Thoracoscopic Repair of a Right-Sided Congenital Diaphragmatic Hernia

Laparoscopic Repair of a Chronic Iatrogenic Diaphragmatic Hernia

We report the diagnosis and repair of a chronic, iatrogenic diaphragmatic hernia using minimally-invasive techniques. A 69-year-old man presented with intermittent abdominal and shoulder pain. He had previously undergone laparoscopic Nissen fundoplication in which a grasper-induced puncture injury to the left hemidiaphragm was noted but not repaired. Radiographs and CT imaging diagnosed a left diaphragmatic hernia, with stomach herniated into the left thoracic cavity. This was repaired successfully via an intra-abdominal laparoscopic approach. This case represents the potential importance of repairing post-traumatic diaphragmatic hernia at the time that they occur, as well as a minimally invasive means for their repair.

Theatre of paediatric surgery

In the 50 years since the first edition of this journal, operative paediatric surgery has undergone radical change. Many of the most common instruments are unchanged, both as a testament to their utility and in recognition of past surgeons remembered eponymously. Surrounding that basic core of instruments, theatre has changed radically as new tools and techniques have arisen. Surgeons have come down from their pedestals, recognising surgery as a team sport rather than a solo performance. More than half of the current paediatric surgical trainees are women, a higher proportion than in any other craft group of the Royal Australasian College of Surgeons. The appearance, and rapid development, of laparoscopy is to many observers the most notable change in surgery over the last 50 years. Placed in its context though, it is simply the most prominent example of a frameshift in surgical thinking. The patient as a whole is now the focus, rather than just the disease. Recent developments are as much about minimising harm to normal tissues as they are about extirpating pathology. As a surgical maxim, 'Primum non nocere' is even more in evidence in 2015 than it was in 1965.

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.

Minimally invasive repair of a congenital right-sided diaphragmatic hernia in an adult

A 75-year-old woman who presented with a cough was found on investigation to have a large right-sided diaphragmatic hernia with intrathoracic herniation of the colon, small bowel, and right kidney. The patient denied any history of trauma and therefore the hernia was felt to be congenital in nature. The patient underwent a combined laparoscopic repair with polytetrafluoroethylene mesh and a thoracoscopic lysis of adhesions of the posterior right-sided diaphragmatic hernia. To our knowledge, this is the first reported case of a combined laparoscopic and thoracoscopic repair of a congential diahphragmatic hernia. Although successful repair can be accomplished laparoscopically, the addition of a thoracoscopic lysis of adhesions facilitated the early reexpansion of our patient's chronically scarred lung.

Beyond feasibility: a comparison of newborns undergoing thoracoscopic and open repair of congenital diaphragmatic hernias

BACKGROUND

Although both laparoscopic and thoracoscopic repair of congenital diaphragmatic hernia (CDH) have been described in the literature, neither appropriate selection criteria nor improved outcomes for minimally invasive repair over open repair have been clearly delineated.

METHODS

We reviewed our experience with neonatal CDH repair between 2004 and 2007 to determine clinical parameters that are associated with successful thoracoscopic CDH repair. We compared these patients to a similarly matched cohort of patients who had undergone an open neonatal CDH repair between 1999 and 2003.

RESULTS

From 2004 to 2007, 20 (61%) of 33 patients underwent successful neonatal thoracoscopic CDH repair. Characteristics common to all patients who underwent successful thoracoscopic repair included absence of congenital heart defects, no need for extracorporeal membrane oxygenation, ventilatory peak inspiratory pressure of less than 26 cmH(2)O, and oxygenation index less than 5 on the day of planned surgery. From 1999 to 2003, 40 patients underwent an open neonatal CDH repair, of which 18 (45%) patients would have matched our selection criteria for thoracoscopic repair. These 2 cohorts were similar in age, estimated gestational age, weight, APGAR scores, and oxygenation index at the time of surgery. The thoracoscopic cohort had statistically and clinically significant quicker return to full enteral feeds, had shorter duration on the ventilator postoperatively, and required less narcotic/sedation postoperatively. Less severe complications occurred in the thoracoscopic cohort. Adjusted total hospital charges were less for the thoracoscopic repair.

CONCLUSIONS

Successful thoracoscopic CDH repair can be expected in newborns, which has limited respiratory compromise. Thoracoscopic CDH repair is associated with lower morbidity and quicker recovery than traditional open repair and without increased risk of recurrence or complications.

Thoracoscopic repair of neonatal diaphragmatic hernia

INTRODUCTION

The use of minimally invasive surgery (MIS) in the neonatal population is increasing. Thoracoscopic intervention for congenital diaphragmatic hernia (CDH) is no exception. In this report, we describe our initial experience with thoracoscopic repair of left-sided diaphragmatic defects in neonates.

MATERIALS AND METHODS

We performed retrospective chart reviews on all neonates who underwent thoracoscopic repair of CDH between November 2004 and January 2008. Neonates that underwent thoracoscopic repair were physiologically stable with resolved pulmonary hypertension and minimal to moderate ventilatory support. They had no associated cardiac anomalies.

RESULTS

We identified 15 neonates with CDH who underwent thoracoscopic repair during the study period. Ten neonates underwent primary repair of the diaphragmatic defect. Five neonates with large defects required closure with a synthetic patch, which was placed thoracoscopically. The average operating room time was 134 minutes. There were no instances of intraoperative respiratory or cardiac instability. Three patients had a recurrence. One recurrence was seen after thoracoscopic patch repair. Two recurrences occurred following primary repair of left diaphragmatic hernias. There were no deaths. Follow-up has been 4-40 months.

CONCLUSIONS

Neonatal MIS for CDH should be limited to stable patients. The ideal candidate is the newborn without associated anomalies, not requiring extracorporeal membrane oxygenation, on minimal ventilatory support, and without evidence of pulmonary hypertension. It is technically possible to perform thoracoscopic repair with a patch.

Thoracoscopic repair of diaphragmatic hernia in neonates and children: a new simplified technique

Needlescopic techniques have been used recently in different pediatric procedures, which made this type of surgery more feasible and less invasive with decreased hospital stay and improved cosmetic results. The technique is being developed further. New techniques with minor modifications are evolving every day. The objective of this study was to describe and assess the results that can be achieved by using a new simplified technique [Reverdin needle (RN)] in thoracoscopic repair of diaphragmatic hernia in neonates and children. Eighteen patients with symptomatic congenital diaphragmatic hernia (CDH), from Al-Azhar University Hospitals, Cairo, Egypt were assigned to elective thoracoscopic repair using RN to insert mattress sutures between the edges of diaphragmatic defects. The technique will be described in detail. A total of 18 diaphragmatic defects were repaired successfully; there were 12 males and 6 females with a mean age of 1.58 +/- 21 months (range, 5 days-9 months). Left-sided CDH was present in 12 cases (67%) and right-sided CDH in 6 cases (33%). The mean operative time was 30.7 +/- 1.18 min (range, 25-60 min) for each CDH repair. There were no intra or postoperative complications. There was one case of conversion and minimal blood loss. The mean postoperative hospital stay was 5.6 days (range, 2-10 days). There was only one case of mortality on the 10th postoperative day. There was no single case of recurrence. The new technique had all the advantages of thoracoscopy in children (less invasive, less pain, shorter hospital stay) combined with the advantages of reduced operating time, simplicity and feasibility. It may be preferable to intracorporeal suturing and knot tying.