenital Morgagni diaphragmatic hernia, who presented with acute onset abdominal pain, shortness of breath, lactic acidosis, hyperbilirubinaemia and transaminasaemia. Computed tomography revealed strangulation of the diaphragmatic hernia and extrinsic compression of the inferior vena cava from the herniated viscera. Emergency surgery was carried out to repair the hernia with a biosynthetic mesh, with complete resolution of the Budd–Chiari syndrome.

The Morgagni hernia (MH) accounts for 3–4% of congenital diaphragmatic hernias. There is a paucity of data regarding this rare defect. The purpose of this study is to describe the characteristics of children with MH, surgical approaches for repair, and patient outcomes. Pediatric patients (ages 0–18) with a MH from 2002 to 2014 at a single, freestanding pediatric hospital were retrospectively reviewed. Patient presentation, demographics, operative methods and findings, and outcomes were evaluated. Twenty-six infants and children with a congenital MH were treated. There were 20 males (77%) and six females (23%) with a median age at diagnosis of 14.75 months (range 1 week to 13 years). Half were symptomatic. Sixteen hernias were repaired laparoscopically, nine by an open approach, and one laparoscopic converted to open. Colon was the most commonly herniated organ (N = 14). Hernia sacs were found in 22 patients of which, 20 were resected. Two patients underwent treatment with ECLS. There was one mortality in a patient who underwent repair on ECLS in the setting of an omphalocele and SVC obstruction. There were no recurrences in our sample. In this series, congenital MH appears to have a male predominance, frequently presents with pulmonary symptoms, and has excellent outcomes regardless of operative approach.

A 36-year-old morbidly obese female with BMI 66 kg/m2, scheduled for elective laparoscopic sleeve gastrectomy. Prior to the surgery patient had symptoms of mild dyspnea, vague abdominal discomfort. CAT scan of thorax and abdomen revealed a right-sided large morgagni diaphragmatic hernia containing omentum and portion of the transverse colon. Patient elected to undergo Laparoscopic sleeve gastrectomy and concomitant morgagni diaphragmatic hernia repair. The post-operative course was uneventful and the patient was discharged on post-operative Day 2.This case is an extremely rare case of super obese patient with Morgagni hernia who desires bariatric surgery and found to have incidental finding of morgagni hernia. This kind of combination can safely undergo concomitant laparoscopic hernia repair with mesh and sleeve gastrectomy.

Congenital Morgagni hernia (CMH) is a rare congenital anomaly is typically diagnosed in childhood and on occasions in adults during work up of unexplained respiratory infections or gastrointestinal symptoms. The average age of laparoscopic repair of CMH was 3.3 years. We describe a newborn with fetal aberrant ductus venosus with progressive right ventricular dilation prompting early delivery. Post-natally, the baby had frequent episodes of cyanosis. Echocardiogram during distress showed compression of the inferior vena cava and of the right heart, with significant right to left shunt through patent foramen ovale. Infant underwent successful laparoscopic diaphragmatic hernia repair with resolution in her episodes of cyanosis. Keywords: Morgagni diaphragmatic hernia, Neonate, Cyanosis, Tamponade

Background/Purpose Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch. Methods We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P Results In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months). Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p = 0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p = 0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p = 0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p = 0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair. Conclusion In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence. Type of Study Systematic review Level of Evidence 3A

Congenital diaphragmatic hernias (CDH) are rare congenital anomalies occurring in 1:5000 live births with a wide range of clinical presentations. The Morgagni hernia is the rarest of these defects with the hernia presenting anteriorly, most commonly on the right. Factors found to predict mortality in infants presenting with CDH include prenatal diagnosis, early gestational age, low birth weight, large diaphragmatic defect, associated congenital anomalies, and low APGAR scores. We present the case of a 27-week gestational age premature girl weighing 460 g who required urgent repair of a Morgagni diaphragmatic hernia and a review of the current literature on the topic. To the best of our knowledge, this is the smallest infant to undergo repair of this CDH reported to date.

BACKGROUND: This study aimed to standardize the surgical correction technique of congenital Morgagni diaphragmatic hernia (CMDH), analyzing the results of an international multicentric survey. METHODS: The medical records of 43 patients (29 boys, 14 girls) who underwent laparoscopic repair of CMDH in 8 pediatric surgery units in a 5-year period were retrospectively reviewed. Their average age was 3.3 years. Ten patients (23.2%) presented associated malformations: 9 Down syndrome (20.9%) and 1 palate cleft (2.3%). Thirty-five patients (81.4%) were asymptomatic, whereas 8 patients (18.6%) presented symptoms such as respiratory distress, cough or abdominal pain. As for preoperative work-up, all patients received a chest X-ray (100%), 15/43 (34.8%) a CT scan, 8/43 (18.6%) a barium enema and 4/43 (9.3%) a US. RESULTS: No conversion to open surgery was reported. Average operative time was 61.2 min (range 45-110 min). In 38/43 (88.3%) patients, a trans-parietal stitch was positioned in order to reduce the tension during the repair. In 14/43 cases (32.5%), the sac was resected; in only 1/43 case (2.3%) a dual mesh of goretex was adopted to reinforce the closure. Average hospital stay was 2.8 days. The average follow-up was 4.2 years, and it consisted in annual clinical controls and chest X-ray. We recorded 2 complications (4.6%): one small pleural opening that required no drain and one recurrence (2.3%), re-operated in laparoscopy, with no further recurrence. CONCLUSIONS: To the best of our knowledge, this is the largest series published in the literature on this topic. Laparoscopic CMDH repair is well standardized: The full-thickness anterior abdominal wall repair using non-resorbable suture with interrupted stitches is the technique of choice. Postoperative outcome was excellent. Recurrence rate was very low, about 2% in our series. We believe that children with CMDH should be always treated in laparoscopy following the technical details reported in this paper.

Purpose Removal of the hernia sac for Morgagni diaphragmatic hernia repair in infants and children is a controversial issue. In our series, we elected not to excise the sac in all the cases. Methods Nine children with retrosternal (Morgagni) hernias underwent primary laparoscopic repair without excision of the hernia sac, and we analyzed our results, complications, and outcome. Results Between January 2007 and March 2011, nine children, comprising five boys and four girls, with Morgagni hernia underwent repair laparoscopically at our hospital. The mean age of the children was 15.1 months (range, 3–38 months), mean operative time was 50.5 min, and mean hospital stay was 3.6 days. There were no intraoperative or postoperative complications. The mean follow-up time was 32.8 months (range, 6–54 months). There were no recurrences. All patients had complete obliteration of the residual cavity. Conclusion Laparoscopic closure of the defect by suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall without excision of the hernia sac is safe and effective in repairing Morgagni hernia without any risk accruing from leaving the hernia sac intact. Keywords: laparoscopic Morgagni hernia repair, Morgagni diaphragmatic hernia, retrosternal diaphragmatic hernia

We report a case of a foramen of Morgagni hernia repaired by a single-port laparoscopic technique. A 20-month-old (10 kg) boy underwent a 97-minute procedure through a 15-mm umbilical incision and had no complications. Although other pediatric single-port case series have been reported in the literature, this case represents the first time a diaphragmatic defect has been addressed. Moreover, unlike previous experiences that involved procedures of resection (appendectomy, cholecystectomy, etc), this case required operative repair and reconstruction with intracorporeal suturing via a single-access site. Advancement in instrument and port technology makes such procedures feasible in pediatric patients.

Both Spigelian and Morgagni hernias cause serious morbidity so early diagnosis and timely treatment are necessary. These two types of hernia are more commonly found on the right side of patients. They are rare individually in adults and even rarer in combination. So far, an association between the two hernias has only been reported on the right. We describe the first case of a Spigelian hernia and a Morgagni hernia in a 62-year-old woman, both occurring on the left side. Our accompanying video describes several laparoscopic features that will help lead to early detection and diagnosis.

Purpose: We report our preliminary experience with laparoscopic repair of anterior midline (Morgagni) diaphragmatic hernia and identify technical issues. Methods: Four consecutive children undergoing laparoscopic Morgagni hernia repair over 3 years were reviewed. Results: The ages ranged from 13 months to 13 years. Three were found incidentally, and one presented with sudden onset of left side chest pain; none had obstructive symptoms. At operation the hernia contained omentum in all cases and bowel in three cases. All four underwent primary laparoscopic repair with interrupted nonabsorbable sutures. A small residual eventration was left along the edge of the pericardium in the one patient with a sac. The patient who presented with chest pain was found grossly and histologically to have acute appendicitis within the left chest, requiring dissection of the inflamed viscera from the mediastinum and chest wall; laparoscopic appendectomy was also done. Median time to full diet was 3 days, morphine was given f...

The aim of this study was to analyze the feasibility of laparoscopic repair of Morgagni diaphragmatic hernia. A questionnaire was sent to members of the Groupe d'Etude en Coeliochirurgie Infantile (GECI) in January 2001. Data for 22 cases were collected. The mean age of the patients was 37 months. Associated anomalies were Down's syndrome (five cases) and myopathy (one case). Three trocars were sufficient in most of the cases. Reduction of the contents of the hernia occurred spontaneously in six cases and was easily accomplished in 15 cases. It was difficult in two cases. The sac was removed in 16 cases. The defect was closed without a prosthetic patch in 18 cases and with a prosthetic patch in four. One operation was converted because of a defect that was too wide. In 18 of the 22 patients, extubation could be performed immediately after the operation. The mean hospital stay was 5.4 days. One recurrence developed 3 months after primary closure without resection of the sac. Redo by laparoscopy was success...

A case of Morgagni hernia presenting in adulthood is presented. This form of congenital diaphragmatic hernia is rare in itself and is known to present in adulthood in some cases. But presentation after having undergone three surgeries-PDA ligation, appendicectomy and a full term pregnancy followed by LSCS is even rarer. This case is therefore by any yardstick an extremely rare one.

Introduction: Anterior diaphragmatic hernias of the Morgagni type are the least common type of congenital diaphragmatic hernia and account for about 6% of all cases. Morgagni hernias often present as an incidental finding on a chest radiograph. Most pediatric surgeons would advocate for elective repair in asymptomatic patients. Laparoscopic repair of Morgagni hernia in children has been previously described.1–3 As the hernia itself produces minimal symptoms, postoperative cosmesis is often of great concern to the parents of the affected child. Percutaneous suturing techniques have been previously described for single-incision laparoscopic surgery. We present our technique of virtually scarless single-incision pediatric endosurgical (SIPES) repair of a Morgagni hernia. Case: The patient was a 20-month-old female child who presented to our hospital with fever and persistent cough. A chest radiograph was obtained, showing an anterior diaphragmatic hernia. The finding was confirmed on computed tomogr...

A large diaphragmatic Morgagni-type hernia that was incidentally discovered in an 8-month-old girl is described. The diaphragmatic defect was closed through laparoscopy. The latter approach is felt to be superior over conventional surgery and is therefore recommended in similar cases.

Morgagni diaphragmatic hernia can be repaired laparoscopically. The aim of this study is to evaluate the outcome of this minimally invasive approach.A retrospective review was conducted on all consecutive children who underwent repair of Morgagni hernia from January 2002 to December 2011 in our hospital. Data are expressed as median (range).There were 12 children with Morgagni hernia. Age at surgery was 7.5 months (2-125). Associated malformations were present in 7 children (58 %). All children underwent initial laparoscopic approach. Two children (16 %) underwent conversion to open surgery. The hernia was closed primarily in 11 children (92 %), using a polyester patch in 1 (8 %). There were no intraoperative or immediate postoperative complications. Five children (42 %), all repaired initially without a patch, had a recurrence of the Morgagni hernia. The repair of the recurrent hernia was performed laparoscopically in four out of the five children, and a patch was used in two patients with no further recurrences or complications.There is a high rate of recurrence after laparoscopic Morgagni hernia repair. This is exclusively associated with laparoscopic repair without patch, and it is in contrast with the low recurrence rate reported previously. More frequent use of patch may be beneficial.

Laparoscopic repair of a diaphragmatic hernia through the right sternocostal foramen of Morgagni in an obese 42-year-old man is described. The indications for surgery were symptoms of strain-induced dyspnea and tightness in the chest. The technique was carried out by incorporating a marlex mesh into the defect and fixing it in place with hernia staples. The patient had an immediate recovery after repair of the hernia and has remained free of recurrence or complaints 9 months after surgery.

Asymptomatic Morgagni hernia can be discovered in adults as an incidental finding or because of acute gastrointestinal symptoms. We report a case of a 76-year-old man with an incidental diagnosis of seizure attack. Obesity and the increased abdominal pressure caused by abdominal muscles contraction during seizure could have contributed to the clinical presentation. The omentum, small bowel, and transverse colon were found in the right side of the chest using an open transabdominal approach. The hernia sac was excised and the diaphragmatic defect closed by direct suturing. The postoperative period was uneventful and the shortness of breath attributed to obesity disappeared.

Morgagni hernias are well suited to laparoscopic repair. A primary suture closure may result in tension on the repair, thereby predisposing the patient to a recurrence. A prosthetic patch (PP) can be used to provide a tension-free repair. In this study, we reviewed our experience with the laparoscopic PP repair of Morgagni hernias in children.A retrospective chart review of all patients undergoing a laparoscopic Morgagni hernia repair using a PP was undertaken between November 2002 and January 2006. Outcome measures included age, gender, defect size, use of mesh, and outcome. The time of follow-up was from 6 to 37 months.Seven (7) patients (6 male, 1 female) underwent a laparoscopic repair of Morgagni hernia during this time period. Six (6) patients had a congenital hernia, and 1 patient was thought to have an iatrogenic hernia following a sternotomy for heart surgery. Defect size ranged from 4 to 7 cm in maximum dimension. All operations were completed laparoscopically, no patients presented with recurrence, and no PP complications were encountered.The laparoscopic repair of Morgagni hernia using a PP can be performed with relative ease and with a positive outcome, and may prevent future recurrence by effecting a tension-free repair.

Se presenta un caso de hernia diafragmática de Morgagni en una paciente de 77 años, sin antecedente traumático, con historia de múltiples hospitalizaciones por cuadros respiratorios manejados sistemáticamente como neumonías. Se establece el diagnóstico de hernia de Morgagni en base al estudio imagenológico tras una nueva hospitalización. Se resuelve quirúrgicamente por abordaje transabdominal con excelente resultado. La hernia de Morgagni corresponde a la más infrecuente de las hernias diafragmáticas congénitas. En general se manifiestan en edad pediátrica, sin embargo algunas pueden evolucionar asintomáticas y manifestarse en adultos a través de cuadros inespecíficos que dificultan el diagnostico

A 4-month-old infant with trisomy 21 is brought to the emergency department for breathing difficulty. Subsequently, he is diagnosed with a Morgagni diaphragmatic hernia. Tachypnea in an infant with trisomy 21 may be the result of diagnosis such as congenital heart disease, infectious processes, structural anomalies, or aspiration secondary to gastroesophageal reflux or swallowing dysfunction. Knowledge of these abnormalities is important when generating a differential diagnosis in these patients. Although uncommon, a Morgagni hernia may present beyond the newborn period and should be considered when evaluating an infant with trisomy 21 and respiratory difficulty.

Background/Purpose: Previous reports of laparoscopic repair of Morgagni hernias in children have involved relatively complex laparoscopic techniques. This report describes a simpler method of repair that we have applied to 4 children. Methods: Four children with retrosternal (Morgagni) hernias underwent primary laparoscopic repair by placement of interrupted synthetic nonabsorbable sutures through the full-thickness of the anterior abdominal wall, incorporating the posterior rim of the defect and returning back out through the anterior abdominal wall, with the sutures tied in the subcutaneous tissue. Results: The children, ranging in age from 11 to 36 months, underwent laparoscopic repair of their Morgagni hernias and had an uneventful postoperative recovery, apart from a port site hernia in one. Conclusions: This technique for primary laparoscopic repair of Morgagni hernia is easy to perform, well tolerated by the patient, and gives excellent cosmetic results. Laparoscopic closure of the defect by suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall would appear to provide a safe and effective means of repairing this type of hernia. J Pediatr Surg 38:768-770. © 2003 Elsevier Inc. All rights reserved.

Purpose: Single-site laparoscopic surgery has become increasingly common. We herein report an easy and low-cost thoracic trocar technique (TTT) for these types of procedures and recommend the simpler name “transumbilical scarless surgery” (TUSS) to minimize confusion in nomenclature. Methods: We retrospectively reviewed patients who underwent TUSS by TTT using a thoracic trocar and surgical glove in our hospital between November 2011 and November 2012. Operating time, postoperative stay, and complications were detailed. Results: A total of 101 TUSS by TTT were successfully performed, comprising appendectomy (n = 63), ovarian cyst excision (n = 7), splenectomy (n = 5), nephroureterectomy (n = 5), orchidopexy (n = 4), pyeloplasty (n = 3), nephrolithotomy (n = 2), orchiectomy (n = 2), varicocelectomy (n = 2), lymphangioma excision (n = 2), ureterectomy (n = 1), Morgagni diaphragmatic hernia repair (n = 1), ovarian detorsion (n = 1), antegrade continence enema (n = 1), intestinal resection anastomosis (n = 1), and intestinal duplication excision (n = 1). Kirschner wires were used for some organ traction. Nine patients required an additional port, but no major complications occurred. The postoperative stay (mean ± standard deviation) was 3.2 ± 1.4 days, and operating time was 58.9 ± 38.3 minutes. Conclusion: We recommend the simpler name of TUSS to minimize confusion in nomenclature for all transumbilical single-incision laparoendoscopic surgeries. TTT is an easy and low-cost TUSS technique.

We used a new technique to treat a right-sided Morgagni hernia in a symptomatic adult with a transverse colon that was herniated in the chest. Three trocars were required. The herniated viscera were easily reduced in the abdomen, and the diaphragmatic border that was mobilized from the liver showed the elliptical diaphragmatic defect (9 x 5 cm); however, the hernial sac was not resected. Four transversal 1-cm cutaneous incisions were made just below the costal arch. Using a Reverdin needle holder, we introduced eight ligatures under laparoscopic control through the abdominal wall and through the free diaphragmatic border. Each suture was then held by the grasper and freed from the Reverdin. After the Reverdin was extracted and reintroduced more caudally, the intraabdominal suture was placed into it and finally extracted again. Before knotting, all the sutures were pulled together to achieve perfect closure of the defect. A suction drain was placed in the hernial sac. The duration of the procedure was 12 min. The patient was discharged on the 5th postoperative day. A review of 20 other patients treated via a video-assisted approach is also included here. We found this original technique to be extremely simple, rapid, and effective. It can also be performed by surgeons who are not specially trained in intracorporeal suturing and knotting and can probably also be used for the repair of other types of diaphragmatic defects. The use of laparoscopy and magnification allows the surgeon to achieve a better point of control for simpler solutions.

Summary 1. Six cases of subcostosternal diaphragmatic hernia are reported. 2. Stress is laid on the fact that these hernias are seen either as symptomless Mass Radiography pick-ups, or because of respiratory symptoms. 3. The typical radiological appearances are described. 4. Treatment is surgical—the abdominal route should be employed.

DIAPHRAGMATIC hernias may be divided (after Harrington) into two groups: (1) traumatic (including inflammatory necrosis) and (2) nontraumatic. The latter are structural deficiencies, which may be congenital or acquired. They include (1) esophageal hiatus hernia, due to deficiency of the circular muscle bundles of the hiatus; (2) hernia through the foramen of Bochdalek (pleuroperitoneal hiatus), in which the posterolateral portion of the diaphragm, usually on the left side, fails to fuse; (3) congenital absence of the diaphragm—an enlargement of the foregoing—virtually a more extensive congenital defect extending farther posteriorly, and (4) herniation anteriorly through the foramen of Morgagni or Larrey's spaces. These are the two small spaces devoid of muscle, situated anteriorly on either side of the sternum and immediately behind the anterior costal attachment of the diaphragm. They are filled with loose areolar tissues and contain only the superior epigastric artery and lymphatics. Such a hernia has also been