Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned

doi:10.1016/S0022-3468(03)00564-5

Journal of Pediatric Surgery

Volume 38, Issue 11, November 2003, Pages 1563-1568

https://doi.org/10.1016/S0022-3468(03)00564-5 Get rights and content

Abstract

Background:

Minimally invasive surgery (MIS) for the repair of congenital diaphragmatic hernias (CDH) had been described. This report reviews the authors’ experience with MIS repairs of CDH and discusses the technical development of this approach.

Methods:

From 1999 until now, the authors collected data on children who underwent an MIS approach for CDH repair.

Results:

Seventeen children (11 Morgagni and 7 Bochdalek) had undergone an attempt at MIS repair. All Morgagni defects were treated successfully using laparoscopy (mean age, 28 ± 31 months). Mean follow-up was 22 ± 9 months. There was 1 recurrence. Four children with Bochdalek CDH were treated as newborns (range, 3 to 21 days), and 3 had operations later (4, 11, and 32 months). The first repair was attempted initially transabdominally and was converted to a thoracoscopic approach. The rest of the Bochdalek repairs were performed thoracoscopically. Bochdalek repairs via MIS were successful in 3 children (2 older children and 1 neonate). No child had pulmonary hypertension. Two of the 3 Bochdalek patients did well postoperatively (follow-up, 18 +/− 7 months); the last patient experienced recurrence 11 months after repair.

Conclusions:

MIS for CDH is ideal for Morgagni defects. It should be considered for nonnewborns with a Bochdalek CDH. The MIS approach for a newborn with a CDH cannot be recommended because of the high failure rate and frequent rise in Pco₂ levels.

Section snippets

Materials and methods

From 1999 until now, we collected clinical and operative data on children who underwent an MIS procedure for their CDH. Data abstracted from the medical record included the following: type of hernia, age at presentation, surgical approach, operating time, details of operative repair, postoperative complications, and length of follow-up. Results are expressed as the mean ± SEM. The methodology and scope of this retrospective review met with the approval of the Institutional Review Board for

Morgagni hernias

Eleven children underwent MIS repair of a Morgagni defect. All of these repairs were successful via a laparoscopic approach. Mean age at repair was 28 ± 31 months (range, 0 to 108 months). Presenting symptoms included respiratory difficulty, nausea, and vomiting. Two patients had chest radiographs as part of their workup for gastroesophageal reflux. No one presented with incarceration.

Each child underwent repair within 1 month of diagnosis. Mean operating time was 119 ± 14 minutes. All patients

Discussion

As minimally invasive approaches continue to gain popularity in the pediatric surgical community, it is incumbent upon surgeons to report not only their successes but also their failures. Acquisition of honest information will allow the pediatric surgical community to learn from each member’s experiences and to apply the growing technology appropriately to infants and children. This report is an accounting of our experience regarding MIS repair of CDHs.

Attempting repair of a CDH using minimally

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Abdominal muscle flap for repair of large congenital diaphragmatic hernia: Ultrasound evidence for retained motor muscle function
2019, Journal of Pediatric Surgery Case Reports
Congenital diaphragmatic hernia (CDH) occurs in approximately one of 3500 live births. It includes a congenital defect of the diaphragm through which bowel and other abdominal organs herniate into the thoracic cavity. Pulmonary hypoplasia is an essential feature of the anomaly, with related overload of the right side of the heart. Most CDHs can be sutured directly after initial stabilization of the cardiopulmonary condition. However, in diaphragmatic agenesis or a large defect, alternative techniques like prosthetic patches or tissue flaps are needed. Here we describe three cases, where abdominal muscle flaps were used for diaphragmatic reconstruction. In one of the patient's dynamic ultrasound of the reconstructed diaphragm, functional ventilatory movements were demonstrated, suggesting improved functional results. None of the three patients developed recurrence, and the abdominal bulge on the side of the flap is slowly improving in the surviving patients.
Congenital Diaphragmatic Hernia
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
Morgagni hernia repair in children over two decades: Institutional experience, systematic review, and meta-analysis of 296 patients
2018, Journal of Pediatric Surgery
Citation Excerpt :
Another consideration for open surgery over MIS is the effect of laparoscopy on diaphragmatic splinting, which could potentially put infants with respiratory distress syndrome at increased risk. Nevertheless, laparoscopic repairs in infant as small as one month old have been successfully performed by our group and reported by others [17,27], suggesting appropriate patient selection is the key to success. Traditionally in adult practice when open repair was performed for MH, both thoracotomy and laparotomy had produced equal results [6,50].
Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch.
We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P < 0.05.
In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months).
Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p = 0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p = 0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p = 0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p = 0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair.
In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence.
Systematic review
3A
Minimally Invasive vs Open Congenital Diaphragmatic Hernia Repair: Is There a Superior Approach?
2017, Journal of the American College of Surgeons
The minimally invasive surgery (MIS) approach for congenital diaphragmatic hernia (CDH) repair remains controversial. Our objective was to compare outcomes and complications of the MIS and open approaches, with risk-stratification of patients based on defect size and key patient characteristics.
The multinational CDH Study Group (CDHSG) registry was queried for the period from 2007 to 2015. Patient demographics and operative details, including the CDHSG Staging System defect size (A to D), were reviewed. Open cases consisted of laparotomy and thoracotomy; MIS repairs included laparoscopy and thoracoscopy. Outcomes included length of stay (LOS) for patients surviving to discharge, hernia recurrence, and adhesive small bowel obstruction (SBO) requiring surgery. Regression analyses were performed. Odds ratios (ORs) with 95% CIs were derived.
A total of 3,067 CDH patients underwent open (n = 2,579; 84%) or MIS (n = 488; 16%) repair. Patients undergoing open repair were more likely to be diagnosed prenatally, be premature, have lower 5-minute Apgar scores, and have major cardiac anomalies (all p < 0.001). Among MIS repairs, 79% were low risk (size A and B) defects vs 50% among open repairs (p < 0.001). Patients undergoing MIS repair experienced shorter overall median LOS, higher recurrence rates, and fewer SBO. With multivariable regression adjusting for defect size and key patient characteristics, an MIS approach was significantly associated with decreased LOS (mean −13.4 days; 95% CI −18 to −8.8 days), increased recurrences (OR 3.10; 95% CI 1.91 to 5.04), and decreased SBO (OR 0.19; 95% CI 0.06 to 0.60).
After risk-stratification of CDH patients, an MIS approach was independently associated with decreased LOS and SBO, but higher recurrence rates.
Complications in neonatal surgery
2016, Seminars in Pediatric Surgery
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
Minimally invasive repair of morgagni hernia - A multicenter case series
2016, Revista Portuguesa de Pneumologia (English Edition)
Children may benefit from minimally invasive surgery (MIS) in the correction of Morgagni hernia (MH). The present study aims to evaluate the outcome of MIS through a multicenter study.
National institutions that use MIS in the treatment of MH were included. Demographic, clinical and operative data were analyzed.
Thirteen patients with MH (6 males) were operated using similar MIS technique (percutaneous stitches) at a mean age of 22.2 ± 18.3 months. Six patients had chromosomopathies (46%), five with Down syndrome (39%). Respiratory complaints were the most common presentation (54%). Surgery lasted 95 ± 23 min. In none of the patients was the hernia sac removed; prosthesis was never used. In the immediate post-operative period, 4 patients (36%) were admitted to intensive care unit (all with Down syndrome); all patients started enteral feeds within the first 24 h. With a mean follow-up of 56 ± 16.6 months, there were two recurrences (18%) at the same institution, one of which was repaired with an absorbable suture; both with Down syndrome.
The application of MIS in the MH repair is effective even in the presence of comorbidities such as Down syndrome; the latter influences the immediate postoperative recovery and possibly the recurrence rate. Removal of hernia sac does not seem necessary. Non-absorbable sutures may be more appropriate.

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Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned

Abstract

Background:

Methods:

Results:

Conclusions:

Section snippets

Materials and methods

Morgagni hernias

Discussion

Ann Thorac Surg

Am J Surg

J Pediatr Surg

J Pediatr Surg

Laparoscopic diagnosis and treatment of Morgagni hernia

Surg Laparosc Endosc

Diaphragmatic hernia through the foramen of MorgagniLaparoscopic case report

J Laparoendosc Surg

The laparoscopic approach for repair for Morgagni hernias

J Soc Laparoendosc Surg

Laparoscopic repair of a Morgagni-Larrey hernia

J Laparoendosc Adv Surg Tech, Part A

Morgagni’s hernia resolved by laparoendoscopic surgery

J Laparoendosc Adv Surg Tech, Part A

[Laparoscopic operation of a Morgagni hernia]

Zentralblatt fur Chirurgie

Morgagni-Larrey hernia correction by laparoscopic surgery

Eur J Pediatr Surg

Laparoscopic repair of diaphragmatic hernias

J Laparoendosc Surg