Minimally invasive congenital diaphragmatic hernia repair: a 7-year review of one institution’s experience

Abstract

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 17Bochdalek 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.Keywords Congenital diaphragmatic hernia Á Laparoscopy Á Minimally invasive surgery Á Thoracoscopy Congenital diaphragmatic hernia (CDH) is one of the most commonly encountered congenital anomalies, with an incidence of approximately 1 in 3,000 live births [1]. Unfortunately, the mortality rate for CDH also remains high, even despite advances in the management of these children [2,3].With the recognition that the initial treatment should be directed at minimizing pulmonary hypertension due to the pulmonary hypoplasia associated with CDH, a tremendous focus has centered on the initial medical management of children with CDH. However, the advances in the surgical management of CDH, especially in the newborn period, have been limited.

Synchronous Morgagni and Bochdalek Hernias: A Case Report of a Unique Approach to a Rare Finding

“…Though these two defects could surely have been repaired via a laparotomy as described in the other two cases, thoracoscopy provided excellent visualization and identification of both the large Morgagni and also the smaller, more subtle, Bochdalek hernia which may have been overlooked with an open repair. As stated previously, the Bochdalek hernia is by far the more common CDH and when other pediatric surgeons have repaired it in a minimally invasive approach it is thoracoscopically thus it is reasonable that we started our case thoracoscopically rather than laparoscopically (9). Though the Morgagni hernia was clearly identified thoracoscopically, the position of the heart impeded repair from the chest necessitating repositioning the patient into supine position for a laparoscopic repair of the Morgagni hernia.…”

Advantages of Video-assisted Thoracoscopic Surgery for Adult Congenital Hernia with Severe Adhesion: Report of Two Cases

“…6,13) Transperitoneal laparotomy and laparoscopic approaches are commonly used to repair diaphragmatic hernia in infants or children because they rarely have severe adhesion in the thoracic cavity, and difficult adhesiotomy in the thoracic cavity is unnecessary. 7,13) In adult congenital diaphragmatic hernia, the thoracoscopic view is considered to be the first priority because it allows better control during dissection of thoracic adhesion within minimum invasion. In addition, operative management of singlelung ventilation with a double-lumen endotracheal tube in the adult is much easier than in the neonate minimum size.…”

Thoracoscopic Surgery in Children

“…Ancak özellikle yenidoğan ve solunum fonksiyonları stabil olmayan olgularda torakoskopik yaklaşım güç olabilir veya açık torakotomiye geçiş gerekebilir. Bu nedenle preoperatif dönemde kardiyopulmoner instabilite varlığının, eşlik eden kardiyovasküler veya santral sinir sistemi anomalilerinin varlığının araştırılması gerekmektedir (37)(38)(39) . Bu olgularda ve ayrıca mide ve karaciğerin herniasyonu ile sonuçlanan geniş bir diyafragmatik defekt söz konusu ise torakoskopi kontrendike kabul edilir.…”