Reconstruction of congenital agenesis of hemidiaphragm by combined reverse latissimus dorsi and serratus anterior muscle flaps

doi:10.1053/jpsu.2001.27937

Journal of Pediatric Surgery

Volume 36, Issue 11, November 2001, Pages 1637-1640

Presented at the 34th Annual Meeting of the Pacific Association of Pediatric Surgeons, Kyoto, Japan, April 4-8, 2001.

https://doi.org/10.1053/jpsu.2001.27937 Get rights and content

Abstract

Background/Purpose: Diaphragmatic agenesis (DA) is a distinct clinical entity with poorer survival rate compared with patients with posterolateral diaphragmatic hernia. The large defect in DA is repaired frequently with a synthetic patch in the neonatal period. Well-known, long-term complications include recurrent hernia caused by patch dislodgement, chest wall deformation caused by noncompliant patch, and deteriorating pulmonary function. A reverse latissimus dorsi flap (RLD) allows continued growth of the reconstructed diaphragm with an intact pleuro peritoneal separation. When combined with neuroanastomosis of the phrenic and thoracodorsal nerves it has the potential to function as a native diaphragm. Incorporation of Serratus anterior (SA) muscle enables reconstruction of larger defects. Methods: Two cases of DA are presented. In each case the primary SILASTIC^® (Dow Corning, Midland, MI) patch repair failed and was replaced successfully with a RLD flap reconstruction with or without incorporation of SA and neuroanastomosis. Results: Both patients recovered from surgery with minimal morbidity. The reconstructed diaphragm is intact at long-term follow-up. There is marked improvement of growth of the infants, respiratory difficulties, and chest wall deformity. Conclusions: This technique is recommended in DA when the synthetic patch fails. J Pediatr Surg 36:1637-1640. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Case 1

A male infant weighing 2,542 g (small for gestational age) was delivered by normal vaginal delivery at 38 weeks' gestation. Surgery was performed after initial stabilization over 2 weeks. Agenesis of the left hemidiaphragm was diagnosed during surgery, and a SILASTIC^® (Dow Corning, Midland, MI) patch was used successfully for reconstruction. The large diaphragmatic defect had a 5-mm anterior lip with no identifiable posterior or medial diaphragmatic rim. The patch was sutured with nonabsorbable

Discussion

Management of congenital diaphragmatic hernia continues to improve. The common place posterolateral defects are repaired by approximating the available diaphragmatic tissue around the defect. However, rarer complete diaphragmatic agenesis poses a challenge to pediatric surgeons because of the improved survival rate of these babies. Where a significant portion of the diaphragmatic rim is absent, the approximation even under tension is difficult, and babies initially are treated with synthetic

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Cited by (28)

Pectoralis Major and Serratus Anterior Muscle Flap for Diaphragmatic Reconstruction
2022, Annals of Thoracic Surgery
Citation Excerpt :
The first choice for diaphragmatic reconstruction involves using artificial materials.6 However, reconstruction with these materials requires careful use indications considering infection if postoperative radiotherapy is planned or if there is a high possibility of tumor recurrence.1-5,7 In contrast, autologous tissue reconstruction with blood perfusion is less likely to cause postoperative infection.1-5
The reconstruction of diaphragmatic defects after chondrosarcoma resection is challenging. In diaphragmatic reconstruction with chest wall defects, strong chest wall reconstruction and diaphragmatic flexibility are important to avoid interference with respiration. The artificial material, Gore-Tex (W. L. Gore & Associates), is used as the first choice, but it has drawbacks related to infection, exposure, and durability. As an alternative method using artificial material, we present our alternative technique for diaphragmatic reconstruction using a reversed-combined pectoralis major and serratus anterior muscle flap.
Porcine bladder extracellular matrix as a tissue regenerative strategy in a neonate with omphalocele and diaphragmatic agenesis
2021, Journal of Pediatric Surgery Case Reports
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However, placement of the prosthetic patch in a cone-shaped three-dimensional patch has led to a reduction in rates of recurrence compared to standard patch placement [7]. Muscle flap repair can be fashioned from the internal oblique and transversus abdominis muscle (split abdominal wall muscle flap) or the latissimus dorsi with optional incorporation of serratus anterior muscle (reverse latissimus dorsi repair) [4,6]. Staged reconstruction with prosthetic patch closure and subsequent reverse latissimus dorsi repair once clinical signs of patch disproportion occur have reported good results with proportionate muscle flap growth and no evidence of paradoxical chest wall movement [8].
Porcine bladder extracellular matrix (PEBM) is a biologic membrane that promotes tissue regeneration in neonates with complex surgical disease. PEBM promotes cellular infiltration and capillary ingrowth for site-specific tissue deposition, providing both form and function to the remodeled host tissue. We present a case demonstrating the feasibility of this matrix as a tissue regeneration strategy in a patient presenting with omphalocele and diaphragmatic agenesis. Patient is an ex 36 + 1 week infant with prenatally diagnosed omphalocele containing liver who underwent operative closure on day of life (DOL) 2. During the procedure the posterior half of the right diaphragm was found to be absent. This was subsequently replaced with a 5 × 5cm PEBM patch and 10 × 7cm PEBM sheet over the liver as an underlay to thin fascia with subsequent layered closure. Patient was extubated DOL 5, advanced to goal enteral feeds DOL 18, and discharged home DOL 23. An ultrasound of the chest obtained 6 months post-repair demonstrated normal diaphragmatic motion bilaterally. Patient had no evidence of an abdominal wall defect on exam at 1 year follow up. Chest radiograph at that time also showed normal diaphragmatic contour. Patient is currently 4 years old without clinical or radiographic evidence of recurrence of either defect.
Whole organ and tissue reconstruction in thoracic regenerative surgery
2013, Mayo Clinic Proceedings
Citation Excerpt :
However, the use of local muscle flaps can reduce the abdominal domain. This may leave a large thoracic cavity on the side of the hernia, with an associated risk of atrophy of a denervated muscle.79-82 Engineered diaphragm muscle tissue must provide a patch of functional skeletal muscle, and it should withstand atrophy and carry a low risk of infection.
Development of novel prognostic, diagnostic, and treatment options will provide major benefits for millions of patients with acute or chronic respiratory dysfunction, cardiac-related disorders, esophageal problems, or other diseases in the thorax. Allogeneic organ transplant is currently available. However, it remains a trap because of its dependency on a very limited supply of donated organs, which may be needed for both initial and subsequent transplants. Furthermore, it requires lifelong treatment with immunosuppressants, which are associated with adverse effects. Despite early clinical applications of bioengineered organs and tissues, routine implementation is still far off. For this review, we searched the PubMed, MEDLINE, and Ovid databases for the following keywords for each tissue or organ: tissue engineering, biological and synthetic scaffold/graft, acellular and decelluar(ized), reseeding, bioreactor, tissue replacement, and transplantation.
We identified the current state-of-the-art practices in tissue engineering with a focus on advances during the past 5 years. We discuss advantages and disadvantages of biological and synthetic solutions and introduce novel strategies and technologies for the field. The ethical challenges of innovation in this area are also reviewed.
Innovations in the Surgical Management of Congenital Diaphragmatic Hernia
2012, Clinics in Perinatology
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Based on the lumbar perforating blood vessels, the reverse latissimus dorsi muscle provides a wide pedicle for a tension-free repair. For very large defects, such as agenesis of the diaphragm, combined use of the latissimus dorsi and serratus anterior muscles has been described.54–56 Although autologous muscle flaps are vascularized and tend to grow with the child, these diaphragmatic reconstructions with latissimus dorsi/serratus muscle flaps are typically small and have demonstrated atrophy over time because of denervation of the graft.
Reconstruction of a large diaphragmatic defect in a kitten using small intestinal submucosa (SIS)
2009, Journal of Feline Medicine and Surgery
A double-layer sheet of small intestinal submucosa (SIS) was used to reconstruct a large chronic diaphragmatic defect in a 4-month-old kitten. The SIS graft was easy to use, postoperative recovery was uneventful, no side effects of the SIS implant were observed, and the SIS graft resulted in restoration of normal clinical function while allowing growth of the kitten without restriction of chest wall development. Herniation of fat through the caval hiatus was diagnosed 29 months postoperatively on a CT scan. The cat was free of clinical signs.
Surgical management of neonates with congenital diaphragmatic hernia
2007, Seminars in Pediatric Surgery
Citation Excerpt :
The initial repair in these patients should be considered the first operation of a staged procedure. Case reports of the use of reverse latissimus dorsi and serratus anterior muscle flaps hold promise in these difficult cases, as the native tissue may offer the advantage of continued growth of the reconstructed diaphragm.32 If closure of the abdominal fascia is likely to increase intraabdominal pressure enough to exacerbate the respiratory compromise, the fascia should be left open.
Congenital diaphragmatic hernia (CDH) is one of the most challenging and complex pediatric abnormalities to manage, both medically and surgically. The care of these neonates has seen significant evolution, from previous aggressive ventilation and emergent operation to current permissive hypercapnea, physiologic stabilization, and elective surgical repair, all in less than two decades. These changes have led to many centers reporting survival rates near 80%, a dramatic improvement from the 50% survival reported in the 1970s. This review covers the current principles guiding the surgical management of CDH in the neonate, including preoperative stabilization, operative timing, extracorporeal membrane oxygenation, surgical approach, and management of recurrence. Although many clinical challenges remain, multi-institutional collaboration and ongoing research efforts will hopefully improve the clinical care of these patients.

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^☆: Address reprint requests to Udaya Samarakkody, Department of Paediatric Surgery, Waikato Hospital, Private bag 3200, Hamilton, New Zealand.

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Reconstruction of congenital agenesis of hemidiaphragm by combined reverse latissimus dorsi and serratus anterior muscle flaps☆

Abstract

Section snippets

Case 1

Discussion

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

The impact of extracorporeal membrane support in the treatment of congenital diaphragmatic hernia

J Pediatr Surg

Reconstruction of the toddler diaphragm in severe anterolateral congenital diaphragmatic hernia with the reverse latissimus dorsi flap

Ann Plast Surg