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Thoracoscopic repair of congenital diaphragmatic hernia in neonates: Tips and tricks learned from an institutional
J Sundaram1, M Ramasundaram1, P Agarwal1
1Department of Paediatric Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamilnadu, India.
Background:
Congenital diaphragmatic hernia (CDH) is an anomaly with significant morbidity in neonates. It has been traditionally managed by an open approach with a recent trend toward a minimally invasive approach.
Aim:
This is a retrospective study of our institutional experience with neonatal thoracoscopic management of CDH, with the impact of few technical nuances.
Patients And Methods:
The data was collected on neonatal thoracoscopic CDH repair between January 2015 and December 2018, in terms of the demographics, intra-operative parameters, post-operative status, recurrence, and mortality. While analyzing data, we found few technical modifications adopted by the surgeon such as trimming the margin of the defect, use of prosthetic mesh overlay reinforcement for repairs under tension, and to prefer extra-corporeal knotting along with higher placement of trocar, temporary increase in CO2, maximal use of muscle relaxant, extra-corporeal corner hitch stitch at some point, and continuation for further cases. An internal comparison was made to analyze the technical modifications influencing the outcomes, by dividing them into two groups, those with (group A) and without modifications (group B). The data was analyzed using SPSS software (IBM, Version 23). A P value of <0.05 was considered statistically significant.
Results:
Out of 45 newborns 64.4% were males with an average birth weight of 2.6 kg. Baseline variables were comparable between the groups. The operating time significantly reduced after a higher-level camera port was used (P-value: 0.0001). The mean follow-up was 30.8 months. There were totally seven recurrences (6 in group A and 1 in group B), all within 12 months. Seven parents gave the overall post-treatment feedback as "unsatisfied". The operating time, recurrence rate, and parental satisfaction feedback were significantly less in group B (P-value: 0.001).
Conclusion:
We recommend trimming the margin of the defect, use of prosthetic mesh overlay reinforcement for repairs under tension, and to prefer extra-corporeal knotting along with higher placement of trocar, temporary increase in CO2, maximal use of muscle relaxant, extra-corporeal corner hitch stitch to reduce the operating time, and recurrence after thoracoscopic CDH repair.
