Robotic repair of Morgagni congenital diaphragmatic hernia in an infant

We describe a robotic repair of a large Morgagni congenital diaphragmatic hernia in a 12-month-old infant using the da Vinci surgical robot.     

Thoracoscopic patch repair of a right-sided congenital diaphragmatic hernia in a neonate

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.     

Minimally invasive repair of congenital diaphragmatic hernia

Purpose

Operative approach, including minimally invasive surgery (MIS) in the repair of congenital diaphragmatic hernia (CDH), is variable among institutions. The short-term recurrent hernia rate is not well described. We evaluated the in-hospital recurrence rate of MIS repairs of infants with CDH from the Congenital Diaphragmatic Hernia Registry.

Methods

Prospectively collected data from infants with CDH were analyzed from the Congenital Diaphragmatic Hernia Registry from January 1995 to January 2010. Recurrent hernia was defined as reoperations during initial hospitalization. Operative approaches included abdominal, thoracic, laparoscopic, and thoracoscopic techniques.

Results

Five thousand four hundred eighty infants with CDH were identified, of which 4516 (82.4%) were repaired. Operative data were available in 4390 infants. One hundred fifty-one infants (3.4%) underwent MIS repairs with 12 reported recurrences (7.9%) compared with 114 for open techniques (2.7%, P < .05). Minimally invasive surgery demonstrated a significant increased odds for recurrence (odds ratio, 3.59; 95% confidence interval, 1.92-6.71) after adjusting for gestational age, birth weight, patch repair, and extracorporeal membrane oxygenation.

Conclusion

Minimally invasive techniques appear to have a significant higher recurrent hernia rate, with thoracoscopy being the highest. Although adjusted for patch repair, other factors with regard to disease severity may contribute to differences in outcomes among centers. This study is limited to short-term recurrence during initial hospitalization.     

腹腔镜小儿先天性膈疝修补术

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。     

Chylothorax after congenital diaphragmatic hernia repair

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.     

Laparoscopic repair of congenital diaphragmatic hernia in a 6-month-old child

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.     

“Acquired” congenital diaphragmatic hernia

“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.     

Endobronchial migration of prosthetic patch after congenital diaphragmatic hernia repair

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.     

Thoracoscopic repair for congenital diaphragmatic hernia: lessons from 45 cases

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.     

Free fascia lata repair for a second recurrent congenital diaphragmatic hernia

Repair of recurrent congenital diaphragmatic hernia (CDH) continues to be a difficult problem. Although several materials have been used to repair recurrent CDH, the ideal material has yet to be established. We report the successful use of an autologous free fascia lata graft to repair the diaphragm following a second recurrence of CHD. The fascia lata is one of the strongest fascia in the body and is easy to obtain without extremity functional loss even in children. This procedure is regarded as effective for the repair of recurrent CDH.     

Minimally invasive versus open repair of Bochdalek hernia: a meta-analysis

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.     

Laparoscopic repair of congenital diaphragmatic hernia complicated with sliding hiatal hernia with reflux in adult

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.     

Permacol: a potential biologic patch alternative in congenital diaphragmatic hernia repair

Purpose

Recurrence is a well-known complication after patch repair of congenital diaphragmatic hernia (CDH). We propose that a newer, “bioprosthetic” material may lower recurrence rates. The purpose of this study is to compare outcomes of CDH repair with synthetic Gore-Tex (W. L. Gore and Associates, Neward, Del) to the bioprosthetic Permacol (Tissue Science Laboratories Inc, Andover, Mass).

Methods

We performed a retrospective review of 100 consecutive patients with CDH with survival more than 30 days at Children's Medical Center of Dallas (Dallas, Tex) from 1999 to 2007. The incidence and timing of recurrence, as well as comorbidities were assessed.

Results

Primary repair was performed in 63 patients and patch repair in 37, divided between Gore-Tex (29) and Permacol (8). Overall recurrences were as follows: 1 (2%), 8 (28%), and 0 in the primary, Gore-Tex, and Permacol groups, respectively. Median follow-up was 57 months for Gore-Tex and 20 months for Permacol. Median time to recurrence in the Gore-Tex group was 12 months, with no Permacol recurrences. Both the Gore-Tex and Permacol groups had similar comorbidities, including prematurity, congenital heart disease (76% and 63%, respectively), and the need for extracorporeal membrane oxygenation support (38% and 25%).

Conclusion

Our results suggest that Permacol may have lower recurrence rates compared to Gore-Tex and is a promising alternative biologic graft for CDH repair.     

Laparoscopic repair of late presenting congenital diaphragmatic hernia

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.     

Early repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation

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.     

Intrapericardial diaphragmatic hernia: a rare type of congenital diaphragmatic hernia

An extremely rare case of congenital intrapericardial diaphragmatic hernia is presented. Since 1981, only 14 cases have been reported in the literature. A 5-year-old girl presented with dyspnea on exertion and easy fatigability. Computed tomography was suggestive of an anterior diaphragmatic hernia. Laparoscopy followed by successful open repair of hernia was performed.     

Long-term functional impact of congenital diaphragmatic hernia repair on children

Background/Purpose

Congenital diaphragmatic hernia (CDH) is a malformation requiring neonatal surgical repair with in-hospital survival rates above 90%. We examined the long-term functional impact of CDH repair on a cross-sectional cohort of survivors.

Methods

A cohort of 53 CDH families participated in this study. Functional impact was evaluated with parent report of the Functional Status IIR and the Child Health Ratings Inventories General Health Module. Parents also provided a clinical severity score, the child's medical history, and family demographic information. The primary outcome was the effect of medical morbidity on the Functional Status IIR total score.

Results

Congenital diaphragmatic hernia survivors had a median age of 8 years; 50% were in third grade or above. Sixty-six percent had major medical issues at hospital discharge, whereas 48% had current clinical problems. Functional Status IIR total score was strongly correlated with child's clinical severity (r = −0.65; P < .0001) and was lower among children with ongoing medical morbidity, denoting worse functioning (P = .01). Child Health Ratings Inventories General Health Module scores followed a similar pattern.

Conclusions

A subset of long-term CDH survivors continues to have ongoing clinical problems a median of 8 years after surgery, translating to lower functional status. Affected children and their families may benefit from prospective identification and ongoing interventions.     

Long-term functional evaluation of diaphragmatic motility after repair of congenital diaphragmatic hernia

Background/Purpose

A few studies have taken into account the diaphragmatic function in patients successfully treated for congenital diaphragmatic hernia (CDH). Monodimensional sonography has been reported to be useful in assessing the diaphragmatic motility. Aim of the present study was to investigate, in a long-term follow-up, the diaphragmatic function after CDH repair.

Methods

Ten patients, with a mean age of 16 (5-26) years, were enrolled. All had had a left diaphragmatic hernia repaired, but no one received a patch. Ten subjects of matched age were used as controls. The diaphragmatic excursions appear, at M-mode sonography, as a sinusoid; the amplitude of the curve on the vertical axis measured the movement in centimeters. Chest x-ray and spirometry were also performed in CDH patients.

Results

A reduced diaphragmatic motility on the left (treated) side was recorded. The amplitude of the contraction was significantly reduced when compared with the contralateral side (1.19 ± 0.2 vs 2.33 ± 0.9 cm; P = .017) and was also significantly reduced in comparison with the motion of the left side of controls (1.19 ± 0.2 vs 1.83 ± 0.4 cm; P = .01). There was no difference in the amplitude of contraction between the left and right sides of control patients and between the right side of CDH patients and the controls. Spirometry was normal in all patients but one, who had a slight reduction of ventilation on the left side.

Conclusion

M-mode sonography appears as a very useful tool in quantitative evaluation of diaphragmatic movements and should be extensively used during follow-up of patients after CDH repair. Motility of the repaired diaphragmatic is reduced, even after a long period, but this does not affect the respiratory function in patients who survived CDH repair.