Thoracoscopic repair of congenital diaphragmatic hernia in children

Minimal invasive surgery (MIS) has been first proposed in case of delayed congenital diaphragmatic hernia (CDH). Since then, about 32 cases of thoracoscopic CDH approach in newborns have been published. Conditions of thoracoscopy are reviewed and enlightened with our preliminary series. The advantages of thoracoscopy versus a laparoscopic approach are detailed. Since 1999, all children presenting with CDH after the immediate neonatal period were offered a MIS approach. We started treating stable newborns suffering a CDH by thoracoscopic procedures in 2003. In cases of late presentations, 10 thoracoscopies and 1 laparoscopy were performed. Among them, 4 patients suffered from an incarcerated hernia. One conversion to a thoracotomy, 1 video-assisted thoracic surgery (VATS), and 2 conversions to laparoscopies were required for the reduction of hernia contents. In those last cases, the hernia defects were sutured, coming back to the thoracoscopic approach. Six newborns with neonatal diagnosis of CDH were primarily treated by thoracoscopy. Four procedures were completed without difficulty. The diaphragm was approximated with interrupted 2/0 nonabsorbable sutures. On the lateral part of the defect, in which there is a lack of diaphragm against the ribs, plegetted rib-anchoring stitches were used. A wide defect requiring a patch needed for conversion to a thoracotomy; in this case, we encountered a very rare pericardial defect and had difficulties in reducing the liver. In another case, we went to a VATS with a less than 2-cm opening to insert a Gore Tex patch, which was required. Thoracoscopy for delayed CDH repair seems to be easy and feasible with good results. A combined procedure with both thoracoscopy and laparoscopy has proven its usefulness in case of incarcerated hernia. Thoracoscopic CDH repair in newborns is not feasible in every case due to the patient's conditions. Criteria for eligibility need more cases to be evaluated. The advantages and disadvantages of thoracoscopy versus laparoscopy are reviewed. Nevertheless, the thoracoscopic approach seems easier.