Thoracoscopic repair of a large neonatal congenital diaphragmatic hernia using Gerota's fascia

A large congenital diaphragmatic hernia needing patch repair has a high risk of recurrence. Thus, managing these large congenital diaphragmatic hernias under thoracoscopy has become a problem. Here, a large congenital diaphragmatic hernia that was repaired using Gerota's fascia under thoracoscopy is reported. In the present case, it was impossible to close the hernia directly under thoracoscopy because the hernia was too large. Gerota's fascia was raised up by the left kidney and used for the repair. The left colon adhering to Gerota's fascia was mobilized, and a large space was made under thoracoscopy. Gerota's fascia was fixed to the diaphragmatic defect. The patient's postoperative course was good, and there was no recurrence. This technique could be one option for repairing a large hernia under thoracoscopy.     

Sonographic appearance of intrathoracic kidney in a fetus with left diaphragmatic hernia

Although prenatal diagnosis of congenital diaphragmatic hernia is not a rare event, detection of intrathoracic kidney in association is extremely rare. We present the sonographic findings in such a case. The postnatal outcome after successful respiratory management and surgical repair was good. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011     

Thoracoscopic repair of neonatal left diaphragmatic hernia with sac combined with both extralobar pulmonary sequestration and congenital pulmonary airway malformation

Intradiaphragmatic extralobar pulmonary sequestration (IDEPS) is considered to be very rare among extralobar pulmonary sequestration (EPS), and IDEPS combined with congenital diaphragmatic hernia (CDH) with sac is extremely rare. The patient was a neonatal girl. Left-sided CDH with a hernia sac was diagnosed based on computed tomography (CT). Thoracoscopic repair was planned for the 5th day after birth. Left CDH with sac was recognized on the posterolateral side and isolated EPS was recognized on the sac. The hernia sac, including the EPS, was resected, and the diaphragm defect was closed. The resected specimen consisted of fibrous connective tissue and pulmonary sequestration (PS) connected with the sac. It was diagnosed as the hybrid form, with features of both type 2 congenital pulmonary airway malformation (CPAM) and EPS. The postoperative course was uneventful. At 1 year and 9 mo after the operation, no recurrence of herniation or laterality of the diaphragm was recognized.     

Laparoscopic-assisted thoracoscopic repair of latent traumatic diaphragmatic hernia: A case report

Surgical approaches for traumatic diaphragmatic hernia include transabdominal, transthoracic, and thoracoabdominal. Selection of the optimal approach depends on the timing and organ damage, often minimally invasive approaches with laparoscopy or thoracoscopy are performed. A 47-year-old man with blunt chest trauma was diagnosed with left traumatic diaphragmatic hernia 1 month after the trauma. The prolapsed omentum was detached from the chest wall and around the hernia orifice and returned to the abdominal cavity by coordinated thoracoscopic and laparoscopic manipulations. The 4 × 2 cm herniation in the diaphragm was sutured closed from the thoracic side while preventing re-prolapse of the omentum and abdominal organs from the abdominal side. A combined thoracoscopic and laparoscopic approach can be effective in confirming organ damage, repositioning of prolapsed organs, and safe repair of the diaphragm in latent traumatic diaphragmatic hernia.     

Prenatal diagnosis of thoracic kidney in the 2nd trimester with delayed manifestation of associated diaphragmatic hernia

Ectopic kidney is a rare congenital malformation, caused by renal malpositioning during embryogenesis. We report a rare case of ectopic kidney located in the left hemithorax of a male fetus. The unique features in this case were early sonographic prenatal diagnosis of thoracic kidney at 22 weeks' gestation, which was confirmed by fetal MRI, and delayed sonographic manifestation of the associated congenital diaphragmatic hernia at 27 weeks.     

Left diaphragmatic eventration diagnosed as congenital diaphragmatic hernia by prenatal sonography

Congenital diaphragmatic eventration is an abnormal elevation of the diaphragm resulting from failure of muscle fibers to develop during gestation. A mediastinal shift to the contralateral side may cause significant compression of the affected chest contents, resulting in compromised pulmonary function, especially when both sides are involved. Differentiating between congenital diaphragmatic eventration and congenital diaphragmatic hernia is very difficult but important because eventration has a better perinatal outcome than diaphragmatic hernia has. This report discusses a case of congenital diaphragmatic eventration that was initially diagnosed by prenatal sonography as a diaphragmatic hernia on the left side. In this case, the correct diagnosis was made at the time of surgery shortly after the infant's birth. The defect was repaired by plication, and the infant's outcome was favorable. Although the initial diagnosis was incorrect in this case, the use of sonography can aid in the prenatal detection and diagnosis of congenital diaphragmatic anomalies.     

产前超声在诊断胎儿先天性膈疝的临床价值

目的 探讨产前超声诊断胎儿先天性膈疝的临床价值。方法 选取我院确诊的先天性膈疝胎儿75例为病例组,与病例组相同孕周的正常胎儿40例作为正常对照组,回顾性分析病例组胎儿超声表现,测量其健侧肺的肺头比（LHR）,并比较两组大脑中动脉及脐血流等相关指标。结果 病例组75例胎儿中,左侧膈疝68例,右侧膈疝7例;单纯性膈疝40例,膈疝合并其他畸形35例,其中心血管系统畸形最常见,其次是神经系统、泌尿系统及骨骼系统等。病例组胎儿LHR＞1.6者33例,合并其他畸形13例;LHR＜1.0者20例,合并其他畸形14例;LHR在1.0～1.6之间者22例,合并其他畸形8例。病例组大脑中动脉峰值流速为（29.03±0.22）cm/s,低于正常对照组（42.11±0.17）cm/s,差异有统计学意义（P＜0.001）;但两组搏动指数、阻力指数比较,差异均无统计学意义。结论 产前超声可以准确诊断先天性膈疝,但怀疑有膈疝时,一定需要注意各个系统的筛查,尤其是心血管系统。了解膈疝胎儿健侧肺的LHR及大脑中动脉血流情况,可能为膈疝胎儿产前管理及生后干预提供更多的参考信息。     

Laparoscopic repair of traumatic diaphragmatic hernia with colon incarceration: A case report

Traumatic diaphragmatic hernia is a serious complication of blunt trauma to the abdomen or thorax. Although traumatic diaphragmatic hernia is treated with surgical repair, a laparoscopic approach is infrequently employed. Here we present the case of a 66-year-old man with a bruise on the left side of his back. CT revealed a left pneumothorax and left rib fractures. He was urgently hospitalized and relieved with conservative treatment. However, on day 4 of hospitalization, an incarcerated diaphragmatic hernia containing the transverse colon was observed on CT. The herniated viscera of the abdominal cavity were reduced laparoscopically, and the hernial orifice was repaired with direct closure. One-lung ventilation was used to limit the movement of the affected diaphragm, enabling effective laparoscopic suturing. The patient had an uneventful recovery period and was discharged 8 days postoperatively. The absence of diaphragmatic herniation recurrence was confirmed 6 months after surgery.     

Right thoracic ectopic kidney in a child with breathing difficulties—Sonographic diagnosis

Congenital intrathoracic ectopic kidney is a rare congenital abnormality that is usually found as an incidental lesion on chest radiographs. We report the case of a 6‐month‐old male with a 1‐day history of breathing difficulties whose chest radiograph revealed a soft tissue right basilar mass. Further investigation utilizing ultrasound revealed a thoracic kidney. This case demonstrates the importance of sonography as a diagnostic tool in identifying thoracic kidneys in the pediatric age group. © 2010 Wiley Periodicals, Inc. J Clin Ultrasound 39:108–110, 2011     

Paradoxical movement of abdominal contents: a real-time sonographic finding indicating a congenital diaphragmatic hernia.

OBJECTIVE: A congenital diaphragmatic hernia (CDH) is the most common intrathoracic extracardiac congenital anomaly, and it is associated with high mortality and other fetal abnormalities. Early diagnosis is essential for delivery planning and possible intervention. However, the in utero diagnosis of CDHs by sonography can be challenging. We report the utility of paradoxical movement of the intra-abdominal contents in identifying CDHs. METHODS: Two fetal cases were identified: 1 referred with a suspected CDH and the other with a mediastinal shift and a suspected congenital cystic adenomatoid malformation (CCAM). Real-time sonography was performed in both fetuses with attention on movement of the intra-abdominal contents during fetal breathing, particularly during inspiration. RESULTS: Real-time sonography in both fetuses showed paradoxical movement of the abdominal contents during fetal inspiration. In the case with the presumptive diagnosis of a CCAM, the paradoxical motion was essential in changing the diagnosis from a CCAM to a CDH. CONCLUSIONS: Paradoxical movement of the abdominal contents can be used in addition to the traditional sonographic signs in diagnosing CDHs.     

产前超声检查诊断胎儿先天性膈疝

目的 探讨产前超声检查诊断胎儿先天性膈疝中的应用价值。方法 回顾性分析52胎先天性膈疝胎儿的声像图表现,将产前超声诊断结果与出生后检查、手术或引产后病理结果相对照。结果 52胎先天性膈疝中产前超声诊断正确50胎,漏诊2胎。其中,左侧膈疝45胎(45/52,86.54%),右侧膈疝7胎(7/52,13.46%);合并其他结构异常22胎(22/52,42.31%),合并羊水过多34胎(34/52,65.38%)。结论 产前超声检查可较准确地诊断胎儿先天性膈疝,具有重要的临床应用价值。     

Rare case of a right Bochdalek hernia with retroperitoneal prolapse of organs into the thoracic cavity in infancy: A case report

We report an extremely rare case of a right Bochdalek hernia with a sac, in which the retroperitoneal and intra-abdominal organs prolapsed into the thoracic cavity at the same time. The patient was a 7-month-old female with no comorbidities. She presented with cough and fever, and chest radiography revealed a right diaphragmatic hernia. Computed tomography showed that the right kidney, intestine, colon, and liver had prolapsed into the thoracic cavity. The patient underwent thoracoscopic surgery, which showed that the abdominal and retroperitoneal organs prolapsed into the thoracic cavity through the Bochdalek hernia. The herniated organs were spontaneously reduced using thoracoscopic insufflation. The defect hole was closed with artificial mesh. We adopted a thoracoscopic approach, in terms of easy reduction of herniated organs and accurate evaluation of the hernia orifice, which was useful.     

产前超声评估先天性膈疝预后

目的 探讨产前超声在先天性膈疝预后评估中的应用价值。方法 分析65例出生后经手术或随诊证实为先天性膈疝的胎儿的产前超声声像图特征,测量胎儿健侧肺的肺头比（LHR）、与该孕周正常胎儿的LHR进行比较,计算O/E LHR,探讨其与新生儿预后的关系。结果 65例中,45例出生后行手术治疗后存活,8例手术后死亡,12例未行手术即死亡,总死亡率30.77%（20/65）。肝上型膈疝死亡率66.67%（8/12）;肝下型膈疝死亡率22.64%（12/53）。合并其他结构异常共9例,死亡8例,其中6例合并胸腔内结构异常。LHR为0.40~2.72,平均1.59±0.69;不同LHR膈疝胎儿出生后死亡率差异有统计学意义（χ²=19.360,P<0.001）,LHR≤1.0的膈疝胎儿出生后死亡率高于LHR>1.0的膈疝胎儿。O/E LHR为23%~90%,平均（58.25±17.61）%,不同O/E LHR膈疝胎儿出生后死亡率差异有统计学意义（χ²=15.261,P=0.002）,O/E LHR≤45%的膈疝胎儿出生后死亡率高于O/E LHR>45%的膈疝胎儿。结论 产前超声可用于诊断胎儿先天性膈疝,并评估健侧肺的发育情况及患儿预后。     

Laparoscopic patch repair of a Morgagni hernia in Menkes disease

The association between Morgagni hernia and Menkes disease has not yet been described. Here, we report such a rare association in an 8-year-old boy who presented with subocclusive symptoms. He successfully underwent laparoscopic repair with a patch. The patch was fixed to the anterior abdominal wall by using transfascial sutures with extracorporeal knot tying and to the remaining edges of the diaphragmatic defect by using intracorporeal suturing and spiral tacks. At the 2-year follow-up, the child remained recurrence-free and without gastrointestinal symptoms. The potential relationship between the two conditions and the controversial use of spiral tacks to affix the mesh to the diaphragm are also discussed.     

Three-dimensional sonographic measurement of contralateral lung volume in fetuses with isolated congenital diaphragmatic hernia

PURPOSE: To use 3-dimensional sonography (3DUS) to measure contralateral lung volume and evaluate the potential of this measurement to predict neonatal outcome in isolated congenital diaphragmatic hernia (CDH). METHODS: Between January 2002 and December 2004, the contralateral lung volumes of 39 fetuses with isolated CDH were measured via 3DUS using rotational multiplanar imaging. The observed/expected contralateral fetal lung volume ratios (o/e-ContFLVR) were compared with the lung/head ratio (LHR), observed/expected total fetal lung volume ratio (o/e-TotFLVR), and postnatal outcome. RESULTS: Contralateral lung volumes are less reduced than total lung volumes in CDH. The bias and precision of 3DUS in estimating contralateral lung volumes were 0.99 cm(3) and 1.11 cm(3), respectively, with absolute limits of agreement ranging from -1.19 cm(3) to +3.17 cm(3). The o/e-ContFLVR was significantly lower in neonatal death cases (median, 0.49 cm(3); range, 0.22-0.99 cm(3)) than in survival cases (median, 0.58 cm(3); range, 0.42-0.92 cm(3) [p < 0.01]). Overall accuracy of the o/e-ContFLVR, o/e-TotFLVR, and LHR in predicting neonatal death were 67.7% (21/31), 80.7% (25/31), and 77.4% (24/31), respectively. CONCLUSION: Although o/e-ContFLVR can be precisely measured with 3DUS and can be used to predict neonatal death in CDH, it is less accurate than LHR and o/e-TotFLVR for that purpose.     

新生儿期膈疝的超声表现及诊断价值

目的探讨新生儿期膈疝的超声声像图特点。 方法选择2000年1月至2017年12月首都医科大学附属北京儿童医院超声及手术病理检查确诊为新生儿期膈疝的患儿19例,平均出生（12.8±11.7）d,其中3例产前已诊断膈疝,11例表现为呼吸困难,3例表现为呕吐,2例表现为心动过速。总结19例新生儿超声声像图特点。 结果19例新生儿膈疝术前超声显示自左侧胸腔内疝入小肠4例,胃底2例,脾脏3例,1例疝入物为左侧肾上腺及左肾上极;右侧胸腔内疝入肠管3例,4例疝入物为部分肝脏右叶及胆囊,2例疝入物为右肾上腺及右肾。食道裂孔疝疝入物均为胃。后外侧疝表现为膈肌不连续,位于腹腔内或腹膜后的脏器通过不连续的膈肌进入胸腔水平。食道裂孔疝表现为胃体通过食管裂孔疝入胸腔。术前超声诊断后外侧疝16例,食道裂孔疝2例,1例膈疝与膈膨升不能鉴别。与术前相关影像及手术检查结果对照,术前超声诊断符合率为94.74%（18/19）。 结论新生儿期患儿胸壁软组织薄,超声检查可清晰实时多角度显示膈肌情况,诊断符合率不低于CT或磁共振成像,且无放射性损伤,是新生儿期膈疝患儿首选的影像学检查方法。     

Delayed left traumatic diaphragmatic hernia repaired by laparoscopic surgery

A 77-year-old man injured himself when he fell heavily on the left side of his chest. He had massive subcutaneous emphysema, bleeding, and left hemopneumothorax. He also fractured his seventh through tenth ribs; a fragment of the ninth rib was displaced into the thoracic cavity. The severity of the damage and the patient's pain was assessed using the Abbreviated Injury Scale 1990 (1998 update) as level 3. He was treated with conservative therapy and discharged on the 16 days after the injury. However, the following day, he had acute upper abdominal pain, his blood pressure dropped to 40 s, and he was readmitted. A chest CT showed the transverse colon was prolapsed in the thoracic cavity. The patient was diagnosed as having a delayed traumatic diapharagmatic hernia. A laparoscopic repair was performed. The rupture was classified as a IIIb-type diaphragmatic injury according to the Japanese Association for the Surgery of Trauma's classification system. It is believed that a fragment of a fractured rib that had been displaced in the thoracic cavity ruptured the diaphragm sharply. Since traumatic diapharagmatic hernia rarely occurs, it is relatively difficult to diagnose at the first examination. This condition has a high mortality rate because of the associated injuries. Surgery is the only treatment, but it should only be considered after a second examination. Herein, I report my experience with a case of delayed diaphragmatic hernia repaired by laparoscopic surgery.