Intrathoracic Silo for the Potential Antenatal Repair of Diaphragmatic Herniae with Liver in the Chest

Abstract

Antenatal correction of congenital diaphragmatic hernia in the human fetus is an attractive theoretical possibility that might reverse pulmonary hypoplasia before it becomes too severe for post-natal survival. Initial attempts at correcting these herniae in the human fetus have been beset with many technical problems, one of which has been to prevent acute obstruction to the ductus venosus when the left lobe of the liver is reduced back into the abdomen. We describe a new procedure intended to reduce the liver gradually so that the ductus venosus is never acutely kinked and more normal rib cage mechanics may be maintained.

Congenital Diaphragmatic Hernia: Comparison of Animal Models and Relevance to the Human Situation

“…Examples of investigated interventions are administration of corticosteroids, in utero repair of the diaphragmatic defect and fetal tracheal occlusion or a combination of the two [11,12] . In utero repair has been attempted with either primary closure of the defect by using a patch (immediate reduction) or secondary closure by using the slow 'silo' reduction technique in which the opening gradually reduces as the fetus grows [13][14][15] . After successful in utero repair of induced CDHs in animal models, including nonhuman primates, Harrison et al [14] performed the first human surgical repair in utero.…”

Effect of immediate versus slow intrauterine reduction of congenital diaphragmatic hernia on lung development in the sheep: A morphometric analysis of term pulmonary structure and maturity

“…4,14,17,27,28,35,42,52 Repair of the hernia restores thoracic volume, increasing the space available for lung growth and expansion. Rapid reduction of the hernia, using the patch technique developed by Harrison et al 12 in lambs, is associated with a number of problems including disruption to the chest wall and ribcage mechanics, possibly disturbing fetal breathing and chest wall expansion, thereby itself reducing lung growth potential 24 and occlusion of blood flow in the ductus venosus due both to kinking of the vessel as the liver is returned to the abdomen and to the resultant increased intraabdominal pressure. 10,15 The slow "silo" reduction method developed by Ford et al 24 attempts to address these technical problems while still achieving adequate lung growth.…”

“…Rapid reduction of the hernia, using the patch technique developed by Harrison et al 12 in lambs, is associated with a number of problems including disruption to the chest wall and ribcage mechanics, possibly disturbing fetal breathing and chest wall expansion, thereby itself reducing lung growth potential 24 and occlusion of blood flow in the ductus venosus due both to kinking of the vessel as the liver is returned to the abdomen and to the resultant increased intraabdominal pressure. 10,15 The slow "silo" reduction method developed by Ford et al 24 attempts to address these technical problems while still achieving adequate lung growth. Comparisons of these basic "repair" techniques and their effectiveness in restoring lung growth as assessed by quantitative morphometry and further comparisons of these approaches to the contrasting method of tracheal obstruction for the treatment of CDH have not previously been reported.…”

“…This "silo" took the form of a chimney with the length twice that of the base, sewn along one side and around the apex, as described previously. 24 In the second group (n ‫ס‬ 8), the diaphragmatic defect was exposed through an upper abdominal excision and the herniated viscera were gently pulled down out of the chest. A silastic patch was fashioned to close the defect in the diaphragm, and this was sutured in place.…”