The very large recurrent postoperative scrotal hydrocele after pediatric inguinal hernia repair: a rare problem

Purpose

To report the rare problem of a very large recurrent postoperative scrotal hydrocele after pediatric inguinal hernia repair.

Methods

From July 1969 to December 2007 inclusive, the charts of five boys mean age 8 years (range 7 months–16 years) with very large recurrent postoperative scrotal hydroceles were reviewed (Research Ethics Board approval 1000007698).

Results

In each case, there was a very large recurrent postoperative symptomatic scrotal hydrocele (3 right, 1 left, 1 bilateral). Their ages at the time of these recurrences were between 11 and 16 years; they were repaired within 2–18 months. The first four were repaired via a groin incision on finding no recurrent inguinal hernia. The last two were repaired through a scrotal approach because a groin ultrasound showed no recurrent inguinal hernia. There was 1 second recurrence which was successfully repaired. A followup of 1½–9 years revealed no recurrent hydrocele.

Conclusions

The incidence of a very large recurrent symptomatic postoperative scrotal hydrocele after repair of a pediatric inguinal hernia is 0.06% and usually occurs in older boys. If ultrasonography of the groin is normal (since a recurrent inguinal hernia seems unlikely in such cases), this repair can usually be done via a scrotal approach.

     

Is contralateral inguinal exploration necessary in preterm girls undergoing inguinal hernia repair during the first months of life?

Background

To assess the need for contralateral surgical exploration in preterm girls with symptomatic unilateral inguinal hernia.

Methods

The medical data of girls operated for inguinal hernia between 2004 and 2016 in a single pediatric surgery center were retrospectively collected. Preterm girls operated for unilateral hernia before 6 months of life were selected (55/517 cases) to assess the incidence and risk factors for contralateral metachronous inguinal hernia (CMIH).

Results

CMIH was observed in 7% of cases (4 girls with a right inguinal hernia in 3 cases) at a mean age of 4.2 years. Only one case occurred early (3 months). Birth weight and term were comparable (1674?±?620 g and 32?±?5 WA without CMIH vs. 1694?±?582 g and 33?±?3 WA with CMIH).

Conclusion

Contralateral inguinal hernia is very rare and generally occurs several years after inguinal repair surgery in preterm girls, which should encourage practitioners to follow these children throughout childhood for the subsequent development of inguinal hernia. This study did not find any arguments in favor of systematic contralateral exploration in preterm girls.

     

Laparoscopic repair of sliding inguinal hernia in female children

Purpose

To evaluate the safety and feasibility of laparoscopic repair of sliding inguinal hernia in female children.

Methods

Laparoscopic percutaneous extraperitoneal closure (LPEC) was performed in 482 female inguinal hernia children between 2006 and 2015. Fourteen of these patients were associated with sliding inguinal hernia, and these 14 patients were enrolled and reviewed retrospectively.

Results

The mean age and the body weight at the operation was 9.6 months and 7.8 kg. Seven patients required the reduction of the ovary under general anesthesia. Laparoscopy, however, revealed that five patients had severe sliding of fallopian tube into the inguinal canal. One of these five patients received a simple LPEC, but developed the recurrence due to the low ligation of the hernia sac, and needed the second hernia repair under inguinal approach. Other four patients with fallopian tube sliding required the dissection of the fallopian tube and peritoneal repair, or the conversion to inguinal approach; therefore they had longer surgical time compared to those without fallopian tube sliding.

Conclusion

LPEC is safe and feasible for the sliding inguinal hernia repair except the cases with fallopian tube sliding. Patients with fallopian tube sliding required additional procedure or conversion to inguinal approach.

     

Percutaneous internal ring suturing as a first choice laparoscopic inguinal hernia repair method in girls: a single-center study in 148 patients

Introduction

We sought to retrospectively assess the operative findings and clinical outcomes of 148 girls who underwent laparoscopic inguinal hernia repair with the percutaneous internal ring suturing (PIRS) technique.

Methods

Between 2010 and 2014, girls with inguinal hernia underwent surgery using the laparoscopic PIRS technique described by Patkowski. Demographic and perioperative findings, complications, and recurrences were evaluated.

Results

A total of 205 inguinal hernia repairs were performed in 148 children with a mean age of 5.83 years (1 month–16 years). In 57 girls (38.5 %), the hernias were bilaterally repaired, while in 91 girls (61.5 %) hernias were unilaterally repaired. The mean follow-up time was 3.6 years (range 2.5–6.1 years). No serious complications or recurrence were noted. Granuloma occurred in one patient.

Conclusion

The PIRS technique is a safe, simple and effective procedure for girls. Excellent cosmetic results and reduced recurrence rates are associated with this method. This procedure is particularly suitable for girls because they lack a spermatic cord and vascular structures that can cause complications with this technique in boys. Based on our experience and others in the literature, we suggest that the PIRS procedure might be considered a gold standard for inguinal hernia operations in girls.

     

Testicular atrophy following inguinal hernia repair in children

Purpose

We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children.

Methods

We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including?>?3 million children. We abstracted data on male children?<?12 years who underwent inguinal hernia repair (2005–2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis.

Results

8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1–5). Median follow-up was 3.57 years (IQR 1.69–6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children \(\le\)?5 years, with 72% in children <?2 years. Median time to atrophy was 2.4 years (IQR 0.64–3), with 30% occurring within 1 year and 75% within 3 years.

Conclusion

Testicular atrophy is a rare complication following inguinal hernia repair, with children?<?2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later.

Level of evidence

Prognosis Study, Level II.

     

A nationwide survey of incidence rates and risk factors of inguinal hernia in preterm children

Purpose

Clinical observations showed a higher incidence rate of inguinal hernia (IH) in preterm infants. In this study, we calculated the incidence rate of preterm IH from the National Health Insurance Research Database (NHIRD) of Taiwan.

Methods

From NHIRD, 92,308 subjects born in the year of 1997–2005 were randomly selected as the study cohort. The medical claims of these subjects from birth to 6th year of age were analyzed. Preterm births were defined using ICD code 765.1*. Risk factors such as birth weight, lung disorders, and ventilator supports before IH repairs were investigated. The risk of incarceration and bowel resection were also evaluated.

Results

From 92,308 subjects, 2560 preterm births were identified. IH was repaired in 231 preterm (9.02%) and 3650 term subjects (4.07%). Male (preterm 13.3% and non-preterm 6.3%) had more hernia repairs than female (preterm 3.8% and non-preterm 1.6%). The incidence rate of IH is 13.7% for those under 1500 g, 8.2% for those 1500–1999 g, 7.7% for those 2000–2499 g, and 6.3% for those above 2500 g. The incidence rate of IH in preterms with past history of lung disorders and ventilation supports is 8.7 and 13.6%, respectively. There was no significant difference in the incidences of incarceration and bowel resection between preterms and non-preterms.

Conclusions

Birth weight under 2500 g is a significant risk factor for IH repairs. Other risk factors are male gender, past history of lung diseases, and ventilator supports.

     

Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial

Purpose

Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years.

Methods

A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores.

Results

Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years.

Conclusion

Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

     

Comparison of laparoscopic and open pediatric inguinal hernia repairs at two institutions

Background/Purpose

The proposed benefits of laparoscopic inguinal hernia repair in the pediatric population include easier access to the contralateral groin and avoidance of manipulation of the spermatic cord; however, some studies also report higher recurrence rates. Due to these differences, the traditional open technique is still used by many pediatric surgeons. The objective of this study is to compare the outcomes of two institutions that employed different techniques.

Methods

We retrospectively reviewed pediatric patients who had open repair of inguinal hernias at hospital A or laparoscopic repair at hospital B. Data collection included age of patients, laterality, operative time, and complications.

Results

From 2010 to 2015, 154 patients underwent open repair at hospital A and 220 patients underwent laparoscopic repair at hospital B. The mean operative time was 52 min for the open technique and 23 min for the laparoscopic technique (p?<?0.01). There were 2.6% complications and 0.65% recurrences with the open technique, compared to 4.6% complications and 2.7% recurrences with the laparoscopic technique (p?>?0.2).

Conclusion

Laparoscopic hernia repairs at hospital B are associated with shorter operative times and have similar outcomes as open repairs at hospital A. A prospective study with both techniques done at the same institution is warranted.

     

A multi-model intervention including an occlusive dressing and parental engagement to prevent pediatric surgical site infections for elective ambulatory procedures in a resource-constrained setting: an observational retrospective study from a tertiary center in Central Haiti

Purpose

In resource-limited settings, up to two-thirds of surgical patients develop surgical site infections (SSIs). Our aim was to implement a multimodal protocol including an occlusive dressing and parental engagement to achieve low SSI rates in patients undergoing elective ambulatory pediatric surgery at a tertiary center in Haiti.

Methods

An observational retrospective review of pediatric patients who underwent elective ambulatory procedures from August 2015 to May 2016 following the implementation of a multimodal protocol consisting of: washing and prepping the operative site with chlorhexidine; review of the surgical safety checklist; one dose of cefazolin before incision; after wound closure application of steri strips, gauze, and tegaderm; and with parental engagement maintenance of the dressing until the follow-up visit.

Results

We performed 119 procedures in 99 patients. Mean age was 6.2 years. The most common procedure was inguinal hernia repair (66%); 89% of parents returned to clinic with their children for the follow-up visit, which occurred on average on day 7.6 (range 3–40 days). The SSI rate was 1% (CI 0.00–0.03).

Conclusion

Implementing a multimodal protocol including an occlusive dressing and parental engagement led to a 1% SSI rate in a resource-constrained setting.

     

Umbilical hernia following gastroschisis closure: a common event?

Purpose

To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure.

Methods

With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007–2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis.

Results

Fifty-three patients were identified, gestation 36 weeks (31–38), birth weight 2.39 kg (1–3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10–101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications.

Conclusions

There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.

     

Cardiac diagnostics before oral propranolol therapy in infantile hemangioma: retrospective evaluation of 234 infants

Background

The indication and extent of cardiac screening before oral propranolol therapy (OPT) in patients with infantile hemangioma (IH) has been challenged. In this study, we evaluated pre-OPT cardiac diagnostics in a pediatric IH cohort in our department.

Methods

Retrospective chart review of infants ≤ 12 months old with IH undergoing OPT. The diagnostics prior to OPT, occurrence of complications, and outcome were recorded.

Results

A total of 234 patients were evaluated. The mean age at the onset of OPT was 4.2 ± 0.3 months, the average duration of OPT was 6.1 ± 0.1 months, and the average follow-up was 12.3 ± 0.7 months. Echocardiograms and electrocardiograms were performed prior to OPT in all patients. One hundred and three (44.0%) echocardiograms revealed pathological findings, 19 (8.1%) of which were minor (including atrial septal defects, pulmonary stenosis, and patent ductus arteriosus). Pathological findings were observed in 17 (7.3%) of electrocardiograms, only one (0.4%) of which was minor (suspected cardiac arrhythmia, subsequently excluded by long-term electrocardiogram analysis). These findings did not contraindicate OPT and no severe adverse events associated with OPT occurred during the follow-up period.

Conclusions

Routine cardiac screening by electrocardiogram and echocardiogram before OPT is debatable and not routinely indicated in children with IH. Further studies are necessary to draw definite conclusions on the reasonable indication and extent of this diagnostic approach.

     

Modified PATIO repair for urethrocutaneous fistula post-hypospadias repair: operative technique and outcomes

Background

To describe a modification of PATIO repair for urethrocutaneous fistula repair and evaluate its outcome.

Methods

We studied 15 boys who underwent modified PATIO repair from Jan 2010 to Sept 2015. Parameters studied included age, type of hypospadias, age at first urethroplasty, hypospadias repair technique, number of urethroplasties required, location of fistula, time gap between urethroplasty and fistula repair, method of fistula repair, and outcome of fistula repair.

Results

Mean age of the studied patients was 67.6 months (38–139). Type of hypospadias was Coronal = 3, subcoronal = 8, mid-penile = 2, prominal penile = 1, and penoscrotal = 1. Ten patients had single urethroplasty, while two patients had two urethroplasties, details not available for three patients. Average age at urethroplasty was 43.4 months (18–110). 12 patients had Snodgrass repair, Mathieu = 1 patient, tubularised plate repair = 1 patient, and unknown = 1 patient. Location of fistula was coronal in nine patients and subcoronal in six patients. Average operative time was 47.2 min (30–68). Follow-up is available for 12 patients out of which 2 patients had recurrent fistula, one of which was successfully treated by the redo modified PATIO method.

Conclusion

Modified PATIO method is technically easy method for urethrocutaneous fistula repair, with less operating time and good postoperative outcomes.

     

Current practice regarding timing of patent processus vaginalis ligation for idiopathic hydrocele in young boys: a survey of UK surgeons

Purpose

The aim of this study was to determine the current UK practice regarding timing of surgical repair of hydroceles in young boys.

Methods

Through a validated, online survey, participants were asked their preferred management option in five different clinical scenarios across five age ranges.

Results

71 responses were included in the analysis. The most common age to offer surgical intervention for a congenital hydrocele that is stable or increasing in size, or a hydrocele of the cord is 24–36 months. For a stable hydrocele presenting after 12 months of age, the most common age to offer repair is between 36 and 48 months. Approximately ¼ of respondents defer surgery until 4 years of age for any stable hydrocele. For a congenital hydrocele that is decreasing in size, the majority of respondents (57%) do not offer surgical intervention even over 4 years of age. The majority of respondents (61%) do not differentiate between communicating and non-communicating hydroceles when considering age for repair.

Conclusion

These results suggest that there is uncertainty regarding the optimum age for PPV ligation and adequate underlying variability in practice to support a prospective study of the optimum age for hydrocele repair and the natural history of PPV closure.

     

Evaluating the utility of the “late ECMO repair”: a congenital diaphragmatic hernia study group investigation

Purpose

Optimal timing of congenital diaphragmatic hernia (CDH) repair in patients requiring extracorporeal membrane oxygenation (ECMO) remains controversial. The “late ECMO repair” is an approach where the patient, once deemed stable for decannulation, is repaired while still on ECMO to enable expeditious return to ECMO if surgery induces instability. The goal of this study was to investigate the potential benefit of this approach by evaluating the rate of return to ECMO after repair.

Methods

The CDH Study Group database was used to analyze CDH patients requiring ECMO support. The primary outcome was return to ECMO within 72 h of CDH repair among those repaired following ECMO decannulation (“post-ECMO” patients). Secondary outcomes were death within 72 h of repair and cumulative death and return to ECMO rate.

Results

A total of 668 patients were repaired post-ECMO decannulation. Six patients (0.9%) in the post-ECMO group required return to ECMO within 72 h of surgery and a total of 19 (2.8%) died or returned to ECMO within 72 h of surgery.

Conclusion

The rate of return to ECMO and death following CDH repair is extremely low and does not justify the risks inherent to “on-ECMO” repair. Patients stable to come off ECMO should undergo repair after decannulation.

     

Outcomes of congenital diaphragmatic hernia repair on extracorporeal life support

Purpose

Extracorporeal life support (ECLS) is applied to refractory pulmonary hypertension in congenital diaphragmatic hernia (CDH). We evaluate the single-center outcomes of infants with CDH to determine the utility of late repair on ECLS versus repair post-decannulation.

Methods

Records of infants with CDH (2004–2014) were retrospectively reviewed.

Results

CDH was diagnosed in 177 infants. Sixty six (37%) underwent ECLS, of which, 11 died prior to repair, 33 were repaired post-decannulation, and 22 were repaired on ECLS. Repair was delayed in patients on ECLS (19 versus 10 days, p < 0.001). Patients repaired on ECLS had longer ECLS runs (22 versus 12 days, p < 0.001) and higher rates of bleeding and mortality than those repaired post-decannulation. Survival was 54% in infants undergoing ECLS, 65% in those who underwent repair, 36% in those repaired during ECLS, and 85% in those who were decannulated prior to repair. Eighteen percent (N = 4) of deaths after repair on ECLS were attributable to surgical bleeding. The remainder was due to pulmonary hypertension or sepsis.

Conclusion

Infants who underwent CDH repair post-decannulation had excellent outcomes and no mortalities attributable to repair. Neonates who underwent repair on ECLS late on bypass had the lowest survival rate with only 18% of mortality in this cohort attributable to surgical bleeding.

     

Effective treatment for infantile hemangioma with long-pulsed dye laser with oral propranolol medication: a preliminary report

Purpose

To investigate the efficacy of our treatment of infantile hemangioma (IH)s retrospectively presenting as disfiguring or functionally threatening lesions.

Materials and methods

25 infants with IH treated with long-pulsed dye laser or laser with or without propranolol. Tumor fading after treatment was evaluated using both color and size rating scales, before, during and after treatment.

Results

6 infants were treated by laser, 11, oral propranolol and 8 using both treatments. Each treatment was effective for most IH with a median treatment duration of 7.7 months for laser, and 13.3 months for the latter two. Combination therapy was the most effective in both color-fading and size reduction by the 3rd month. Laser alone was most effective in color-fading with almost complete disappearance of most tumors. Oral propranolol to the three site-specific IHs was effective with disappearance of tumors. There were no apparent side effects related to laser treatment, but one infant suffered from allergy and another from bronchial asthma due to propranolol medication.

Conclusions

Most IHs discolored and regressed considerably with these treatments, including complete disappearance of the three functionally threatening lesions. This combined approach is quite useful for accelerating tumor regression.

     

Polymorphism of 3′ UTR of MAMLD1 gene is also associated with increased risk of isolated hypospadias in Indian children: a preliminary report

Objective

To study MAMLD1 gene polymorphisms, serum LH and testosterone levels amongst Indian children with isolated hypospadias (IH) and controls.

Materials and methods

Screening of the MAMLD1 gene was performed by PCR sequencing method in 100 Indian children aged 0–12 years presenting with IH and 100 controls. LH and testosterone hormone levels were also assessed (categorized in four age-wise groups).

Results

IH subjects had significantly higher incidence of MAMLD1 polymorphism as compared to controls (33 vs 15 %, p = 0.01). Of various genomic variants identified in this study, the noteworthy novel ones were missense mutation P299A and single nucleotide polymorphism c.2960C>T in 3′ UTR of Exon 7. While p 299A was found to cause protein structural instability consequent to amino acid change, eighty percent subjects with c.2960C>T in 3′ UTR of Exon 7 (corresponding to newly discovered currently non-validated exon 11) were found to have lower testosterone levels when compared with their age group mean. IH showed statistically higher incidence of c.2960C>T in comparison to controls (22 vs 10 %, p value 0.046) and about 2.5-folds higher risk of this anomaly.

Conclusion

Occurrence of MAMDL1 gene polymorphisms, specially of c.2960C>T in 3′ UTR of its exon 7 is associated with a higher risk of IH in Indian children, probably by lowering androgenic levels.

     

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC)

Purpose

Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.

Methods

Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

Results

Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5–15 CDH repairs were reported annually per institution; 26–50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III–IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4–5 weeks.

Conclusions

Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.

Level of evidence

V (expert opinion).

     

Single center protocol driven care in 150 patients with gastroschisis 1998–2017: collaboration improves results

Purpose

The treatment of gastroschisis (GS) using our collaborative clinical pathway, with immediate attempted abdominal closure and bowel irrigation with a mucolytic agent, was reviewed.

Methods

A retrospective review of the past 20 years of our clinical pathway was performed on neonates with GS repair at our institution. The clinical treatment includes attempted complete reduction of GS defect within 2 h of birth. In the operating room, the bowel is evaluated and irrigated with mucolytic agent to evacuate the meconium and decompress the bowel. No incision is made and a neo-umbilicus is created. Clinical outcomes following closure were assessed.

Results

150 babies with gastroschisis were reviewed: 109 (77%) with a primary repair, 33 (23%) with a spring-loaded silo repair. 8 babies had a delayed closure and were not included in the statistical analysis. Successful primary repair and time to closure had a significant relationship with all outcome variables—time to extubation, days to initiate feeds, days to full feeds, and length of stay.

Conclusion

Early definitive closure of the abdominal defect with mucolytic bowel irrigation shortens time to first feeds, total TPN use, time to extubation, and length of stay.

     

Congenital diaphragmatic hernia in neonates: factors related to failure of thoracoscopic repair

Purpose

To evaluate factors related to conversion to open repair (OR) during thoracoscopic repair (TR) in congenital diaphragmatic hernia (CDH).

Methods

CDH subjects who were diagnosed prenatally or within 6 h of birth and underwent TR at our institution from 2007 to 2015 were reviewed. Two groups were defined: Group A, subjects who tolerated TR; and Group B, subjects who required conversion to OR.

Results

Twenty-nine subjects (Group A, 20; Group B, 9) underwent TR. Patients’ demographics were not significantly different between the two groups. In Group A, pre-operative arterial blood gas analysis showed mean PaCO₂ 37.4 mmHg, mean pH 7.45, and mean PaO₂ 201.6 mmHg, which were not significantly different from those of Group B (PaCO₂ 40.6 mmHg, pH 7.43, and PaO₂ 251.1 mmHg). Two Group B cases required conversion due to cardiopulmonary instability. The remaining seven cases were converted for technical reasons (large defect in two, anterior location of the defect in two, bleeding from short gastric vessels or spleen in two, and insufficient operative view in one).

Conclusions

TR can be performed safely in selected cases of CDH. CDH with a large defect and/or an unusual location of the defect remains a challenge for pediatric surgeons.