Neonatal thoracoscopic repair of congenital diaphragmatic hernias

Abstract

Objective To perform a retrospective analysis of neonates with congenital diaphragmatic hernia (CDH) and to summarize the dilemmas of thoracoscopic repairing. Methods From April 2014 to April 2019, a total of 27 CDH neonates underwent thoracoscopy. Due to an excellent visual field of pulmonary dysplasia, hernia viscera was sequentially returned into abdomen. Sharp instruments should not be directly compressed for restoring spleen along with stomach and colon. For severe defect of posterolateral diaphragm, suturing diaphragm margin-intercostal muscle-diaphragm margin and moderately tightening wire knot are employed for repairing diaphragm muscle and preventing recurrence. For severe diaphragmatic defect, continuous suture should be performed for closing defect as much as possible. And the size of weak defect was measured. Customized mesh was placed into chest cavity and fixed mesh tightly attached to weak diaphragm by interrupted suturing with 4-0 proline thread. Results The involved side was left (n=25) and right (n=2). Twenty-three cases were diagnosed prenatally. The average gestational age of prenatal diagnosis was (28.2±5.1) weeks, the average gestational age (37.5±2.7) weeks and the average birth weight (2.90±0.70) kg. Thoracoscopic repairs were successful (n=23) and converting into open operation (n=4). Among 23 survivors, the average operative age was (41±40) hours and the average operative duration (159±14) min. The average durations of ventilator supports and hospitalization were (5.1±1.2) and (18.0±4.0) days respectively. Three cases complicated with chylothorax were cured after conservative measures. There was one case of recurrence. However, based upon illness severity and operative duration, the prognoses of different groups showed no significant statistical differences. Conclusions Thoracoscopic repair is both safe and feasible for severe congenital diaphragmatic hernia in neonates. If a surgeon has extensive experiences, thoracoscopy may be selected as a first choice and completed successfully with patching. When cardiopulmonary functions are unstable and PaCO2 is continuously higher than (65-75) mmHg, thoracoscopy should be converted timely into open surgery. The thoracoscopic tolerance of low-weight premature infants is no less than that of full-term infants. Key words: Hernia, diaphragmatic; Neonate; Thoracoscopy