Thoracoscopic Repair for Right Congenital Diaphragmatic Hernia

Thoracoscopic approach in management of congenital diaphragmatic hernia

Thoracoscopic repair is feasible and safe for congenital diaphragmatic hernia (CDH). The operation can be performed with three trocars using carbon dioxide insufflations at a pressure of 4-6 mmHG. From January 2001 to July 2012, we performed thoracoscopic repair for 311 children with CDH including 152 newborns and 159 infants and toddlers. Mean operative time was 75 ± 27 min. HFOV was used in 24 patients. Direct closure of two rims of diaphragmatic hernia was carried out in 175 patients. Closure of two rims of diaphragmatic hernia with the thoracic wall was performed in 136 patients. Prosthetic patches were required in 54 patients. Conversion to open surgery was required in 38 patients (12.2%). There were no intraoperative deaths. 38 patients died postoperatively (13.5%).

Paediatric thoracoscopic surgery

Thoracoscopic surgery is now an integral part of paediatric practice. The evolution of instrumentation, optics and haemostatic devices have enabled even the most complex procedures to be carried out thoracoscopically. Although randomised studies are limited in children, thoracoscopic surgery appears to offer outcomes at least equivalent to that of open operations with less post-operative pain, less scarring and a more rapid recovery. Furthermore many of the long term musculo-skeletal deformities associated with a thoracotomy are avoided. There are however several surgical and anaesthetic challenges that make the widespread application of these techniques beyond that of specialised centres difficult.

Does thoracoscopic congenital diaphragmatic hernia repair cause a significant intraoperative acidosis when compared to an open abdominal approach?

PURPOSE

Thoracoscopic congenital diaphragmatic hernia (CDH) repair is increasingly reported. A significant intraoperative acidosis secondary to the pneumocarbia, as well as an increased recurrence rate, are possible concerns. Our aim was to review our early experience of the technique.

METHODS

A prospective and retrospective data collection was carried out on all patients undergoing either an open or thoracoscopic CDH repair for a 4-year period. Preoperative blood gas values were identified at various stages of the operative procedure. A pH of 7.2 was considered to be a significant acidosis. The duration of surgery, complications, and recurrence rates were also recorded. Data were analyzed using the Mann-Whitney U test, and a P value of .05 or less was considered significant.

RESULTS

Twenty-two patients were included. One death occurred before surgery. Twelve patients underwent thoracoscopic repair (8 neonatal), and 9 underwent open repair (8 neonatal). There were 9 left-sided defects in the thoracoscopic group and 9 in the open group. Operative time was longer in the thoracoscopic group compared to the open group (median, 135 vs 93.5 minutes; P = .02). Neonates undergoing thoracoscopic repair were heavier compared to the open group (median, 3.9 vs 2.9 kg; P = .05), and their preoperative requirements for ventilation and inotropes were comparable. However, the association between those patients who required preoperative inotropes and those who required a patch repair was statistically significant P = .03. Two patients in each group developed an intraoperative acidosis. A further patient in the thoracoscopic group had a severe acidosis present at the beginning of surgery. There was no statistical difference in pH values or recurrence rate between the 2 groups. All recurrences were in patients requiring patch repairs. No postoperative mortality occurred.

CONCLUSIONS

We present our early experience of thoracoscopic CDH repair. Our results from thoracoscopic repair appear similar to the open procedure performed over the same period. No clear difference in intraoperative pH or recurrence rate has been demonstrated in our series. There is a need for a multicenter prospective study to establish the longer term outcome of this technique.

Thoracoscopic repair for congenital diaphragmatic hernia: experience with 139 cases

PURPOSE

To analyze indications and to present details of surgical technique and outcomes of thoracoscopic repair for congenital diaphragmatic hernia (CDH) in 139 patients.

METHODS

We reviewed medical records of all patients with CDH who underwent thoracoscopic repair by the same surgical team from June 2001 to October 2009. Patients were placed in the lateral decubitus position. The operations were performed using three trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-6 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots. A prosthetic patch was used when direct closure of the hernia defect was not feasible.

RESULTS

There were 139 patients, including 91 boys and 48 girls. Seventy-five patients were newborns, and 64 were infants or children. The hernia was located on the left side in 113 patients (81.3%) and on the right side in 26 patients (18.7%). The mean operative time for thoracoscopic approach was 66 ± 27 minutes. Conversion was required in 11 patients (7.9%) from 2001 to 2007. There were no conversions in 2008 or 2009. A prosthetic patch was used in 7 patients. There were 14 postoperative deaths (10%). Follow-up was obtained in 114 patients, ranging from 1 to 84 months (mean 26.3 ± 24.7 months). Five patients had recurrence (3.6%).

CONCLUSIONS

Thoracoscopic repair is feasible and safe for children with CDH, including newborns. The conversion rate decreased, and indications increased with surgical team experience.

Thoracoscopic repair in the neonatal intensive care unit for congenital diaphragmatic hernia during high-frequency oscillatory ventilation

AIM

The aim of this work was to report the technique and result of thoracoscopic repair for a newborn with congenital diaphragmatic hernia (CDH) under high-frequency oscillatory ventilation (HFOV) in the neonatal intensive care unit (NICU).

METHODS

Ventilation was supported by HFOV. The patient was placed in the right lateral decubitus position. Thoracoscopic surgery was performed through three 5-mm trocars. Carbon dioxide insufflation was maintained in the thoracic cavity at a pressure of 6-8 mm Hg. The hernia defect was repaired by using interrupted sutures with extracorporeal knots.

RESULTS

The operation lasted 60 minutes. The intraoperative course was uneventful. Normal vital signs and PO(2) value were maintained throughout the operation. The patient had a normal chest X-ray 1 month after discharge.

CONCLUSION

Thoracoscopic repair of CDH in the NICU during HFOV is feasible and safe.

Thoracoscopic repair of congenital diaphragmatic hernia in neonates: lessons learned

PURPOSE

We sought to characterize our recent experience with thoracoscopic congenital diaphragmatic hernia (CDH) repair and identify patient selection factors.

METHODS

We reviewed the medical records of full-term neonatal (<1 month of age) patients who underwent thoracoscopic CDH repair between 2004 and 2008 (n = 15). We obtained data on prenatal diagnosis, characteristics of the CDH and repair, complications, and outcome.

RESULTS

All patients were stabilized preoperatively and underwent repair at an average of 5.7 +/- 1.3 days. Six patients were prenatally diagnosed, including the 5 inborn. Thirteen defects were left-sided. All were intubated shortly after birth and 2 required extracorporeal membrane oxygenation (ECMO). Twelve of 15 (80%) patients underwent successful thoracoscopic primary repair, including 1 of the patients who required ECMO prior to repair. Conversion to open repair occurred in 3 of 15 (20%) patients because of the need for patch closure or intraoperative instability. Among those converted to open, all had left-sided CDH defects and 3 had stomach herniation (of 5 such patients). Patients spent an average of 6.9 +/- 1.0 days on the ventilator following repair. The average time until full-enteral feeding was 16.7 +/- 2.25 days, and average length of hospital stay was 23.8 +/- 2.73 days. All patients survived to discharge, and average length of follow-up was 15.3 +/- 3.6 months.

CONCLUSIONS

Thoracoscopic repair of CDH is a safe, effective strategy in patients who have undergone prior stabilization. Stomach herniation is associated with, but does not categorically predict, conversion to open repair. ECMO use prior to repair should not be an absolute contraindication to thoracoscopic repair.