Approach to Recurrent Congenital Diaphragmatic Hernia: Results of an International Survey

Abstract

Although recurrence remains one of the most feared complications following congenital diaphragmatic hernia (CDH) repair, there are minimal data on the optimal surgical approach to these complex situations. The purpose of this study was to survey the international pediatric surgery community to ascertain practice patterns for both minimally invasive (MIS) and open approaches for recurrent CDH. A survey was e-mailed to members of an online community of pediatric surgeons. The questionnaire elicited surgeons' clinical experience, the continent in which they practice, and their surgical approach (laparotomy, thoracotomy, laparoscopy, or thoracoscopy) to five clinical cases, including initial and recurrent Bochdalek hernias. Fisher's exact test and chi-square test were used for statistical analysis. Two-hundred eighty pediatric surgeons responded to the survey. In total, 52.1% of surgeons chose an MIS approach for an initial repair of left CDH with the younger surgeons more likely to use an MIS approach. For the recurrence scenarios, 42.5%-55.5% of these surgeons would attempt an MIS repair after a recurrence. Specifically, thoracoscopy was favored over laparoscopy following both prior laparotomy (30.0% versus 7.5%) and prior right thoracoscopy (26.4% versus 10.0%), less favored following thoracotomy (9.3% versus 18.9%), and relatively similar proportions following prior left thoracoscopy (17.5% versus 16.4%). Laparotomy was the preferred open approach both for initial presentation and all recurrence scenarios. Among surgeons who would treat initial CDH with an open procedure, between 10.4% and 17.9% would switch to an MIS approach, most commonly after prior failed laparotomy. Approximately half surgeons who approach initial left CDH in an MIS manner would attempt an MIS approach for recurrence. The tendency to approach CDH recurrence from the opposite body cavity as the initial repair clearly impacted the surgical approach. This was particularly pronounced for MIS repairs, whereas for open approach, laparotomy remained, by far, the most popular in all scenarios.