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King S, Carr BDE, Mychaliska GB, Church JT. Surgical approaches to congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151441. [PMID: 38986242 DOI: 10.1016/j.sempedsurg.2024.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.
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Affiliation(s)
- Sarah King
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Benjamin D E Carr
- Doernbecher Children's Hospital, Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University. Portland, OR, USA
| | - George B Mychaliska
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA
| | - Joseph T Church
- C.S. Mott Children's Hospital, Section of Pediatric Surgery, Department of Surgery, University of Michigan. Ann Arbor, MI, USA.
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Shibuya S, Paraboschi I, Giuliani S, Tsukui T, Matei A, Olivos M, Inoue M, Clarke SA, Yamataka A, Zani A, Eaton S, De Coppi P. Comprehensive meta-analysis of surgical procedure for congenital diaphragmatic hernia: thoracoscopic versus open repair. Pediatr Surg Int 2024; 40:182. [PMID: 38980431 PMCID: PMC11233350 DOI: 10.1007/s00383-024-05760-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Previous studies have shown a higher recurrence rate and longer operative times for thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) compared to open repair (OR). An updated meta-analysis was conducted to re-evaluate the surgical outcomes of TR. METHODS A comprehensive literature search comparing TR and OR in neonates was performed in accordance with the PRISMA statement (PROSPERO: CRD42020166588). RESULTS Fourteen studies were selected for quantitative analysis, including a total of 709 patients (TR: 308 cases, OR: 401 cases). The recurrence rate was higher [Odds ratio: 4.03, 95% CI (2.21, 7.36), p < 0.001] and operative times (minutes) were longer [Mean Difference (MD): 43.96, 95% CI (24.70, 63.22), p < 0.001] for TR compared to OR. A significant reduction in the occurrence of postoperative bowel obstruction was observed in TR (5.0%) compared to OR (14.8%) [Odds ratio: 0.42, 95% CI (0.20, 0.89), p = 0.02]. CONCLUSIONS TR remains associated with higher recurrence rates and longer operative times. However, the reduced risk of postoperative bowel obstruction suggests potential long-term benefits. This study emphasizes the importance of meticulous patient selection for TR to mitigate detrimental effects on patients with severe disease.
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Affiliation(s)
- Soichi Shibuya
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK.
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan.
| | - Irene Paraboschi
- Department of Biomedical and Clinical Science, University of Milano, Milan, Italy
| | - Stefano Giuliani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Takafumi Tsukui
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan
| | - Andreea Matei
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Mikihiro Inoue
- Department of Pediatric Surgery, Fujita Health University, Aichi, Japan
| | - Simon A Clarke
- Chelsea and Westminster NHS Foundation Trust, London, UK
| | - Atsuyuki Yamataka
- Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo City, Tokyo, 113-8431, Japan
| | - Augusto Zani
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Simon Eaton
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK
| | - Paolo De Coppi
- Stem Cell and Regenerative Medicine Section, Developmental Biology and Cancer Research & Teaching Department, Zayed Centre for Research Into Rare Disease in Children, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1E, UK.
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.
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da Costa KM, Stratulat I, Saxena AK. Reasons for conversions in thoracoscopic repairs of neonatal congenital diaphragmatic hernias: a systematic review. Surg Endosc 2024; 38:2405-2410. [PMID: 38619557 DOI: 10.1007/s00464-024-10831-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE This systematic review focused on reasons for conversions in neonates undergoing thoracoscopic congenital diaphragmatic hernia (CDH) repair. METHODS Systematic search of Medline/Pubmed and Embase was performed for English, Spanish and Portuguese reports, according to PRISMA guidelines. RESULTS Of the 153 articles identified (2003-2023), 28 met the inclusion criteria and offered 698 neonates for analysis. Mean birth weight and gestational age were 3109 g and 38.3 weeks, respectively, and neonates were operated at a mean age of 6.12 days. There were 278 males (61.50%; 278/452) and 174 females (38.50%; 174/452). The reasons for the 137 conversions (19.63%) were: (a) defect size (n = 22), (b) need for patch (n = 21); (c) difficulty in reducing organs (n = 14), (d) ventilation issues (n = 10), (e) bleeding, organ injury, cardiovascular instability (n = 3 each), (f) bowel ischemia and defect position (n = 2 each), hepatopulmonary fusion (n = 1), and (g) reason was not specified for n = 56 neonates (40.8%). The repair was primary in 322 neonates (63.1%; 322/510) and patch was used in 188 neonates (36.86%; 188/510). There were 80 recurrences (12.16%; 80/658) and 14 deaths (2.48%; 14/565). Mean LOS and follow-up were 20.17 days and 19.28 months, respectively. CONCLUSIONS Neonatal thoracoscopic repair for CDH is associated with conversion in 20% of cases. Based on available data, defect size and patch repairs have been identified as the predominant reasons, followed by technical difficulties to reduce the herniated organs and ventilation related issues. However, data specifically relating to conversion is poorly documented in a high number of reports (40%). Accurate data reporting in future will be important to better estimate and quantify reasons for conversions in neonatal thoracoscopy for CDH.
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Affiliation(s)
- Karina Miura da Costa
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK
- Department of Health Sciences, Cesumar University (Unicesumar), Maringá, Paraná, Brazil
| | - Iulia Stratulat
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK
| | - Amulya Kumar Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK.
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Lian TCY, Fung ACH, Wong KKY. Open Versus Thoracoscopic Repair of Congenital Diaphragmatic Hernia: A 19-Year Review in a Tertiary Referral Centre in Hong Kong. J Pediatr Surg 2024; 59:583-586. [PMID: 38160186 DOI: 10.1016/j.jpedsurg.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/07/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a developmental defect that causes herniation of abdominal organs into the thoracic cavity with significant morbidity. Thoracoscopic repair of CDH is an increasingly prevalent yet controversial surgical technique, with limited long-term outcome data in the Asian region. The aim of this study was to compare open laparotomy versus thoracoscopic repair of CDH in paediatric patients in a major tertiary referral centre in Asia. METHODS We performed a retrospective analysis of neonatal patients who had open laparotomy or thoracoscopic repair for CDH in our institution between July 2002 and November 2021. Demographic data, perioperative parameters, recurrence rates and surgical complications were analysed. RESULTS 64 patients were identified, with 54 left sided CDH cases. 33 patients had a prenatal diagnosis and 35 patients received minimally invasive surgical repair. There was no significant difference between open and minimally invasive repair in recurrence rate (13 % vs 17 %, P = 0.713), time to recurrence (184 ± 449 days vs 81 ± 383 days, P = 0.502), or median length of ICU stay (11 ± 14 days vs 13 ± 15 days, P = 0.343), respectively. Gastrointestinal complications occurred in 7 % of neonates in the open group and none in the thoracoscopic group. Median follow-up time was 9.5 years. CONCLUSIONS This study is a large congenital diaphragmatic hernia series in Asia, with long term follow-up demonstrating no significant difference in recurrence rate, time to recurrence or median length of ICU stay between open and minimally invasive repair, suggesting thoracoscopic approach is a non-inferior surgical option with avoidance of gastrointestinal complications compared to open repair. LEVEL OF EVIDENCE: 3 TYPE OF STUDY Retrospective Cohort Study.
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Affiliation(s)
- Tony Chao Yen Lian
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2050, Australia
| | - Adrian Chi Heng Fung
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China.
| | - Kenneth Kak Yuen Wong
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong, Hong Kong, China
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Tanaka K, Mikami T, Kato H, Okazaki T. Combined laparoscopic and thoracoscopic approaches for Bochdalek hernia with hernia sac in an 8-years-old boy: Case report. Asian J Endosc Surg 2022; 15:674-677. [PMID: 35293150 DOI: 10.1111/ases.13053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/26/2022]
Abstract
Bochdalek hernia (BH) is characterized by a defect of the posterolateral diaphragm and intrathoracic herniation of abdominal organs. The laparoscopic or thoracoscopic approach has recently become the surgical standard. However, studies on combined approaches are limited. An 8-year-old boy diagnosed with left BH was treated using a combined laparoscopic and thoracoscopic approach. On laparoscopy, BH with hernia sac was identified. Spleen, pancreas tail, kidney, and transverse colon had herniated into the left thoracic cavity. After the adhesion between transverse colon and hernia sac was dissected, all abdominal organs were restored to the abdominal cavity. On thoracoscopy, an 8 × 8 cm hernia orifice defect was identified and closed by suture. The postoperative course was uneventful, with no recurrence. A combined laparoscopic and thoracoscopic approach is safe and effective with a good field of view for left BH with hernia sac in children. To the best of our knowledge, this is the first case with left BH reporting the use of both approaches in a child without conversion.
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Affiliation(s)
- Keiichiro Tanaka
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Takafumi Mikami
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Haruki Kato
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Tadaharu Okazaki
- Department of Pediatric Surgery, Juntendo University Urayasu Hospital, Chiba, Japan
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Ieiri S, Hino Y, Irie K, Taguchi T. Single incision laparoscopic repair for late-onset congenital diaphragmatic hernia using oval-shaped multichannel port device (E•Z ACCESS oval type)-2 months infantile case of Bochdalek hernia. Asian J Endosc Surg 2022; 15:235-239. [PMID: 34008334 DOI: 10.1111/ases.12956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/01/2021] [Accepted: 05/09/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Late-onset congenital diaphragmatic hernia constitutes 10%-36% of congenital diaphragmatic hernias. They qualify for endoscopic treatment including both thoracoscopic and laparoscopic approaches because this type of patient is in relatively stable condition compared with neonatal cases. However, single incision laparoscopic approach has not been reported. We herein report an infantile case of late-presenting diaphragmatic hernia who underwent single incision laparoscopic repair using an oval-shaped multichannel port device. MATERIALS AND SURGICAL TECHNIQUE A 2 month old female infant had sudden onset dyspnea with cyanosis and was diagnosed as having left diaphragmatic hernia (Bochdalek hernia) by chest X-ray. As her respiratory condition became stable under conservative treatment using combination of decompression of the gastrointestinal tract and mild sedation, we electively planned laparoscopic repair. Preoperative enhanced computed tomography imaging found that herniated organs were stomach, spleen, pancreatic tail, small intestine and right colon. The patient also had an umbilical hernia, so we decided to perform single incision repair through this umbilical hernia. Three trocars were introduced using an oval-shaped multichannel port device and herniated organs were reduced by gentle manipulation. The defect of the diaphragm was closed by bi-hand needle driving for upper and lower limb using a stay suture. The umbilical hernia was also repaired. Postoperative course was uneventful and no recurrence was recognized. DISCUSSION Wider trocar separation was achieved using the oval-shaped device, making the needle driving easier to perform. By using an oval-shaped multichannel port device and ingenuity of needle driving, single incision repair of infant diaphragmatic hernia was enabled.
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Affiliation(s)
- Satoshi Ieiri
- Department of Pediatric Surgery, Research Field in Medical and Health Sciences, Medical and Dental Area, Research and Education Assembly, Kagoshima University, Kagoshima, Japan
| | - Yuko Hino
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keiko Irie
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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Eeftinck Schattenkerk LD, Musters GD, Nijssen DJ, de Jonge WJ, de Vries R, van Heurn LWE, Derikx JPM. The incidence of abdominal surgical site infections after abdominal birth defects surgery in infants: A systematic review with meta-analysis. J Pediatr Surg 2021; 56:1547-1554. [PMID: 33485614 DOI: 10.1016/j.jpedsurg.2021.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/22/2020] [Accepted: 01/07/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Surgical site infections (SSI) are a frequent and significant problem understudied in infants operated for abdominal birth defects. Different forms of SSIs exist, namely wound infection, wound dehiscence, anastomotic leakage, post-operative peritonitis and fistula development. These complications can extend hospital stay, surge medical costs and increase mortality. If the incidence was known, it would provide context for clinical decision making and aid future research. Therefore, this review aims to aggregate the available literature on the incidence of different SSIs forms in infants who needed surgery for abdominal birth defects. METHOD The electronic databases Pubmed, EMBASE, and Cochrane library were searched in February 2020. Studies describing infectious complications in infants (under three years of age) were considered eligible. Primary outcome was the incidence of SSIs in infants. SSIs were categorized in wound infection, wound dehiscence, anastomotic leakage, postoperative peritonitis, and fistula development. Secondary outcome was the incidence of different forms of SSIs depending on the type of birth defect. Meta-analysis was performed pooling reported incidences in total and per birth defect separately. RESULTS 154 studies, representing 11,786 patients were included. The overall pooled percentage of wound infections after abdominal birth defect surgery was 6% (95%-CI:0.05-0.07) ranging from 1% (95% CI:0.00-0.05) for choledochal cyst surgery to 10% (95%-CI:0.06-0.15) after gastroschisis surgery. Wound dehiscence occurred in 4% (95%-CI:0.03-0.07) of the infants, ranging from 1% (95%-CI:0.00-0.03) after surgery for duodenal obstruction to 6% (95%-CI:0.04-0.08) after surgery for gastroschisis. Anastomotic leakage had an overall pooled percentage of 3% (95%-CI:0.02-0.05), ranging from 1% (95%-CI:0.00-0.04) after surgery for duodenal obstruction to 14% (95% CI:0.06-0.27) after colon atresia surgery. Postoperative peritonitis and fistula development could not be specified per birth defect and had an overall pooled percentage of 3% (95%-CI:0.01-0.09) and 2% (95%-CI:0.01-0.04). CONCLUSIONS This review has systematically shown that SSIs are common after correction for abdominal birth defects and that the distribution of SSI differs between birth defects.
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Affiliation(s)
- Laurens D Eeftinck Schattenkerk
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, and Vrije Universiteit Amsterdam, Meibergdreef 9, 1005 AZ Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Gijsbert D Musters
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, and Vrije Universiteit Amsterdam, Meibergdreef 9, 1005 AZ Amsterdam, the Netherlands
| | - David J Nijssen
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, and Vrije Universiteit Amsterdam, Meibergdreef 9, 1005 AZ Amsterdam, the Netherlands
| | - Wouter J de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of General, Visceral, Thoracic, and Vascular Surgery, University Hospital Bonn, Bonn, Germany
| | - Ralph de Vries
- Medical Library, Vrije Universiteit, Amsterdam, the Netherlands
| | - L W Ernest van Heurn
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, and Vrije Universiteit Amsterdam, Meibergdreef 9, 1005 AZ Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joep P M Derikx
- Department of Paediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, and Vrije Universiteit Amsterdam, Meibergdreef 9, 1005 AZ Amsterdam, the Netherlands; Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Eeftinck Schattenkerk LD, Musters GD, Nijssen DJ, de Jonge WJ, de Vries R, van Heurn LE, Derikx JP. The incidence of different forms of ileus following surgery for abdominal birth defects in infants: a systematic review with a meta-analysis method. Innov Surg Sci 2021; 6:127-150. [PMID: 35937853 PMCID: PMC9294340 DOI: 10.1515/iss-2020-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/06/2021] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objectives
Ileus following surgery can arise in different forms namely as paralytic ileus, adhesive small bowel obstruction or as anastomotic stenosis. The incidences of these different forms of ileus are not well known after abdominal birth defect surgery in infants. Therefore, this review aims to estimate the incidence in general between abdominal birth defects.
Content
Studies reporting on paralytic ileus, adhesive small bowel obstruction or anastomotic stenosis were considered eligible. PubMed and Embase were searched and risk of bias was assessed. Primary outcome was the incidence of complications. A meta-analysis was performed to pool the reported incidences in total and per birth defect separately.
Summary
This study represents a total of 11,617 patients described in 152 studies of which 86 (56%) had a follow-up of at least half a year. Pooled proportions were calculated as follows; paralytic ileus: 0.07 (95%-CI, 0.05–0.11; I
2=71%, p≤0.01) ranging from 0.14 (95% CI: 0.08–0.23) in gastroschisis to 0.05 (95%-CI: 0.02–0.13) in omphalocele. Adhesive small bowel obstruction: 0.06 (95%-CI: 0.05–0.07; I
2=74%, p≤0.01) ranging from 0.11 (95% CI: 0.06–0.19) in malrotation to 0.03 (95% CI: 0.02–0.06) in anorectal malformations. Anastomotic stenosis after a month 0.04 (95%-CI: 0.03–0.06; I
2=59%, p=0.30) ranging from 0.08 (95% CI: 0.04–0.14) in gastroschisis to 0.02 (95% CI: 0.01–0.04) in duodenal obstruction. Anastomotic stenosis within a month 0.03 (95%-CI 0.01–0.10; I
2=81%, p=0.02) was reviewed without separate analysis per birth defect.
Outlook
This review is the first to aggregate the known literature in order approximate the incidence of different forms of ileus for different abdominal birth defects. We showed these complications are common and the distribution varies between birth defects. Knowing which birth defects are most at risk can aid clinicians in taking prompt action, such as nasogastric tube placement, when an ileus is suspected. Future research should focus on the identification of risk factors and preventative measures. The incidences provided by this review can be used in those studies as a starting point for sample size calculations.
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Affiliation(s)
- Laurens D. Eeftinck Schattenkerk
- Department of Paediatric Surgery , Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam , Amsterdam , Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Gijsbert D. Musters
- Department of Paediatric Surgery , Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam , Amsterdam , Netherlands
| | - David J. Nijssen
- Department of Paediatric Surgery , Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam , Amsterdam , Netherlands
| | - Wouter J. de Jonge
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
- Department of General, Visceral-, Thoracic and Vascular Surgery , University Hospital Bonn , Bonn , Germany
| | - Ralph de Vries
- Medical Library, Vrije Universiteit , Amsterdam , Netherlands
| | - L.W. Ernest van Heurn
- Department of Paediatric Surgery , Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam , Amsterdam , Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
| | - Joep P.M. Derikx
- Department of Paediatric Surgery , Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam , Amsterdam , Netherlands
- Tytgat Institute for Liver and Intestinal Research, Amsterdam UMC, University of Amsterdam , Amsterdam , Netherlands
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Liu H, Le C, Chen J, Xu H, Yu H, Chen L, Liu H. Anesthetic management of thoracoscopic procedures in neonates: a retrospective analysis of 45 cases. Transl Pediatr 2021; 10:2035-2043. [PMID: 34584873 PMCID: PMC8429869 DOI: 10.21037/tp-21-265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 08/05/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Advances in medical techniques and equipment have enabled the thoracoscopic repair of certain congenital abnormalities in neonates including congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH). A retrospective analysis was conducted to examine the anesthetic management of neonates (7 days or younger) undergoing thoracoscopic surgery in our hospital department, and to determine the efficacy of anesthetic management in neonates. METHODS Clinical data from 45 neonates who underwent thoracoscopic surgery in our hospital from December 2015 to March 2020 were retrospectively analyzed. A total of 25 patients underwent repair of CDH and 20 underwent repair of an EA/TEF. RESULTS All patients received general anesthesia with endotracheal intubation, standard ASA monitoring, and arterial blood gas (ABG) analysis. All patients survived the surgery. A total of 14 patients experienced decreases in SpO2, pH, PaO2, and increases in PETCO2 and PaCO2 30 minutes after CO2 insufflation. Our anesthetic management protocols are outline and analyzed. CONCLUSIONS Thorough preoperative preparation is critical for a desirable outcome in neonates undergoing a thoracoscopic repair of CDH or EA/TEF. In our cohort, intraoperative ventilation strategies included pressure control ventilation with peak airway pressure maintained at 15-25 cmH2O, a respiratory rate of 35-55 breaths/minute, a fraction of inspired oxygen (FiO2) of 60-80%, an inspiratory/expiratory ratio (I:E) of 1:1-1.5, and careful airway suctioning to clear secretions. Postoperatively, maintaining normovolemia and hemodynamic stability are critical for successful weaning of ventilatory support and extubation.
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Affiliation(s)
- Hua Liu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Chengjin Le
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Jing Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Heng Xu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Hui Yu
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Lin Chen
- Department of Anesthesiology, Hubei Women & Children's Hospital, Wuhan, China
| | - Henry Liu
- Department of Anesthesiology and Perioperative Medicine, Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, PA, USA
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Pandey V, Gopal SC. Congenital Diaphragmatic Hernia: Experience and Results of Thoracoscopic Repair from a Tertiary Care Hospital. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2020. [DOI: 10.1055/s-0040-1714200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction Congenital diaphragmatic hernia (CDH) is one of the most common congenital anomalies encountered by pediatric surgeons. With the advances in the pediatric minimal access surgery, its role in the repair of CDH has also increased. We have been using thoracoscopy for the repair for CDH since 2015. We herein report our experience of CDH repair in newborns.
Materials and Methods A retrospective review was conducted from July 2015 to December 2019 in the Department of Pediatric surgery after ethical approval from the institutional review board and included all the children with CDH who underwent thoracoscopic repair. The case records were used to assess the demographic details, type of defect, and early and late postoperative complications of thoracoscopy in CDH.
Results Thoracoscopic repair was attempted in 29 patients of CDH. Eight (27.5%) patients converted to open procedure and were excluded from the study. Primary closure of the diaphragmatic defect was performed in 90.4% (19) patients. Also, 9.5% (2) children required mesh repair. There was no intraoperative death. Postoperative ventilation was required in 57.1% (12) children. The mean time on the ventilator was 3.03 ± 0.9 days. The mean age of children requiring postoperative ventilation was less compared with children who were extubated in the postoperative period (p = 0.032). The median follow-up in our study was 12 months and 28.5% of patients developed recurrence of the diaphragmatic hernia. All the children underwent laparotomy and repair of the diaphragmatic defect.
Conclusion Thoracoscopic repair is a safe and effective option for the repair of CDH in children performed by surgeons with significant procedure experience.
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Affiliation(s)
- Vaibhav Pandey
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Saroj C. Gopal
- Department of Pediatric Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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11
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Thoracoscopic repair of congenital diaphragmatic hernia: a new anatomical reconstructive concept for tension dispersal at primary closure. Surg Endosc 2020; 35:3279-3284. [PMID: 32617656 DOI: 10.1007/s00464-020-07764-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Several measures were implemented among authors striving to tail off recurrence rates of thoracoscopic congenital diaphragmatic hernia repair. In the presented study, we extended the use of rib-anchoring stitches to reorient the diaphragmatic muscle leaflets in the types B&C diaphragmatic hernias, to achieve tension dispersal at primary thoracoscopic repair. PATIENTS AND METHODS Included in this study were early and late-onset lateral congenital diaphragmatic hernia patients, who had been operated upon in the years 2012 through 2018. A preliminary stitch was taken between posterior muscle edge and rib cage to reorient the diaphragmatic defect into a reversed C-shaped line. The lateral portion was closed by additional rib-anchoring stitches, while the medial one necessitated muscle to muscle stitches. Primary outcome being validated was the recurrence rate within a year post repair. RESULTS In the 7-year inclusion period, 36 congenital diaphragmatic hernia cases were managed using the described approach. The repair was accomplished thoracoscopically in all but two cases, who were excluded from the study. Mean operative time was 76 min. No pledgets or synthetic patches were applied. Mean length of hospital stay was 7.6 days. Early postoperative course was uneventful in all but four cases; two ventilatory barotrauma and two mortalities. After a mean follow-up period of 29 months, five recurrences were reported (16%). Ipsilateral chest wall deformity was noticed in one case 3 years post repair. CONCLUSION In the presented study, authors adopted thoracoscopic reorientation of diaphragmatic muscle leaflets in lateral congenital diaphragmatic hernia cases to achieve tension dispersal at primary repair. Short and mid-term results supported the efficacy and reproducibility of the described approach. However, long-term comparative studies seemed a necessity to validate this outcome.
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12
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Kamran A, Zendejas B, Demehri FR, Nath B, Zurakowski D, Smithers CJ. Risk factors for recurrence after thoracoscopic repair of congenital diaphragmatic hernia (CDH). J Pediatr Surg 2018; 53:2087-2091. [PMID: 30017067 DOI: 10.1016/j.jpedsurg.2018.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/19/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE To identify technical modifications concerning factors that may lower the risk of recurrence following thoracoscopic repair of congenital diaphragmatic hernia (CDH). METHODS All CDH patients who underwent thoracoscopic repair from April 2003 to September 2017 were retrospectively reviewed. Some of the more recently treated patients underwent technically modified repairs with underlay and overlay buttresses. RESULTS Sixty-eight patients underwent thoracoscopic repair of a diaphragmatic hernia that presented either neonatally (n = 52) or beyond the neonatal period (>1 month) (n = 16). At our institution, the minimally invasive surgical approach is considered for clinically stable CDH patients, who are likely to have type A or B defects. 21 patients had a sac-type defect. Forty-seven patients with type A defect had primary closure, buttressed in 6 cases. In 21 patients, the type B defect was repaired with a patch, buttressed in 11 patients. Median follow-up was 36 months (IQR 9-45). Recurrence occurred in 13 patients (overall 19% recurrence rate); all had a neonatally presented defect (25% vs. 0%, p = 0.03). Patients with a sac-type defect had a lower recurrence rate than patients with no hernia sac (5% vs. 26%, p = 0.05). Recurrence complicated 7 of 47 (15%) patients after primary closure and 6 of 21 (29%) patients with patch repair; none of the 17 cases with buttressed repairs had a recurrence. CONCLUSIONS Due to a higher rate of recurrence following thoracoscopic CDH repair compared to the standard open approach, we suggest a sandwich-type buttress repair with underlay and overlay components for both primary and patch repairs. LEVEL OF EVIDENCE Level III cohort study.
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Affiliation(s)
- Ali Kamran
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Benjamin Zendejas
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Farokh R Demehri
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Bharath Nath
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - David Zurakowski
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Charles J Smithers
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, United States.
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13
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Wall JK, Sinclair TJ, Kethman W, Williams C, Albanese C, Sylvester KG, Bruzoni M. Advanced minimal access surgery in infants weighing less than 3kg: A single center experience. J Pediatr Surg 2018; 53:503-507. [PMID: 28549685 DOI: 10.1016/j.jpedsurg.2017.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 05/03/2017] [Accepted: 05/07/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants. STUDY DESIGN A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts. RESULTS A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort. CONCLUSION Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- James K Wall
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Tiffany J Sinclair
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - William Kethman
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Christina Williams
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Craig Albanese
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Karl G Sylvester
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Matias Bruzoni
- Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, United States.
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14
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Schneider A, Becmeur F. Pediatric thoracoscopic repair of congenital diaphragmatic hernias. J Vis Surg 2018; 4:43. [PMID: 29552525 DOI: 10.21037/jovs.2018.02.03] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 01/29/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare congenital disease requiring neonatal surgical treatment. The traditional surgical management of CDH consists of diaphragmatic repair by laparotomy. Thoracoscopic repair techniques have been well described for CDH with late presentation. Nevertheless, its feasibility for CDH treatment in neonates emerged only the past few years because the use of thoracoscopy with carbon dioxide insufflation remains controversial in these patients more vulnerable to hypothermia and acidosis. However, we think that thoracoscopy can be safely used to repair CDH in selected patients and the major limiting factor is pulmonary hypoplasia. Some patients should be excluded based on their higher potential need for patch closure with its technical difficulty and increased operative time. The close collaboration between pediatric surgeon, anesthetist and neonatologist is essential. We discuss here the patient selection criteria, expose the pre- and post-operative management, the procedure steps; regarding to our experience we deliver some tips to achieve the safest surgical procedure for the pediatric patient.
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Affiliation(s)
- Anne Schneider
- Department of Pediatric Surgery, University Hospital, Strasbourg, France
| | - François Becmeur
- Department of Pediatric Surgery, University Hospital, Strasbourg, France
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15
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Hazboun R, Rodriguez S, Thirumoorthi A, Baerg J, Moores D, Tagge EP. Laparoscopic skills assessment: an additional modality for pediatric surgery fellowship selection. J Pediatr Surg 2017; 52:1904-1908. [PMID: 28947326 DOI: 10.1016/j.jpedsurg.2017.08.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/28/2017] [Indexed: 11/16/2022]
Abstract
AIM The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity. MATERIALS AND METHODS Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data. RESULTS Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01). CONCLUSIONS Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability. TYPE OF STUDY Prospective study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Rajaie Hazboun
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA
| | - Samuel Rodriguez
- Department of General Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA
| | - Arul Thirumoorthi
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA
| | - Joanne Baerg
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA
| | - Donald Moores
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA
| | - Edward P Tagge
- Division of Pediatric Surgery, Loma Linda University School of Medicine, Coleman Pavilion, Loma Linda, CA, USA.
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16
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Inoue M, Uchida K, Kusunoki M. Letter to the Editor regarding the article "Congenital diaphragmatic hernia in neonates: factors related to failure of thoracoscopic repair". Pediatr Surg Int 2017; 33:513-514. [PMID: 28116502 DOI: 10.1007/s00383-016-4055-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Mikihiro Inoue
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
| | - Keiichi Uchida
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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17
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Abstract
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.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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18
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Kohli N, Mitreski G, Yap CH, Leong M. Massive symptomatic right-sided Bochdalek hernia in an adult man. BMJ Case Rep 2016; 2016:bcr-2016-217432. [PMID: 27852660 DOI: 10.1136/bcr-2016-217432] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 22-year-old man presented to a rural hospital in Australia with right-sided pleuritic chest pain, right shoulder pain and dyspnoea. The patient had been receiving chronic asthma therapy without improvement. CT of the chest was performed after an abnormal X-ray, incidentally revealing one of the largest documented right-sided diaphragmatic hernias, with left lung compression due to mediastinal shift. The patient was definitively managed with thoracotomy alone. The contents of the hernia sac included colon and multiple loops of small bowel with a 10 cm neck. Definitive treatment was achieved with significant reduction in hernia size and formation of a neo-diaphragm with composite mesh. The postoperative period was complicated only by a wound infection. Two weeks after discharge the patient remained clinically well. Repeat chest X-ray showed no recurrence of the hernia. Congenital diaphragmatic hernias should be considered in patients with ongoing respiratory symptoms. Thoracotomy provides a safe approach.
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Affiliation(s)
- Naman Kohli
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Goran Mitreski
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Cheng-Hon Yap
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
| | - Matthew Leong
- Department of Surgery, Barwon Health, Geelong, Victoria, Australia
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19
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He QM, Zhong W, Zhang H, Li L, Wang Z, Tan Y, Lv J, Liu F, Yu J, Xia H. Standardized Indications to Assist in the Safe Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates. J Laparoendosc Adv Surg Tech A 2016; 26:399-403. [DOI: 10.1089/lap.2015.0327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Qiu-ming He
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
- Southern Medical University, Guangzhou, Guangdong, China
| | - Wei Zhong
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hong Zhang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Le Li
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhe Wang
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yunpu Tan
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Junjian Lv
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Fen Liu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiakang Yu
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Huimin Xia
- Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
- Southern Medical University, Guangzhou, Guangdong, China
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20
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Lacher M, St Peter SD, Laje P, Harmon CM, Ure B, Kuebler JF. Thoracoscopic CDH Repair—A Survey on Opinion and Experience Among IPEG Members. J Laparoendosc Adv Surg Tech A 2015; 25:954-7. [DOI: 10.1089/lap.2015.0243] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Martin Lacher
- Center of Pediatric Surgery, Hannover Medical School, Hannover, Germany
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Shawn D. St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Pablo Laje
- Division of General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Carroll M. Harmon
- Department of Surgery, State University of New York at Buffalo, Buffalo, New York
| | - Benno Ure
- Center of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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21
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Jackson HT, Shah SR, Hathaway E, Nadler EP, Amdur RL, McGue S, Kane TD. Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children’s hospitals. Surg Endosc 2015; 30:2281-7. [DOI: 10.1007/s00464-015-4227-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
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22
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Fujishiro J, Ishimaru T, Sugiyama M, Arai M, Suzuki K, Kawashima H, Iwanaka T. Minimally invasive surgery for diaphragmatic diseases in neonates and infants. Surg Today 2015; 46:757-63. [PMID: 27246508 DOI: 10.1007/s00595-015-1222-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
Abstract
Owing to recent advances in minimally invasive surgery (MIS), laparoscopic and thoracoscopic surgery have been gradually introduced for use in neonates and infants. This review focuses on two popular MIS procedures for diaphragmatic diseases in neonates and infants: congenital diaphragmatic hernia (CHD) repair and plication for diaphragmatic eventration. While several advantages of MIS are proposed for CDH repair in neonates, there are also some concerns, namely intraoperative hypercapnia and acidosis and a higher recurrence rate than open techniques. Thus, neonates with severe CDH, along with an unstable circulatory and respiratory status, may be unsuitable for MIS repair, and the use of selection criteria is, therefore, important in these patients. It is generally believed that a learning curve is associated with the higher recurrence rate. Contrary to CDH repair, no major disadvantages associated with the use of MIS for diaphragmatic eventration have been reported in the literature, other than technical difficulty. Thus, if technically feasible, all pediatric patients with diaphragmatic eventration requiring surgical treatment are potential candidates for MIS. Due to a shortage of studies on this procedure, the potential advantages of MIS compared to open techniques for diaphragmatic eventration, such as early recovery and more rapid extubation, need to be confirmed by further studies.
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Affiliation(s)
- Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masahiko Sugiyama
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Mari Arai
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Keisuke Suzuki
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Hiroshi Kawashima
- Division of Surgery, Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo, 113-8655, Japan.,Saitama Children's Medical Center, Magome 2100, Iwatsuki-ku, Saitama, Saitama, 339-8551, Japan
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23
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Inoue M, Uchida K, Otake K, Nagano Y, Mori K, Hashimoto K, Matsushita K, Koike Y, Uemura A, Kusunoki M. Thoracoscopic repair of congenital diaphragmatic hernia with countermeasures against reported complications for safe outcomes comparable to laparotomy. Surg Endosc 2015; 30:1014-9. [DOI: 10.1007/s00464-015-4287-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 05/23/2015] [Indexed: 11/24/2022]
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24
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Davenport M, Rothenberg SS, Crabbe DCG, Wulkan ML. The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia. J Pediatr Surg 2015; 50:240-6. [PMID: 25638610 DOI: 10.1016/j.jpedsurg.2014.11.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results.
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Affiliation(s)
- Mark Davenport
- Department of Paediatric Surgery, Kings College Hospital, London, UK.
| | - Steven S Rothenberg
- 2055 High St Suite 370, Rocky Mountain Hospital For Children, Denver, CO, USA.
| | - David C G Crabbe
- Department of Paediatric Surgery, Leeds General Infirmary, Leeds, UK.
| | - Mark L Wulkan
- Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA.
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25
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Thoracoscopic repair of congenital diaphragmatic hernia: two centres' experience with 60 patients. Pediatr Surg Int 2015; 31:191-5. [PMID: 25430524 DOI: 10.1007/s00383-014-3645-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Congenital diaphragmatic hernia is a potentially life-threatening neonatal condition which required surgical intervention. With the advances in endosurgical instruments and techniques, thoracoscopic approach is gaining popularity as a standard procedure in the treatment of this condition. In this study, we reviewed our two centres' experience with thoracoscopic repair of congenital diaphragmatic hernia in recent years. METHODS All patients who underwent thoracoscopic repair of congenital diaphragmatic hernia between 2010 and 2013 at the two tertiary referral centres were identified. Medical records were retrospectively reviewed. Data including patients' demographics, peri-operative outcomes, length of hospitalisation and post-operative complications were extracted and analysed. RESULTS 60 patients were identified over the study period, with 46 males and 14 females. 48 patients received operation within the first 7 days of life. There were seven patients with delayed presentation and were operated after 1 month old. The average body weight was 3.03 kg. Left-sided hernia was more prevalent (n = 50). The mean operative time was 88.5 min (range 31-194 min). No conversion to open thoracotomy or laparotomy was required in any of the patients. All patients except one were intubated and paralysed in neonatal intensive care units for at least 3 days after operation. Average hospital stay was 14.6 days. There was no mortality in this series. There were five recurrences, one being the patient without post-operative paralysis, and the others with deficient posterior muscle rim. No musculoskeletal deformity was noted on follow-up examination. CONCLUSION Thoracoscopic repair of congenital diaphragmatic hernia can be performed safely in specialised centres. The post-operative recovery and cosmesis are excellent. Diaphragmatic hernia with large defect remains a challenge for surgeons.
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Ballouhey Q, Villemagne T, Cros J, Vacquerie V, Bérenguer D, Braik K, Szwarc C, Longis B, Lardy H, Fourcade L. Assessment of paediatric thoracic robotic surgery. Interact Cardiovasc Thorac Surg 2014; 20:300-3. [DOI: 10.1093/icvts/ivu406] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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27
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Zani A, Zani-Ruttenstock E, Pierro A. Advances in the surgical approach to congenital diaphragmatic hernia. Semin Fetal Neonatal Med 2014; 19:364-9. [PMID: 25447986 DOI: 10.1016/j.siny.2014.09.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Congenital diaphragmatic hernia is a birth defect that affects about one in 2500 live births. Although the overall survival has improved over the last several decades thanks to advancements in postnatal resuscitation and intensive care treatment, morbidity and mortality remain high. The surgical management of these infants is far from being standardized, and many aspects are still disputed among experts. The timing of surgical repair remains controversial and the indications for the ideal time for surgery have not been validated. The main novelty in the surgical treatment is related to the use of minimally invasive techniques, although these have been associated with intraoperative blood gas disturbances and higher recurrence rates. Herein, we report and comment on the main controversies of postnatal CDH repair in this rapidly evolving field.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elke Zani-Ruttenstock
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
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28
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Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the newborn: current status and evidence. Semin Pediatr Surg 2014; 23:249-56. [PMID: 25459008 DOI: 10.1053/j.sempedsurg.2014.09.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The evolution of minimally invasive surgery (MIS) in the newborn has been delayed due to the limited working space and the unique physiology. With the development of smaller instruments and advanced surgical skills, many of the initial obstacles have been overcome. MIS is currently used in specialized centers around the world with excellent feasibility. Obvious advantages include better cosmesis, less trauma, and better postoperative musculoskeletal function, in particular after thoracic procedures. However, the aim of academic studies has shifted from proving feasibility to a critical evaluation of outcome. Prospective randomized trials and high-level evidence for the benefit of endoscopic surgery are still scarce. Questions to be answered in the upcoming years will therefore include both advantages and potential disadvantages of MIS, especially in neonates. This review summarizes recent developments of MIS in neonates and the evidence for its use.
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Affiliation(s)
- Martin Lacher
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany.
| | - Joachim F Kuebler
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Jens Dingemann
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
| | - Benno M Ure
- Center of Pediatric Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30625, Germany
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Abstract
Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.
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Affiliation(s)
- Hope T Jackson
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Timothy D Kane
- Department of Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA; Surgical Residency Training Program, Division of Pediatric Surgery, Department of Surgery, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Avenue, Northwest, Washington, DC 20010-2970, USA.
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Burgmeier C, Schier F. Hemodynamic Effects of Thoracoscopic Surgery in Neonates with Cardiac Anomalies. J Laparoendosc Adv Surg Tech A 2014; 24:265-7. [DOI: 10.1089/lap.2013.0157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Christine Burgmeier
- Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany
- Department of Pediatric Surgery, University Medical Center Ulm, Ulm, Germany
| | - Felix Schier
- Department of Pediatric Surgery, University Medical Center Mainz, Mainz, Germany
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Pérez-Merino EM, Usón-Casaús JM, Zaragoza-Bayle C, Rivera-Barreno R, Rodríguez-Alarcón CA, Palme R, Sánchez-Margallo FM. Development of an optimal diaphragmatic hernia rabbit model for pediatric thoracoscopic training. Exp Anim 2014; 63:93-8. [PMID: 24521868 PMCID: PMC4160932 DOI: 10.1538/expanim.63.93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Our objectives were to standarize the procedure needed to reproduce a similar surgical
scene which a pediatric surgeon would face on repairing a Bochdalek hernia in newborns and
to define the optimal time period for hernia development that achieve a realistic surgical
scenario with minimimal animal suffering. Twenty New Zealand white rabbits weighing 3–3.5
kg were divided into four groups depending on the time frame since hernia creation to
thoracoscopic repair: 48 h, 72 h, 96 h and 30 days. Bochdalek trigono was identified and
procedures for hernia creation and thoracoscopic repair were standarized. Blood was
collected for hematology (red blood cells, white blood cells, platelets, hemoglobin and
hematocrit), biochemistry (blood urea nitrogen, creatinine, alanine aminotransferase,
aspartate aminotransferase, lactate dehydrogenase and creatine kinase) and gas analysis
(arterial blood pH, partial pressure of oxygen, partial pressure of carbón dioxide, oxygen
saturation and bicarbonate) at baseline and before the surgial repairment. Glucocorticoid
metabolites concentration in faeces was measured. Thoracoscopy video recordings were
evaluated by six pediatric surgeons and rated from 0 to 10 according to similarities with
congenital diaphragmatic hernia in newborn and with its thoracoscopic approach.
Statistical methods included the analysis of variance, and comparisons between groups were
followed by a post-hoc Tukey’s test. Fourty -eight h showed to be the optimal time frame
to obtain a diaphragmatic hernia similar to newborn scenario from a surgical point of view
with minimal stress for the animals.
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Affiliation(s)
- Eva M Pérez-Merino
- Department of Animal Medicine and Surgery, Veterinary Faculty, University of Extremadura, Avda. Universidad s/n, 10003 Cáceres, Spain
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Usón-Casaús J, Pérez-Merino EM, Rivera-Barreno R, Rodríguez-Alarcón CA, Sánchez-Margallo FM. Evaluation of a Bochdalek diaphragmatic hernia rabbit model for pediatric thoracoscopic training. J Laparoendosc Adv Surg Tech A 2014; 24:280-5. [PMID: 24475882 DOI: 10.1089/lap.2013.0358] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND/AIM This study evaluated the usefulness of a Bochdalek hernia rabbit model as a tool for advanced thoracoscopic training, teaching the specific skills required for thoracoscopic repair of congenital diaphragmatic hernia. MATERIALS AND METHODS An incision was made in the Bochdalek triangle of 25 New Zealand rabbits (weighing 3-3.5 kg) to induce an experimental diaphragmatic hernia. At 72 hours later, a thoracoscopic repair of the hernia as described for newborns was performed by 25 pediatric surgeons divided into two groups: expert and novice. The tasks assessed were organ relocation and diaphragm suture. A visual analog scale was used to evaluate technical performance. The objective performance measure was completion time. Complications were recorded, and suture quality was scored. The surgeons evaluated the model by completing a questionnaire, grading items on a 5-point scale. RESULTS All 25 animals developed a diaphragmatic hernia with protrusion of the intestine into the thoracic cavity. Expert trainees had significantly shorter completion times and better performance scores than novices. Experts also received higher scores for suture quality. Five novices caused perforations or bleeding, but no experts did. The surgeons rated the model positively, highlighting the similarities between the model and newborn hernias and its usefulness for pediatric training programs. CONCLUSIONS The Bochdalek hernia rabbit model can be used to detect different levels of experience in pediatric thoracoscopy. This realistic and easily reproducible model can help to perfect thoracoscopic skills in a realistic recreation of a pediatric Bochdalek hernia repair.
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Affiliation(s)
- Jesús Usón-Casaús
- 1 Department of Animal Medicine and Surgery, Faculty of Veterinary Science, University of Extremadura , Cáceres, Spain
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Abstract
Thoracoscopic repair is feasible and safe for congenital diaphragmatic hernia (CDH). The operation can be performed with three trocars using carbon dioxide insufflations at a pressure of 4-6 mmHG. From January 2001 to July 2012, we performed thoracoscopic repair for 311 children with CDH including 152 newborns and 159 infants and toddlers. Mean operative time was 75 ± 27 min. HFOV was used in 24 patients. Direct closure of two rims of diaphragmatic hernia was carried out in 175 patients. Closure of two rims of diaphragmatic hernia with the thoracic wall was performed in 136 patients. Prosthetic patches were required in 54 patients. Conversion to open surgery was required in 38 patients (12.2%). There were no intraoperative deaths. 38 patients died postoperatively (13.5%).
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Cha C, Hong YJ, Chang EY, Chang HK, Oh JT, Han SJ. Minimally invasive surgery in infants with congenital diaphragmatic hernia: outcome and selection criteria. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 85:84-8. [PMID: 23908966 PMCID: PMC3729992 DOI: 10.4174/jkss.2013.85.2.84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/10/2013] [Accepted: 05/16/2013] [Indexed: 11/30/2022]
Abstract
Purpose The aim of the study was to determine clinical indications for performing minimally invasive surgery (MIS) with acceptable results by reviewing our experience in congenital diaphragmatic hernia (CDH) repair and comparing outcomes of MIS with open surgery. Methods Medical records of patients who underwent CDH repair were reviewed retrospectively between January 2008 and December 2012, and outcomes were compared between MIS and open repair of CDH. Results From 2008 to 2012, 35 patients were operated on for CDH. Among these patients, 20 patients underwent open surgery, and 15 patients underwent MIS. Patients with delayed presentations (60.0% [9/15] in the MIS group vs. 20.0% [4/20] in the open surgery group; P = 0.015) and small diaphragmatic defect less than 3 cm (80.0% [12/15] in the MIS group vs. 0.0% [0/20] in the open surgery group; P < 0.001) were more frequently in the MIS group than the open surgery group. All 10 patients who also had other anomalies underwent open surgery (P = 0.002). Moreover, nine patients who needed a patch for repair underwent open surgery (P = 0.003). Patients in the MIS group showed earlier enteral feeding and shorter hospital stays. There was no recurrence in either group. Conclusion CDH repair with MIS can be suggested as the treatment of choice for patients with a small sized diaphragmatic defect, in neonates with stable hemodynamics and without additional anomalies, or in infants with delayed presen tation of CDH, resulting in excellent outcomes.
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Affiliation(s)
- Chihwan Cha
- Department of Pediatric Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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Lukish J, Rasmussen S, Garrett D, Stewart D, Buck J, Abdullah F, Colombani P. Utilization of a novel unidirectional knotless suture during minimal access procedures in pediatric surgery. J Pediatr Surg 2013; 48:1445-9. [PMID: 23845647 DOI: 10.1016/j.jpedsurg.2013.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/29/2013] [Accepted: 03/01/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND The application of minimally invasive surgery (MIS) for advanced procedures in children is logical. However, the intracorporeal placement and tying of suture can be challenging, leading to prolonged anesthesia and morbidity. We describe our initial experience with the use of a novel unidirectional barbed knotless suture (V-LOC, Covidien, Mansfield, MA) that permits a safe and efficient advanced MIS reconstruction in infants and children. METHODS From August 2010 to February 2012, 11 infants and children underwent diaphragmatic reconstruction utilizing either the absorbable or the permanent V-LOC suture. Data retrieval included gender, weight, diagnosis, operative time, complications and follow up. RESULTS Thoracoscopic or laparoscopic repairs were carried out in all children. Two of the infants with congenital diaphragmatic hernia of Bochdalek (CDH) developed a recurrence at 4 and 6 months of age and required reoperation. There were no other complications or recurrence in the remaining 9 children, and there were no mortalities in the group. CONCLUSION This is the first study to evaluate the use of the unidirectional barbed knotless suture in pediatric surgery. We demonstrate that the use of the V-LOC barbed suture is an innovative, safe and time saving option for pediatric MIS. Prospective analysis with long-term follow-up is required to confirm these initial results and to ascertain if this novel approach can be utilized in other pediatric surgical conditions.
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Affiliation(s)
- Jeffrey Lukish
- Division of Pediatric Surgery, Department of Surgery, The Johns Hopkins University, Baltimore, MD 21287, USA.
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Peycelon M, Parmentier B, Raquillet C, Louvet N, Audry G, Auber F. [Video-assisted surgery in children: current progress and future perspectives]. Arch Pediatr 2013; 20:509-16. [PMID: 23566581 DOI: 10.1016/j.arcped.2013.02.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 02/01/2013] [Accepted: 02/24/2013] [Indexed: 01/10/2023]
Abstract
This review presents the evidence of video-assisted surgery in the pediatric population and discusses future progress in this field. Videosurgery minimizes the cosmetic impact and the pain induced by open procedures and has been in constant development in adults and children. Earlier training of surgeons and residents combined with advances in anesthetics and technology have expanded the use of videosurgery for more complex interventions. Although most feasible surgical procedures have been performed by laparoscopy, the literature has not yet defined it as the gold standard for most interventions, especially because of the lack of evidence for many of them. However, laparoscopy for cholecystectomy is now the preferred approach with excellent postoperative outcomes and few complications. Although no evidence has been demonstrated in children, laparoscopy has been shown to be superior in adults for gastroesophageal reflux disease and splenectomy. Laparoscopic appendectomy remains controversial. Nevertheless, meta-analyses have concluded in moderate but significant advantages in terms of pain, cosmetic considerations, and recovery for the laparoscopic approach. Laparoscopy is now adopted for undescended testes and allows both localization and surgical treatment if necessary. For benign conditions, videosurgery can be an excellent tool for nephrectomy and adrenalectomy. However, laparoscopy remains controversial in pediatric surgical oncology.
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Affiliation(s)
- M Peycelon
- Service de chirurgie viscérale pédiatrique et néonatale, hôpital Armand-Trousseau, hôpitaux universitaires Est Parisien, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris cedex 12, France.
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Gomes Ferreira C, Kuhn P, Lacreuse I, Kasleas C, Philippe P, Podevin G, Bonnard A, Lopez M, De Lagausie P, Petit T, Lardy H, Becmeur F. Congenital diaphragmatic hernia: an evaluation of risk factors for failure of thoracoscopic primary repair in neonates. J Pediatr Surg 2013; 48:488-95. [PMID: 23480901 DOI: 10.1016/j.jpedsurg.2012.09.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Revised: 08/18/2012] [Accepted: 09/10/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Publications aiming to prove the feasibility and safety of thoracoscopic CDH-repair in neonates grow in numbers. Some teams use selection criteria, but none have proven statistical evidence. The aim of this study is to detect risk factors for failure of thoracoscopic primary closure of CDH in neonates. METHODS In 8 centers performing minimal access surgery (MAS), complete prenatal, postnatal, and operative data were evaluated for a retrospective study concerning patients with thoracoscopic congenital diaphragmatic hernia (CDH) repair. Most of the selection criteria and risk factors mentioned in the literature were analyzed. Two groups were defined: Group A - neonates who tolerated thoracoscopic primary repair, and Group B - neonates who required conversion or presented with major complications after thoracoscopic repair. Univariate and multivariate logistic regressions were used to compare these two groups. RESULTS From 2006 to 2010, thoracoscopy was performed in 40 neonates: Group A consisting of 28 neonates, and Group B 9 patients. Three patients were excluded because of insufficient data or major associated malformations. Significant statistical differences were found in Group B for postnatal PaCO2 >60 mmHg, need of iNO during postnatal stabilization, intrathoracic position of the stomach, pulmonary hypertension signs on the postnatal cardiac ultrasound, and preoperative OI >3.0. On multivariate analysis, only an OI >3.0 was significantly associated with conversion or major post-operative complication of thoracoscopic primary repair. CONCLUSION CDH can be safely repaired in the neonatal period by thoracoscopy. The limiting factor for thoracoscopic CDH repair is PPHN. The best preoperative indicator for PPHN is OI. Prospective studies are nonetheless necessary to prove the effectiveness of using these risk factors as selection criteria to help design surgical management protocols for neonates presenting CDH.
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Affiliation(s)
- Cindy Gomes Ferreira
- Department of Pediatric Surgery of the University Hospitals, Strasbourg, France.
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Hepatopulmonary fusion in a newborn. An uncommon intraoperatory finding during right congenital diaphragmatic hernia surgery: case description and review of literature. Hernia 2013; 18:417-21. [DOI: 10.1007/s10029-012-1042-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 12/27/2012] [Indexed: 10/27/2022]
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Bae MJ, I H, Kim DH, Jeong YJ, Kim YD, Cho JS. One-stage Laparoscopic Repair of Morgagni and Inguinal Hernias in a Two-month Old Male. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 45:415-7. [PMID: 23275927 PMCID: PMC3530729 DOI: 10.5090/kjtcs.2012.45.6.415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 07/24/2012] [Accepted: 08/16/2012] [Indexed: 11/16/2022]
Abstract
The development of Morgagni hernias is related to malformations of the embryologic septum transversum after failure of the sternal and costal fibrotendinous elements of the diaphragm to fuse. The overall incidence of Morgagni hernias among all congenital diaphragmatic defects is 3% to 4%. Inguinal hernias are the most common hernias in males and females (25% and 2%, respectively). An inguinal hernia is defined as a protrusion of the abdominal cavity contents through the inguinal canal. The combination of Morgagni and inguinal hernias is rare, and treatment using laparoscopic surgery has not been previously reported. This case presents a one-stage laparoscopic repair of Morgagni and inguinal hernias in a 2-month-old male.
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Affiliation(s)
- Mi Ju Bae
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Pusan National University School of Medicine, Korea. ; Pusan National University Medical Research Institute, Korea
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Pettiford-Cunningham J, Adibe OO, Gasior AC, Ostlie DJ, St. Peter SD. Laparoscopic Repair of Incarcerated Congenital Diaphragmatic Hernias Presenting Beyond the Newborn Period. J Laparoendosc Adv Surg Tech A 2012; 22:1014-6. [DOI: 10.1089/lap.2012.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Obinna O. Adibe
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Alessandra C. Gasior
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Daniel J. Ostlie
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Shawn D. St. Peter
- Department of Surgery, Children's Mercy Hospitals and Clinics, Kansas City, Missouri
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Conséquences de la médecine fœtale sur la chirurgie pédiatrique. Arch Pediatr 2012. [DOI: 10.1016/s0929-693x(12)71151-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Szavay PO, Obermayr F, Maas C, Luenig H, Blumenstock G, Fuchs J. Perioperative Outcome of Patients with Congenital Diaphragmatic Hernia Undergoing Open Versus Minimally Invasive Surgery. J Laparoendosc Adv Surg Tech A 2012; 22:285-9. [DOI: 10.1089/lap.2011.0356] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Philipp O. Szavay
- Department of Pediatric Surgery, University Children's Hospital, Tuebingen, Germany
| | - Florian Obermayr
- Department of Pediatric Surgery, University Children's Hospital, Tuebingen, Germany
| | - Christoph Maas
- Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - Holger Luenig
- Department of Anesthesiology, University Hospital, Tuebingen, Germany
| | - Gunnar Blumenstock
- Department of Statistics and Medical Biometry, University of Tuebingen, Tuebingen, Germany
| | - Joerg Fuchs
- Department of Pediatric Surgery, University Children's Hospital, Tuebingen, Germany
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Ceelie I, van Dijk M, Bax N, de Wildt S, Tibboell D. Does minimal access major surgery in the newborn hurt less? An evaluation of cumulative opioid doses. Eur J Pain 2012; 15:615-20. [DOI: 10.1016/j.ejpain.2010.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2010] [Revised: 11/07/2010] [Accepted: 11/24/2010] [Indexed: 10/18/2022]
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Simplified technique for minimally invasive repair of congenital diaphragmatic hernia using hollow-needle snare and transthoracic traction stitches. J Pediatr Surg 2012; 47:258-63. [PMID: 22244427 DOI: 10.1016/j.jpedsurg.2011.10.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 10/08/2011] [Accepted: 10/10/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimally invasive (MI) congenital diaphragmatic hernia (CDH) repair can be challenging. Placing rib-anchoring stitches without creating skin incisions and closing wider defects are some of the difficulties. In Bochdaleck hernia repair, maintaining visceral reduction and minimizing pneumothorax use are additional obstacles. We describe the use of hollow-needle snares (HNS) and transthoracic traction stitches (TTS) to overcome these challenges. METHODS Hollow-needle snares is assembled by passing a prolene stitch through a hollow needle creating a retractable snare, which is used to extract the placed anchoring stitches by passing it over the ribs but through the same stitch's skin entrance site. In Bochdaleck hernia, the early placement of TTS using HNS can facilitate visceral reduction, patch lay down, and tension-free closure of possible residual V-shaped defects. RESULTS Between July 2009 and April 2011, we performed 10 consecutive MI CDH repairs for 9 patients, including 7 Bochdaleck and 3 Morgagni hernias. The median age was 8 days (range, 3-172 days), and the mean operative time was 148.5 ± 37.8 minutes for Bochdaleck hernia repairs. For Morgagni hernia, the median age was 18.3 months (range, 10.5-37 months), and the mean operative time was 100 ± 26.5 minutes. All cases were completed without conversion. One patient had a hernia recurrence and was repaired similarly, whereas the others had uneventful recovery at a median follow-up of 5.8 months (range, 1.1-23.7 months). CONCLUSION Hollow-needle snare and TTS are simple and available tools that can facilitate MI repair of CDH. This initial experience demonstrates the technique's effectiveness and its excellent cosmetic outcomes.
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Abstract
The advent of minimally invasive surgical techniques in the neonate has been delayed due to the limited working space and the unique physiology of the newborn. In the last decade, with the introduction of new instruments and techniques, many of the initial problems have been solved making minimally invasive surgery feasible for a variety of indications in the neonate and a favored approach in specialized centers around the world. Although an increasing number of reports document the feasibility of this exciting technique, data demonstrating its benefit compared to conventional surgery is limited. This review focuses on recent developments in minimally invasive surgery in neonates and the evidence for its use.
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Liem NT, Nhat LQ, Tuan TM, Dung LA, Ung NQ, Dien TM. Thoracoscopic repair for congenital diaphragmatic hernia: experience with 139 cases. J Laparoendosc Adv Surg Tech A 2011; 21:267-70. [PMID: 21204646 DOI: 10.1089/lap.2010.0106] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To analyze indications and to present details of surgical technique and outcomes of thoracoscopic repair for congenital diaphragmatic hernia (CDH) in 139 patients. METHODS We reviewed medical records of all patients with CDH who underwent thoracoscopic repair by the same surgical team from June 2001 to October 2009. Patients were placed in the lateral decubitus position. The operations were performed using three trocars. Pleural insufflation with carbon dioxide was maintained at a pressure of 2-6 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extracorporeal knots. A prosthetic patch was used when direct closure of the hernia defect was not feasible. RESULTS There were 139 patients, including 91 boys and 48 girls. Seventy-five patients were newborns, and 64 were infants or children. The hernia was located on the left side in 113 patients (81.3%) and on the right side in 26 patients (18.7%). The mean operative time for thoracoscopic approach was 66 ± 27 minutes. Conversion was required in 11 patients (7.9%) from 2001 to 2007. There were no conversions in 2008 or 2009. A prosthetic patch was used in 7 patients. There were 14 postoperative deaths (10%). Follow-up was obtained in 114 patients, ranging from 1 to 84 months (mean 26.3 ± 24.7 months). Five patients had recurrence (3.6%). CONCLUSIONS Thoracoscopic repair is feasible and safe for children with CDH, including newborns. The conversion rate decreased, and indications increased with surgical team experience.
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Affiliation(s)
- Nguyen Thanh Liem
- Department of Surgery, National Hospital of Pediatrics, Hanoi, Vietnam.
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48
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Neonatal endosurgical congenital diaphragmatic hernia repair: a systematic review and meta-analysis. Ann Surg 2010; 252:20-6. [PMID: 20505506 DOI: 10.1097/sla.0b013e3181dca0e8] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare outcomes of open and endosurgical neonatal congenital diaphragmatic hernia (CDH) repairs. BACKGROUND Historically a surgical emergency, neonatal CDH repair is now deferred pending stabilization of characteristically labile cardiopulmonary physiology. Usually accomplished via laparotomy, surgical repair may acutely worsen lung function; conversely, by reducing the visceral hernia, surgery might improve it. Theoretically, endosurgical repair could minimize deleterious effects of surgery while garnering benefits from decompressing the CDH lung. As endosurgical repair gains popularity, it is important to investigate whether or not minimally-invasive neonatal CDH repair has benefits. METHODS We searched Medline, Embase, and Cochrane Trials databases for studies comparing open with endosurgical CDH repair. Non-neonatal series and reports without comparison groups were excluded. References from papers and conference proceedings were also hand searched. Meta-analysis used a fixed effects model and was reported in accordance with PRISMA. RESULTS We included 3 studies (1 unpublished; none randomized); all compared thoracoscopic and open CDH repair and together described 143 patients. All studies had limitations, including use of historical controls. Demographics, CDH sidedness, APGAR and associated anomaly prevalence were similar between groups. For endosurgical repair, recurrence was higher (RR: 3.2 [1.1, 9.3], P = 0.03) and operative time longer (WMD 50 minutes [32, 69], P < 0.00001). Survival and patch usage were not different between open and endosurgical groups. CONCLUSIONS Neonatal thoracoscopic CDH repair has greater recurrence rates and operative times but similar survival and patch usage compared with open surgery. A prospective registry for all such cases would guide development of trials (Stage 2b; IDEAL recommendations).
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Keijzer R, van de Ven C, Vlot J, Sloots C, Madern G, Tibboel D, Bax K. Thoracoscopic repair in congenital diaphragmatic hernia: patching is safe and reduces the recurrence rate. J Pediatr Surg 2010; 45:953-7. [PMID: 20438934 DOI: 10.1016/j.jpedsurg.2010.02.017] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 02/03/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Congenital diaphragmatic hernia (CDH) has traditionally been repaired via a laparotomy. More and more reports on thoracoscopic repair are being published. The aim of this study was to evaluate our series of thoracoscopic CDH repair and compare this group to an open repair group treated during the same period in the same institute. PATIENTS AND METHODS Between June 2006 and December 2008, 49 children with posterolateral CDH were admitted, of whom 23 (47%) were operated thoracoscopically and 23 (47%) using an open repair, depending on the discretion of the attending surgeon and the clinical condition of the patient. Three patients (6%) with CDH were not treated because of associated anomalies (twice Cornelia de Lange syndrome and once hypoplastic left heart syndrome). Six thoracoscopic operations (26%) were converted to open surgery. Nine defects (39%) were closed thoracoscopically without a patch. In 8 (35%) patients, a patch was used. We used a patch in 20 open procedures (87%). RESULTS Three (33%) of the 9 thoracoscopic repairs without patch and 1 (12%) of the 8 with a patch developed a recurrence. All these recurrences were repaired thoracoscopically. The 3 recurrences from the thoracoscopic primary repair were repaired using a patch. In the open group, 3 patients (13%) developed a recurrence, of whom 2 were repaired thoracoscopically. Mean operative time was significantly longer in the thoracoscopic patch repair group (158 minutes), when compared to the open repair group (125 minutes). CONCLUSION As in open repair, it seems wise to use large patches liberally, not only to reconstruct the dome of the diaphragm but also to avoid undue tension on the repair and prevent recurrences. The thoracoscopic approach is also considered feasible in case of a recurrence from either a thoracoscopic or open repair.
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Affiliation(s)
- Richard Keijzer
- Department of Pediatric Surgery, ErasmusMC-Sophia, PO Box 2060, 3000 CB, Rotterdam, The Netherlands.
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Mattes D, Silajdzic E, Mayer M, Horn M, Scheidbach D, Wackernagel W, Langmann G, Wedrich A. Surgical smoke management for minimally invasive (micro)endoscopy: an experimental study. Surg Endosc 2010; 24:2492-501. [PMID: 20339874 DOI: 10.1007/s00464-010-0991-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 02/26/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to investigate the use of surgical smoke-producing procedures such as laser ablation or electrosurgery in minimally invasive microendoscopic procedures. This study proposes a technical solution to efficiently remove surgical smoke from very small endoscopic cavities using microports as small as 20 G (0.9 mm) in diameter. METHODS The experimental laboratory study used small, rigid, transparent plastic cavity models connected with tubes and pressure sensors to establish an endoscopic in vitro laboratory model. A Kalium-Titanyl-Phosphate (KTP) laser with a 0.5-mm fiber optic probe was used to produce smoke from bovine scleral tissue in the cavity. Endoscopic gas insufflation into the model was generated by pressurized air and a microvalve. A laboratory vacuum pump provided smoke and gas suction via a microvalve. A self-built control and steering system was utilized to control intracavital pressure during experimental insufflation and suction. RESULTS Problems related to smoke-generating processes, such as laser vaporization or electrocautery, in small closed cavities were first analyzed. A theoretical and mechatronic laboratory model was established and tested. Intracavital pressure and gas flow were measured first without and then with smoke generation. A new construction design for the suction tube was proposed due to rapid obstruction by smoke particles. CONCLUSIONS Surgical smoke evacuation from endoscopic cavities that are as small as 2 cm in diameter via minimally invasive ports as small as 20 G (0.9 mm) in diameter may be safe and efficient if sufficient gas exchange is provided during smoke generation by laser or electrosurgical instruments. However, maintaining a low and constant pressure in the cavity during gas exchange and adopting a special construction design for the suction tube are essential to provide an excellent view during the surgical maneuver and to minimize potential toxic side effects of the smoke.
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Affiliation(s)
- Dietmar Mattes
- Department of Ophthalmology, Medical University of Graz, Auenbruggerplatz 4, 8036, Graz, Austria.
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