Abdominal wall plasty for a premature infant with congenital diaphragmatic hernia

Comparison of the Surgical Outcomes in Neonates with Left-sided Congenital Diaphragmatic Hernia with Only Skin Closure versus Abdominal Muscle Closure

Aim

This study aims to compare the outcome of neonatal left congenital diaphragmatic hernia (CDH, Bochdalek type) repair through laparotomy with and without abdominal muscle closure.

Materials and Methods

This retrospective study was conducted between January 2012 and May 2021 at a neonatal surgical unit of a Tertiary Care Center. Demographic details, preoperative management, Two-dimensional-echo, intra-operative findings, postoperative course, and follow-up data were collected and analyzed.

Results

The study group comprised 50 neonates with a mean standard deviation (SD) age at admission: 4.44 (5.12) days, male: female ratio of 3:2, and mean (SD) weight: 2.73 (0.51) kg. Following repair of the diaphragmatic defect through laparotomy, 26 (52%) underwent skin closure alone, whereas 24 (48%) underwent abdominal muscle closure. Postoperatively, there was a significant fall in the level of platelets (P = 0.021), increase in pressure support by at least 4-5 cm H2O (P = 0.027), and increase in the blood urea (P < 0.001), creatinine (P = 0.005), lactate (P = 0.019), and acidosis (P = 0.048) in the muscle closure group. Although not statistically significant, there was a fall in the urine output and blood pressure in this group. There was no significant difference in the duration of inotropes. Mortality was 8 (32%) in the skin closure group, and 14 (61%) in the muscle closure group (P = 0.05).

Conclusions

Neonates undergoing left CDH repair through the abdominal route with skin closure alone, had better survival, as well as hematological, renal, and ventilatory parameters than those who underwent muscle closure. It is a useful surgical modification to improve outcome in centers with limited facilities.

Congenital diaphragmatic hernia repair analysis in relation to postoperative abdominal compartment syndrome and delayed abdominal closure

AIM

Limited abdominal space in congenital diaphragmatic hernia (CDH) might result in abdominal compartment syndrome (ACS) and require delayed abdominal closure (DAC). This study reviewed outcomes in pediatric ACS/DAC after CDH repair.

METHODS

Medline/PubMed, Scopus, Web of Science, Ovid and Lilacs databases were reviewed. Data from studies published in English/Spanish/Portuguese between 1990-2020 was collected. Results are presented as descriptive statistics.

RESULTS

Sixteen reports offered 118 children, 112 (94.9%) being neonates. There were six ACS (5.1%) and 112 DAC (94.9%). Regarding ACS, the diagnosis was made clinically (n = 4; 66.7%), using Doppler scans (n = 1; 16.7%) or bladder pressure measurement (n = 1; 16.7%). There was one (16.7%) lethal outcome. The rationale to perform DAC was not clearly stated, and measurement of abdominal pressure was not mentioned in all reports. Silo was the preferred approach in 36 children (32.1%), followed by skin closure only (n = 16; 14.3%), vacuum (n = 10; 8.9%), fascia patch and skin closure (n = 5; 4.5%), fascia patch and vacuum dressing (n = 1; 0.9%), fasciotomy (n = 1; 0.9%); with no DAC technique reported in 43 patients (38.4%). Complications after DAC were reported in nine children (8.1%). One DAC using vacuum dressing that was clinically diagnosed with ACS required silo placement. There were 19 (17%) lethal outcomes.

CONCLUSIONS

ACS/DAC after CDH repair are reported more frequently in neonates (112/118; 94.9%). There is no clear rationale stated behind the decision to perform DAC, with the silo being the preferred approach. Criteria need to be worked for DAC in CDH with large herniated content and small volume abdomen to prevent ACS.

Abdominal wall closure in neonates after congenital diaphragmatic hernia repair

PURPOSE

Repair of Congenital Diaphragmatic Hernia (CDH) abruptly increases intra-abdominal pressure. This study sought to characterize the incidence and significance of ACS and delayed fascial closure (DFC) after CDH repair.

METHODS

We reviewed the CAPSNet database from 2006 to 2011, identifying the subset of patients that developed ACS or required DFC. Prenatal and demographic information, operative and physiologic details, and outcomes were investigated.

RESULTS

Of 349 patients with CDH, 3 (0.8%) were diagnosed with ACS, while 43 patients (12%) had DFC at the time of CDH repair. Patients more often had right-sided defects (26% vs 13%, p=0.04) and trended toward requiring a patch repair (41% vs 31.2%, p=0.23) and having a liver lobe above the diaphragmatic rim (47% vs 32.7, p=0.09). Patients with ACS or DFC had increased length of stay (47.5 vs 33.9, p=0.01), days fasting (8.2 vs 5.8, p=0.01), days on parenteral nutrition (23.6 vs 15.5, p=0.003), and days on mechanical ventilation (16.3 vs 9.0, p=0.001).

CONCLUSIONS

While ACS in neonates after CDH repair is rare (<1%), DFC is required relatively commonly (>10%) and is associated with right-sided diaphragmatic hernias. Inability to close abdominal fascia is associated with increased morbidity. Clinicians caring for neonates with CDH should be facile with strategies to manage delayed abdominal fascia closure.

Congenital diaphragmatic hernia

Congenital Diaphragmatic Hernia (CDH) is defined by the presence of an orifice in the diaphragm, more often left and posterolateral that permits the herniation of abdominal contents into the thorax. The lungs are hypoplastic and have abnormal vessels that cause respiratory insufficiency and persistent pulmonary hypertension with high mortality. About one third of cases have cardiovascular malformations and lesser proportions have skeletal, neural, genitourinary, gastrointestinal or other defects. CDH can be a component of Pallister-Killian, Fryns, Ghersoni-Baruch, WAGR, Denys-Drash, Brachman-De Lange, Donnai-Barrow or Wolf-Hirschhorn syndromes. Some chromosomal anomalies involve CDH as well. The incidence is < 5 in 10,000 live-births. The etiology is unknown although clinical, genetic and experimental evidence points to disturbances in the retinoid-signaling pathway during organogenesis. Antenatal diagnosis is often made and this allows prenatal management (open correction of the hernia in the past and reversible fetoscopic tracheal obstruction nowadays) that may be indicated in cases with severe lung hypoplasia and grim prognosis. Treatment after birth requires all the refinements of critical care including extracorporeal membrane oxygenation prior to surgical correction. The best hospital series report 80% survival but it remains around 50% in population-based studies. Chronic respiratory tract disease, neurodevelopmental problems, neurosensorial hearing loss and gastroesophageal reflux are common problems in survivors. Much more research on several aspects of this severe condition is warranted.