Simple and safe thoracoscopic repair of neonatal congenital diaphragmatic hernia by a new modified knot-tying technique

Surgical management of the diaphragmatic defect in congenital diaphragmatic hernia: a contemporary review

Worldwide, 150 children are born each day with congenital diaphragmatic hernia (CDH), a diaphragmatic defect with concomitant abnormal lung development. Patients with CDH with large defects are particularly challenging to treat, have the highest mortality, and are at significant risk of long-term complications. Advances in prenatal and neonatal treatments have improved survival in high-risk patients with CDH, but surgical treatment of large defects lacks standardization. Open repair by an abdominal approach has long been considered the traditional procedure, but the type of defect repair (patch or muscle flap) and patch material (non-absorbable, synthetic or absorbable, biological) remain subjects of debate. Increased experience and improved techniques in minimally invasive surgery (MIS) have expanded selection criteria for thoracoscopic defect repair in cardiopulmonary stable patients with small defects. However, the application of MIS to repair large defects remains controversial due to increased recurrence rates and unknown long-term effects of perioperative hypercapnia and acidosis resulting from capnothorax and reduced ventilation. Current recommendations on the surgical management rely on cohort studies of varying patient numbers and data on the long-term outcomes are sparse. Here, we discuss surgical approaches for diaphragmatic defect repair highlighting advancements, and knowledge gaps in surgical techniques (open surgery and MIS), patch materials and muscle flaps for large defects, as well as procedural adjuncts and management of CDH variants.

Reasons for conversions in thoracoscopic repairs of neonatal congenital diaphragmatic hernias: a systematic review

PURPOSE

This systematic review focused on reasons for conversions in neonates undergoing thoracoscopic congenital diaphragmatic hernia (CDH) repair.

METHODS

Systematic search of Medline/Pubmed and Embase was performed for English, Spanish and Portuguese reports, according to PRISMA guidelines.

RESULTS

Of the 153 articles identified (2003-2023), 28 met the inclusion criteria and offered 698 neonates for analysis. Mean birth weight and gestational age were 3109 g and 38.3 weeks, respectively, and neonates were operated at a mean age of 6.12 days. There were 278 males (61.50%; 278/452) and 174 females (38.50%; 174/452). The reasons for the 137 conversions (19.63%) were: (a) defect size (n = 22), (b) need for patch (n = 21); (c) difficulty in reducing organs (n = 14), (d) ventilation issues (n = 10), (e) bleeding, organ injury, cardiovascular instability (n = 3 each), (f) bowel ischemia and defect position (n = 2 each), hepatopulmonary fusion (n = 1), and (g) reason was not specified for n = 56 neonates (40.8%). The repair was primary in 322 neonates (63.1%; 322/510) and patch was used in 188 neonates (36.86%; 188/510). There were 80 recurrences (12.16%; 80/658) and 14 deaths (2.48%; 14/565). Mean LOS and follow-up were 20.17 days and 19.28 months, respectively.

CONCLUSIONS

Neonatal thoracoscopic repair for CDH is associated with conversion in 20% of cases. Based on available data, defect size and patch repairs have been identified as the predominant reasons, followed by technical difficulties to reduce the herniated organs and ventilation related issues. However, data specifically relating to conversion is poorly documented in a high number of reports (40%). Accurate data reporting in future will be important to better estimate and quantify reasons for conversions in neonatal thoracoscopy for CDH.

Unidirectional barbed sutures vs. interrupted intracorporeal knots in thoracoscopic repair of congenital diaphragmatic hernia in pediatrics

Background

Intracorporeal suturing knots continue to be one of the most challenging and time-consuming steps in the thoracoscopic repair of congenital diaphragmatic hernia (CDH). Barbed unidirectional knotless sutures are designed to shorten surgical procedures by eliminating the need to tie knots. This work aimed to compare unidirectional barbed sutures and interrupted intracorporeal knots in the thoracoscopic repair of CDH in pediatrics regarding the time required to suture, operative time and complications.

Methods

This retrospective study included 139 patients presented with Bochdalek CDH. Patients were classified into early (neonatal) and late presentations. The hernia defect was repaired by unidirectional Barbed sutures (V-LocTM and StratafixTM sutures) in group B or by Conventional interrupted intracorporeal knots in group C.

Results

In both early and delayed presentations, the time required to suture (15 and 13 min in group B, 33 and 28 min in group C for neonatal and delayed presentation respectively) was significantly shorter in group B. Complications (visceral perforation, wound infection, and recurrence) insignificantly differed between group B and group C of early presentation. No patients suffered from major complications in both groups.

Conclusions

Both unidirectional barbed sutures and intracorporeal knots were safe and effective. However, unidirectional barbed sutures are a time-saving choices for CDH thoracoscopic repair in early and late presentations.

A Systematic Review Comparing the Surgical Outcomes of Open Versus Minimally Invasive Surgery for Congenital Diaphragmatic Hernia Repair

Introduction: Surgical intervention is the definitive management for congenital diaphragmatic hernia (CDH) repair from 1902. Since this time, two mainstay approaches have been used, open and minimally invasive surgical (MIS) repair. An invasive laparotomy is used in around 91% of cases. So, this systematic review of the published literature will compare the surgical outcomes of open (CDH) repair vs MIS for CDH repair and will determine which approach is superior. Material and Methods: Our literature search across MEDLINE and EMBASE included articles from 2004 to 2022, incorporating pediatric CDH repairs, human subjects only, and English language articles. Primary outcomes analyzed were rate of recurrence, length of surgery, length of hospital stay, use of diaphragmatic patch, mortality, postoperative chylothorax, and extracorporeal membrane oxygenation (ECMO) use postoperatively. Results: After application of exclusion criteria, 32 articles were reviewed. Comparison of MIS repair versus open repair had a rate of recurrence at 8.6% versus 1.6% (P < .00001). Length of hospital stay was 19.6 days versus 33.6 days (P = .0012), mortality rate at 4.6% versus 16.6% (P < .0001), patch repair required in 19.6% versus 55.4% (P = < .00001), and postoperative ECMO use of 3.7% versus 12.3% (P < .00001), respectively. Conclusion: MIS repair is associated with decreased length of hospital stay, reduced mortality rate, and postoperative ECMO usage. Hernia recurrence is still high among MIS repair groups compared to the open repair groups. Large, multicentered randomized control trials are recommended for further analysis to decipher the true superior surgical intervention.

Tension-free thoracoscopic repair of congenital diaphragmatic hernia combined with a percutaneous extracorporeal closure technique: how to do it

PURPOSE

Thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) is associated with a higher recurrence rate than the conventional open method. We evaluated the effectiveness of our strategy for quality improvement, named "tension-free TR of CDH".

METHODS

The subjects of this retrospective analysis were 11 consecutive patients with CDH who underwent TR at our hospital between 2017 and 2021. Tension-free TR of CDH included the proactive use of an oversized patch for dome-shaped reconstruction and gapless suturing. We developed a percutaneous extracorporeal closure technique for secure suturing using a commercially available needle.

RESULTS

Patch repair was performed in 8 (73%) patients and none required conversion to open surgery because of technical difficulties. Recurrence developed in one patient (9%), who underwent successful reoperation via TR. All patients had an uneventful postoperative course.

CONCLUSION

Tension-free TR combined with extracorporeal closure could reduce the difficulty of suturing and the risk of recurrence of CDH.

Thoracoscopic Guided Pericostal Sutures as a Solid Fixation for Primary Closure of Congenital Diaphragmatic Hernias

Purpose: To describe a minimally invasive technique with primary closure and strong suture connection that is feasible in cases of larger, most common type B defects of congenital diaphragmatic hernia (CDH). Background: The thoracoscopic approach (TA) is a favorable technique for the repair of CDH and is still evolving globally. A common issue is finding the optimal suture technique for secure closure in order to prevent recurrences. Whether a defect can be closed only by sutures or by using a patch depends on the size of CDH, the presence of a muscular rim along the inner thoracic surface and finally on the surgeon’s experience. From a geometrical point of view, the challenge is to transform the circular defect into a line, without tension, with a strong compound and preferably without additional material. To address this, we apply a setting of the sutures in a “T-shape” and a way to lead the sutures around the rib bones in order to increase stability. This method allows for the primary closure of CDHs and also applies to larger defects. Cases: We present seven newborns with posterolateral CDH on the left side. The defects were solely repaired by TA and by the suturing technique described in detail.

Congenital Diaphragmatic Hernia: Experience and Results of Thoracoscopic Repair from a Tertiary Care Hospital

Introduction Congenital diaphragmatic hernia (CDH) is one of the most common congenital anomalies encountered by pediatric surgeons. With the advances in the pediatric minimal access surgery, its role in the repair of CDH has also increased. We have been using thoracoscopy for the repair for CDH since 2015. We herein report our experience of CDH repair in newborns.

Materials and Methods A retrospective review was conducted from July 2015 to December 2019 in the Department of Pediatric surgery after ethical approval from the institutional review board and included all the children with CDH who underwent thoracoscopic repair. The case records were used to assess the demographic details, type of defect, and early and late postoperative complications of thoracoscopy in CDH.

Results Thoracoscopic repair was attempted in 29 patients of CDH. Eight (27.5%) patients converted to open procedure and were excluded from the study. Primary closure of the diaphragmatic defect was performed in 90.4% (19) patients. Also, 9.5% (2) children required mesh repair. There was no intraoperative death. Postoperative ventilation was required in 57.1% (12) children. The mean time on the ventilator was 3.03 ± 0.9 days. The mean age of children requiring postoperative ventilation was less compared with children who were extubated in the postoperative period (p = 0.032). The median follow-up in our study was 12 months and 28.5% of patients developed recurrence of the diaphragmatic hernia. All the children underwent laparotomy and repair of the diaphragmatic defect.

Conclusion Thoracoscopic repair is a safe and effective option for the repair of CDH in children performed by surgeons with significant procedure experience.