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1.
Sohail R. Shah George K. Gittes Katherine A. Barsness Timothy D. Kane 《Surgical endoscopy》2009,23(1):215-215
Purpose Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate
operative technique for the management of congenital diaphragmatic hernias in neonates [1–3]. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in
a 3-day-old male.
Methods Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient’s
remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD),
and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic
stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed
with a thoracoscopic repair of the CDH.
Results The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully
repaired thoracoscopically using a 5 × 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second
postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and
division at 1 month of age. There has been no evidence of CDH recurrence in follow-up.
Conclusions As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully
repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used
in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge
this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in
a neonate with significant congenital cardiac anomalies.
Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. 相似文献
2.
Background
Diaphragmatic hernia can be repaired by open or minimally invasive surgery (MIS), although it is unclear which technique has better outcomes. Our objective was to compare the outcomes of these procedures in a systematic review and meta-analysis.Methods
We sought all publications describing both techniques through MEDLINE, Embase, and CENTRAL. Our primary outcome of interest was recurrence. We conducted statistical analyses using Review Manager 5.2.Results
We did not identify any randomized controlled trials. Our pooled estimate of results from 10 studies showed that total recurrence was higher after MIS (OR: 2.81 [1.73, 4.56], p < 0.001). Subgroup analyses indicated higher recurrence after MIS for patch repairs (OR: 4.29 [2.13, 8.67], p < 0.001), but not for primary repairs. Operative time was longer for MIS (MD: 55.25 [40.21, 70.28], p < 0.001), while postoperative ventilator time and postoperative mortality were higher after open surgery (MD: 1.33 [0.05, 2.62], p = 0.04; OR: 7.54 [3.36, 16.90], p < 0.001, respectively).Conclusions
Recurrence rate is higher after MIS than open repair when a patch is used. Operative time is also longer with MIS. Poorer outcomes after open surgery may be a result of selection bias rather than surgical technique. Surgeons should carefully consider the potential morbidity associated with MIS when deciding on a repair method. 相似文献3.
We describe a robotic repair of a large Morgagni congenital diaphragmatic hernia in a 12-month-old infant using the da Vinci
surgical robot. 相似文献
4.
Sameh M. Said 《Journal of pediatric surgery》2010,45(4):e5
Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000 to 3000 live births and accounts for 8% of all major congenital anomalies. Bilateral hernias account for no more than 1% of all types of CDH; furthermore, they are usually fatal prenatally. Those that survive are identified through a limited number of case reports. We are presenting an unusual case of bilateral CDH hernia in a neonate that was repaired successfully using a staged thoracoscopic approach. To our knowledge, this represents the first case in the world literature of bilateral CDH that was repaired thoracoscopically. In carefully selected patients, appropriate use of disruptive new technologies such as thoracoscopy can be achieved. 相似文献
5.
Cory N. Criss Megan A Coughlin Niki Matusko Samir K. Gadepalli 《Journal of pediatric surgery》2018,53(4):635-639
Introduction
Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.Methods
All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients < 36 weeks gestation, birth weight < 1500 g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.Results
The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23 days, p = 0.03), days on ventilator (5 vs. 12, p = 0.02), days to start of enteral feeds (5 vs. 10, p < 0.001), and days to goal feeds (11 vs. 20, p = 0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p = 0.28). Median time to recurrence was 88 days for the open repair and 183 days (IQR 165–218) for the thoracoscopic group. There were no mortalities in either group.Conclusions
In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.Level of evidence
Level III. 相似文献6.
Minimally invasive repair for a Bochdalek congenital diaphragmatic hernia has been performed over the last few years with mixed results. Although the anomaly has been approached from both the abdomen and the chest, the defect can be difficult to close as the posterolateral region may be difficult to reach with precise suturing using standard rigid laparoscopic instruments. The articulating instruments of robotic surgery offer a substantial improvement in degrees of freedom and may help over come these obstacles. However, other limitations including instrument length in relation to patient size need to be accounted for when planning a robotic procedure in small children. We present a robotic repair of a foramen of Bochdalek congenital diaphragmatic in a 2.2 kg neonate using and abdominal approach with the Da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). 相似文献
7.
Ali Kamran Benjamin Zendejas Farokh R. Demehri Bharath Nath David Zurakowski Charles J. Smithers 《Journal of pediatric surgery》2018,53(11):2087-2091
Purpose
To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH).Methods
All CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses.Results
Sixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (n?=?52) or beyond the neonatal period (> 1?month) (n?=?16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36?months (IQR 9–45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, p?=?0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, p?=?0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence.Conclusions
Due to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs.Level of Evidence
Level III cohort study. 相似文献8.
Raquel Gonzalez 《Journal of pediatric surgery》2009,44(6):1181-1185
Purpose
Chylothorax after congenital diaphragmatic hernia (CDH) repair contributes significantly to morbidity. Our aim was to identify factors contributing to chylothorax and effective treatment strategies.Methods
We reviewed 171 patients with CDH from 1997 to 2008 and analyzed hernia characteristics, extracorporeal membrane oxygenation (ECMO) use, operative details, and treatment approaches for chylothorax.Results
Ten (7%) patients developed chylothorax; all were left sided. Using univariate analysis, prenatal diagnosis, ECMO use, and patch repair were associated with development of chylothorax. Logistic regression analysis showed that patch repair was the only variable predictive of chylothorax (P = .028; confidence interval, 0.032-0.823). Although survival was not affected, patients with chylothorax had a significant increase in ventilator days and length of stay (t = 3.57; P = .000; t = 2.74; P = .007). All received thoracostomy and total parenteral nutrition. Six patients received octreotide, 5 of whom required pleurectomy because of failed medical management; the remaining patient died of overwhelming sepsis.Conclusions
The incidence of chylothorax at our institution was relatively low. Patch repair was associated with the formation of chylothorax. Morbidity was substantial, but survival was not significantly affected. Total parenteral nutrition and thoracostomy were appropriate initial treatments. Octreotide was not an effective adjunct. Refractory cases were successfully treated with pleurectomy. 相似文献9.
腹腔镜小儿先天性膈疝修补术 总被引:3,自引:0,他引:3
目的探讨腹腔镜小儿先天性膈疝修补术的疗效。方法2002年6月-2005年12月,我们对11例小儿先天性膈疝(3例新生儿年龄3—24h,余8例2—24个月)施行三孔或四孔腹腔镜手术。还纳疝内容物,丝线缝合膈肌修补缺损。结果10例手术修补成功。1例新生儿腹腔镜手术后3d膈疝复发,再次腹腔镜手术修补成功。手术时间55—180min,平均100min,术中出血量1—2ml。术后1—2d开始进食。11例随访9—24个月,平均16个月,X线检查膈肌位置正常。结论腹腔镜小儿先天性膈疝修补术安全可靠,创伤小,可清晰显露术野,术中还可探查有无腹部其他先天性畸形。 相似文献
10.
Cindy Gomes Ferreira Olivier Reinberg François Becmeur Hossein Allal Pascal De Lagausie Hubert Lardy Paul Philippe Manuel Lopez François Varlet Guillaume Podevin Jürgen Schleef Max Schlobach 《Surgical endoscopy》2009,23(7):1650-1659
Background Minimally invasive surgery (MIS) for late-presenting congenital diaphragmatic hernia (CDH) has been described previously,
but few neonatal cases of CDH have been reported. This study aimed to report the multicenter experience of these rare cases
and to compare the laparoscopic and thoracoscopic approaches.
Methods Using MIS procedures, 30 patients (16 boys and 14 girls) from nine centers underwent surgery for CDH within the first month
of life, 26 before day 5. Only one patient had associated malformations. There were 10 preterm patients (32–36 weeks of gestational
age). Their weight at birth ranged from 1,800 to 3,800 g, with three patients weighing less than 2,600 g. Of the 30 patients,
18 were intubated at birth.
Results The MIS procedures were performed in 18 cases by a thoracoscopic approach and in 12 cases by a laparoscopic approach. No severe
complication was observed. For 20 patients, reduction of the intrathoracic contents was achieved easily with 15 thoracoscopies
and 5 laparoscopies. In six cases, the reduction was difficult, proving to be impossible for the four remaining patients:
one treated with thoracoscopy and three with laparoscopy. The reasons for the inability to reduce the thoracic contents were
difficulty of liver mobilization (1 left CDH and 2 right CDH) and the presence of a dilated stomach in the thorax. Reductions
were easier for cases of wide diaphragmatic defects using thoracoscopy. There were 10 conversions (5 laparoscopies and 5 thoracoscopies).
The reported reasons for conversion were inability to reduce (n = 4), need for a patch (n = 5), lack of adequate vision (n = 4), narrow working space (n = 1), associated bowel malrotation (n = 1), and an anesthetic problem (n = 1). Five defects were too large for direct closure and had to be closed with a patch. Four required conversion, with one
performed through video-assisted thoracic surgery. The recurrences were detected after two primer thoracoscopic closures,
one of which was managed by successful reoperation using thoracoscopy.
Conclusions In the neonatal period, CDH can be safely closed using MIS procedures. The overall success rate in this study was 67%. The
indication for MIS is not related to weeks of gestational age, to weight at birth (if >2,600 g), or to the extent of the immediate
neonatal care. Patients with no associated anomaly who are hemodynamically stabilized can benefit from MIS procedures. Reduction
of the herniated organs is easier using thoracoscopy. Right CDH, liver lobe herniation, and the need for a patch closure are
the most frequent reasons for conversion. 相似文献
11.
Shah SR Wishnew J Barsness K Gaines BA Potoka DA Gittes GK Kane TD 《Surgical endoscopy》2009,23(6):1265-1271
Background Minimally invasive surgery (MIS) has been described for the repair of congenital diaphragmatic hernias (CDH) in neonates,
infants, and children. This report evaluates patient selection, operative technique, and clinical outcomes for MIS repair
of CDHs from a single center’s experience.
Methods All cases of CDH at a tertiary care pediatric hospital with an initial attempt at MIS repair from January 2001 to December
2007 were reviewed.
Results A total of 22 children underwent an initial attempt at MIS repair of their CDH (5 Morgagni and 17 Bochdalek hernias). The
children ranged in age from 1 day to 6 years (mean, 13.9 ± 23 months) and weighed 2.2 to 21 kg (mean, 7.4 ± 5.50 kg) at the
time of the operation. All five Morgagni hernias were managed successfully with laparoscopic primary repair. Six of the Bochdalek
hernias were found in infants and children (age range, 6–71 months). All these were managed successfully with primary repair
by an MIS approach (2 by laparoscopy and 4 by thoracoscopy). The remaining 11 Bochdalek hernias were found in neonates (age
range, 1 day to 8 weeks). Four of the Bochdalek hernias were right-sided. Nine of the Bochdalek hernias in neonates were repaired
thoracoscopically. One neonate required conversion to laparotomy, and another underwent conversion to thoracotomy. Four of
the neonates with Bochdalek hernias required a prosthetic patch. Two of the neonates also had significant associated congenital
cardiac defects. Overall, there were two recurrences involving one 3-day-old who underwent a primary thoracoscopic repair
and another 3-day-old who underwent a thoracoscopic patch repair. The follow-up period ranged from 5 months to 5 years.
Conclusions Morgagni hernias can be managed successfully by laparoscopy, whereas thoracoscopy is preferred for neonatal Bochdalek hernias.
Either approach can be successful for infants and children with Bochdalek hernias. Additionally, patients with congenital
cardiac defects and those requiring prosthetic patches can undergo a MIS CDH repair with a successful outcome. 相似文献
12.
“Acquired” congenital diaphragmatic hernia (ACDH), has been defined as delayed or late appearance of a congenital diaphragmatic hernia after a documented time period of postnatal life with no evidence of herniation. Three new cases are presented. This diagnosis has been characterized on the basis of a review of these cases and 14 additional patients from the literature. A classification based upon timing of herniation and state of pulmonary development is presented. 相似文献
13.
Libretti L Ciriaco P Carretta A Melloni G Puglisi A Casiraghi M Zannini P 《Journal of pediatric surgery》2006,41(1):e65-e67
Surgical repair of congenital diaphragmatic hernia (CDH) can be performed by means of either direct suturing of the diaphragm or positioning of a prosthetic patch. However, half of all prosthetic patches show evidence of reherniation. We describe the case of an 8-year-old girl who presented with prosthesis dislocation and fistulization in the right lower bronchus as a complication of a CDH repair that she underwent when she was 1 year old. Abdominal ultrasound and magnetic resonance imaging suggested a hernia relapse, whereas chest computed tomographic scan failed to identify the diaphragmatic defect. Only fibrobronchoscopy allowed fistulization of the prosthesis into the bronchi to be correctly diagnosed. 相似文献
14.
Merrill McHoney 《Journal of pediatric surgery》2010,45(2):355-359
Introduction
Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been described, but its efficacy and safety have not been validated. The aim was to compare our experience of thoracoscopy with laparotomy repair.Methods
After ethics approval, we reviewed the notes of neonates with CDH operated in our institution between 2003 and 2008. Two historical groups were compared: infants who underwent laparotomy (2003-2008) or thoracoscopy (2007-2008). Data were compared by t test or Mann-Whitney tests.Results
Thirty-five children had open repair of CDH, and 13 had thoracoscopic repair. Groups were homogeneous for age and weight. Five (38%) neonates who had thoracoscopy were converted to open for surgical difficulties (n = 4) and O2 desaturation (n = 1). Patch repair was used in 12 (34%) open and 6 (46%) thoracoscopic repairs. End-tidal CO2 was significantly elevated during thoracoscopy, but this was not reflected in arterial CO2 or pH. There were 3 (8%) recurrences after open repair and 2 (25%) after thoracoscopy (P = .19).Conclusion
Thoracoscopic repair of CDH is feasible. Arterial blood gases should be closely monitored. Despite higher EtCO2, conversion to open was mainly because of difficult repair. A randomized trial is necessary to assess the effect of thoracoscopy on ventilation and recurrences. 相似文献15.
Congenital diaphragmatic hernia usually presents in the neonatal period, with delayed presentation being uncommon. Traditionally
repair was performed by laparotomy or thoracotomy. We have performed laparoscopic repair of a previously undiagnosed congenital
diaphragmatic hernia that presented acutely in a 10-year-old male. Laparoscopic repair of late-presenting congenital diaphragmatic
hernia is a safe and effective approach even in an emergency. The laparoscopic approach has advantages including reduced hospital
stay, excellent visualisation of the defect even for obese patients, and improved cosmesis. 相似文献
16.
This report describes the laparoscopic approach of closure of a congenital left posterolateral diaphragmatic hernia in a 6-month-old boy. The pros and cons of such an approach are discussed. 相似文献
17.
Georgios D. Ayiomamitis Panayiotis Ch. Stathakis Efstratios Kouroumpas Alexandra Avraamidou Phivos Georgiades 《International journal of surgery case reports》2012,3(12):597-600
INTRODUCTIONCongenital diaphragmatic hernia (CDH) in adults is a relatively rare condition being asymptomatic in the majority of cases. Symptomatic CDH should prompt surgical management because they may lead to intestinal obstruction or severe pulmonary disease. This is the first reported case of a symptomatic CDH complicated with sliding hiatal hernia (SHH).PRESENTATION OF CASEA 65 years old women with reflux and dysphagia was complaining of postprandial paroxysmal dyspnea and epigastric pain radiating to her back. Upper endoscopy diagnosed sliding and para-esophageal diaphragmatic hernia with severe esophagitis. Computed tomography-scan revealed a large Bochdalek hernia at the left diaphragm.DISCUSSIONDiagnostic laparoscopy was decided, which confirmed the SHH, but also revealed a CDH defect at the tendonous part of the left diaphragm. The left bundle of the right crus was intact, separating the two hernia components (sliding and congenital). Extensive adhesiolysis was performed, dissecting and separating the stomach away from the diaphragm. Posterior cruroplasty at the esophageal hiatus was performed for the SHH with Nissen fundoplication as antireflux procedure. Primary continuous suture repair was performed for the CDH, reinforced with prosthetic mesh on top. Operative time was 150 min with no morbidity. The patient was discharged home uneventfully the third postoperative day. On 12-months follow-up, she reported no symptoms and improvement in quality of life.CONCLUSIONLaparoscopy is a unique method for a precise diagnosis of symptomatic congenital diaphragmatic hernia in adults being also a safe and viable technique for a successful repair at the same time. Experience of advanced laparoscopic surgery is required. 相似文献
18.
Melvin S. Dassinger Daniel R. Copeland Danny C. Little Samuel D Smith 《Journal of pediatric surgery》2010,45(4):693-697
Background
Timing of repair of congenital diaphragmatic hernia (CDH) in babies that require stabilization on extracorporeal membrane oxygenation (ECMO) remains controversial. Although many centers delay operation until physiologic stabilization has occurred or ECMO is no longer needed, we repair soon after ECMO has been initiated. The purpose of this study is to determine if our approach has achieved acceptable morbidity and mortality.Methods
Charts of live-born babies with CDH treated at our institution between 1993 and 2007 were retrospectively reviewed. Data were then compared with The Congenital Diaphragmatic Hernia Study Group and Extracorporeal Life Support Organization registries.Results
Forty-eight (39%) patients required ECMO Thirty-four of these 48 neonates were cannulated before operative repair. Venoarterial ECMO was used exclusively. The mean (SD) time of repair from cannulation was 55 (21) hours. Survival for this subset of patients was 71%. Three patients (8.8%) who underwent repair on ECMO experienced surgical site hemorrhage that required intervention.Conclusion
Early repair of CDH in neonates on ECMO can be accomplished with acceptable rates of morbidity and mortality. 相似文献19.
Purpose
To describe the surgical technique, initial results, and overview indications of thoracoscopic repair of congenital diaphragmatic hernia (CDH).Materials and Methods
A retrospective review was undertaken of patients with CDH who underwent thoracoscopic repair by the same surgeon from January 2001 to January 2005. Patients underwent surgery under general anesthesia. Reduction of the hernia contents was carried out using 1 optical trocar and 2 operating trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2 to 4 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots.Results
There were 45 patients, including 29 boys and 16 girls. Among 19 newborn patients, there were 13 patients younger than 7 days. The other 26 patients were infants and elders. The hernia was located in the left side in 37 patients and in the right side in 8 patients. The mean operative time was 54 minutes. Conversion was required in 4 patients. There were no complications. However, there were 2 postoperative deaths.Conclusions
Thoracoscopic repair is feasible and safe for children with CDH, including selective newborn. The technique causes minimal trauma, results in good respiratory function, and promotes early recovery. 相似文献20.
Arena F Romeo C Calabrò MP Antonuccio P Arena S Romeo G 《Journal of pediatric surgery》2005,40(7):1078-1081