The split abdominal wall muscle flap--a simple, mesh-free approach to repair large diaphragmatic hernia

Surgical approaches to congenital diaphragmatic hernia

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.

Abdominal wall muscle weakness outcomes after split abdominal flap repair of large congenital diaphragmatic hernias in newborn

PURPOSE

Split abdominal wall muscle flap (SAWMF) is a technique to repair large defects in congenital diaphragmatic hernia (CDH). A possible objection to this intervention could be any associated abdominal muscle weakness. Our aim is to analyze the evolution of this abdominal muscle wall weakness.

METHODS

Retrospective review of CDH repair by SAWMF (internal oblique muscle and transverse) from 2004 to 2023 focusing on the evolution of muscle wall weakness.

RESULTS

Eighteen neonates of 148 CDH patients (12,1%) were repaired using SAWMF. Mean gestational age and birth weight were 35.7 ± 3.5 weeks and 2587 ± 816 g. Mean lung-to-head ratio was 1.49 ± 0.28 and 78% liver-up. Seven patients (38%) were prenatally treated by tracheal occlusion. Ninety-four percent of the flaps were used for primary repair and one to repair a recurrence. One patient (5.6%) experienced recurrence. Abdominal muscle wall weakness was present in the form of a bulge. Resolution of weakness at 1, 2 and 3 years was 67%, 89% and 94%, respectively. No patient required treatment for weakness or died.

CONCLUSIONS

Abdominal muscular weakness after a split abdominal wall muscle flap repair is not a limitation for its realization since it is asymptomatic and presents a prompt spontaneous resolution.

LEVEL OF EVIDENCE

IV.

Diaphragmatic Defects in Infants: Acute Management and Repair

Congenital diaphragmatic hernia (CDH) is a complex and highly variable disease process that should be treated at institutions with multidisciplinary teams designed for their care. Treatment in the neonatal period focuses on pulmonary hypoplasia, pulmonary hypertension, and cardiac dysfunction. Extracorporeal membrane oxygenation (ECMO) can be considered in patients refractory to medical management. Repair of CDH early during the ECMO course seems to improve mortality compared with other times for surgical intervention. The choice of surgical approach to CDH repair should consider the patient's physiologic status and the surgeon's familiarity with the operative approaches available, recognizing the pros/cons of each technique.

Muscle Flap Technique Safe for On-ECMO Congenital Diaphragmatic Hernia Repair

INTRODUCTION

Prosthetic patches (patch) and muscle flaps (flap) are techniques used for repair of congenital diaphragmatic hernia (CDH) with a large defect unamenable to primary closure. We hypothesized that the flap technique for CDH repair while on extra-corporeal membrane oxygenation (on-ECMO) would have decreased bleeding complications compared to patch due to the hemostatic advantage of native tissue.

METHODS

A single-center retrospective comparative study of patients who underwent on-ECMO CDH repair between 2008 and 2022 was performed.

RESULTS

Fifty-two patients met inclusion criteria: 18 patch (34.6%) and 34 flap (65.4%). There was no difference in CDH severity between groups. On univariate analysis, reoperation for surgical bleeding was lower following flap repair compared to patch (23.5% vs 55.6%, respectively; p = 0.045), 48-h postoperative blood product transfusion was lower after flap repair (132 mL/kg vs 273.5 mL/kg patch; p = 0.006), and two-year survival was increased in the flap repair group compared to patch (53.1% vs 17.7%, respectively; p = 0.036). On multivariate analysis adjusting for CDH side, day on ECMO repaired, and day of life CDH repaired, flap repair was significantly associated with lower five-day postoperative packed red blood cell transfusion amount, improved survival to hospital discharge, and improved two-year survival.

CONCLUSIONS

Our experience suggests that the muscle flap technique for on-ECMO CDH repair is associated with reduced bleeding complications compared to prosthetic patch repair, which may in part be responsible for the improved survival seen in the flap repair group. These results support the flap repair technique as a favored method for on-ECMO CDH repair.

LEVEL OF EVIDENCE

Level III.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative

OBJECTIVE

The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'.

DESIGN AND MAIN OUTCOME MEASURES

Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field.

RESULTS

Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH.

CONCLUSIONS

The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.

Biological versus synthetic patch for the repair of congenital diaphragmatic hernia: 8-year experience at a tertiary center

PURPOSE

The aim of this study is to compare outcome between small intestinal submucosal (SIS) and polytetrafluoroethylene (PTFE) patches in patients with congenital diaphragmatic hernia (CDH) with large muscular defects.

MATERIAL AND METHODS

We performed a retrospective review of prospectively collected data of patients who underwent CDH repair from January 2011 to June 2019, with a minimum follow-up of 1 year. Data were collected regarding length of stay (LOS), mortality and recurrence. Kaplan-Meier analyses was used.

RESULTS

In the study period, 195 patients with CDH were admitted, 176 underwent surgical repair and 19 died before surgery. Sixty-two (35%) required a patch. Over the last 5 years, our institution transitioned from the use of all SIS to all PTFE. SIS was used in 18 cases and PTFE in 25. Overall survival rate was 89% (174/195). There was no significant difference regarding LOS and mortality. Nine patients (50%) of SIS and 1 (4%) of PTFE repairs recurred (P < 0.01; log-rank test P <  0.01), with a time course of recurrence of 18 (SD = 13) and 8 months, respectively. Median follow-up was 60 months (SD: 23) for the SIS group and 26 (SD: 10) for the PTFE group.

CONCLUSION

A significant lower recurrence was found using PTFE patches instead of SIS for the repair of large CDH.

LEVEL OF EVIDENCE

Level 3. Retrospective comparative study.

A Novel Thoracic Ultrasound Measurement After Congenital Diaphragmatic Hernia Repair Identifies Decreased Diaphragmatic Excursion Associated With Adverse Respiratory and Surgical Outcomes

Background and Aim: Congenital diaphragmatic hernia (CDH) is a rare defect often associated with pulmonary hypoplasia and abnormal pulmonary vascular development. Even after successful hernia repair, pulmonary disease may persist into adulthood. Impaired diaphragmatic motility may lead to compromised respiratory function long after index repair. This study investigates whether a novel ultrasound measurement, the diaphragmatic excursion ratio, can be a simple and non-invasive method to evaluate routine diaphragmatic motion after CDH repair, and whether it correlates with adverse surgical and respiratory outcomes. Materials and Methods: A cross-sectional study was conducted in consecutive patients who presented at medium-term follow-up visit between December 2017 and December 2018 after CDH repair at single pediatric hospital. Transthoracic ultrasound was performed with craniocaudal diaphragmatic excursion measured bilaterally during routine breathing. Diaphragmatic excursion ratios (diaphragmatic excursion of repaired vs. unrepaired side) were calculated and retrospectively compared with clinical data including demographics, length of stay, respiratory adjuncts, oral feeding, and need for gastrostomy. Results: Thirty-eight patients (median age at ultrasound, 24 months, interquartile range 11-60) were evaluated. Nine patients underwent primary repair, 29 had non-primary repair (internal oblique muscle flap or mesh patch). Patients with a diaphragmatic excursion ratio below the median (0.54) had longer hospital stays (median 77 vs. 28 days, p = 0.0007) more ventilator days (median 16 vs. 9 days, p =0.004), and were more likely to have been discharged on oxygen (68 vs. 16%, p = 0.001). They were also less likely to be exclusively taking oral feeds at 1-year post-surgery (37 vs. 74%, p = 0.02) and more likely to require a gastrostomy tube in the first year of life (74 vs. 21%, p = 0.003). Conclusions: Transthoracic ultrasound after CDH repair is practical method to assess diaphragm motion, and decreased diaphragm excursion ratio is associated with worse respiratory outcomes, a longer length of stay, and dependence on gastrostomy tube feeding within 1 year. Further prospective studies may help validate this novel ultrasound measurement and offer prognostic value.

Propeller Flaps for the Anterior Trunk

Various types of propeller flaps from multiple donor sites can be used to reconstruct anterior trunk skin defects. The actual selection depends on the condition and location of the recipient site, especially if it is to be the chest or abdomen that requires attention. Before surgery commences, it is always important to use an imaging analyses such as computed tomography angiography to examine and identify perforators that could perfuse a perforator-pedicled propeller flap (PPPF), as it is the most multifaceted imaging technique. Clusters of perforators that can be commonly used for the "workhorse" PPPFs for the thoracic and abdominal regions are the internal mammary artery perforator, the musculophrenic artery perforator, and the deep inferior epigastric perforator. These perforators are reliable and large enough to support long and large propeller flaps that will cover most defects in this region, while still allowing primary donor-site closure.

When primary repair is not enough: a comparison of synthetic patch and muscle flap closure in congenital diaphragmatic hernia?

PURPOSE

Primary closure is often inadequate for large congenital diaphragmatic hernia (CDH) and necessitates repair by prosthetic patch or autologous muscle flap. Our aim was to evaluate outcomes of open patch versus flap repair, specifically diaphragmatic reherniation.

METHODS

A retrospective review (IRB #2017-6361) was performed on all CDH patients repaired from 2005 to 2016 at a single academic children's hospital. Patients were excluded from final analysis if they had primary or minimally invasive repair, expired, or were lost to follow-up.

RESULTS

Of 171 patients, 151 (88.3%) survived to discharge, 9 expired after discharge and 11 were lost to follow up, leaving 131 (86.8%) long-term survivors. Median follow-up was 5 years. Open repair was performed in 119 (90.8%) of which 28 (23.5%) underwent primary repair, 34 (28.6%) patch repair, and 57 (47.9%) flap repair. Overall, 6/119 (5%) patients reherniated, 1/28 (3.6%) in the primary group, 3/34 (8.8%) in the patch group, and 2/57 (3.5%) in the flap group. Comparing prosthetic patch to muscle flap repair, there was no significant difference in the number of patients who recurred nor time to reherniation (3 vs. 2, p = 0.295; 5.5 ± 0.00 months vs. 53.75 ± 71.06 months, p = 0.288). One patient in the patch group recurred twice.

CONCLUSIONS

Both muscle flap and patch repair of large CDH are feasible and durable with a relatively low risk of recurrence.

Flap repair in congenital diaphragmatic hernia leads to lower rates of recurrence

BACKGROUND

Congenital diaphragmatic hernia (CDH) repair is technically challenging with different approaches for repair. The aim of this study was to compare outcomes between patch and flap repair.

METHODS

CDH repairs performed at a quaternary care children's hospital between 2008 and 2018 were reviewed. Seventy CDH repairs were analyzed after primary repairs were excluded (n = 52). Analysis included proportions or median with interquartile range and chi-square or Wilcoxon rank-sum test.

RESULTS

Comparing patch and flap repairs, demographic characteristics and hernia parameters were similar. Examining outcomes, length of stay, 30-day mortality, and 1-year mortality were all similar between groups, but total/symptomatic recurrence was higher in the patch group (10%/7% vs. 3%/0%), and the median time to recurrence was 3 months. A sub-analysis comparing those who recurred to those who did not demonstrated no significant difference between the two groups.

CONCLUSION

Patients who undergo flap repair have a lower risk of recurrence compared to those who undergo patch repair, and this may be due to the ability of the flap to grow over time with the child.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

III.

Hemorrhage after on-ECMO repair of CDH is equivalent for muscle flap and prosthetic patch

BACKGROUND/PURPOSE

Prosthetic patch (patch) and muscle flap (flap) techniques are utilized for severe congenital diaphragmatic hernia (CDH) repair; however, when performed on extracorporeal membrane oxygenation (ECMO), the risk of hemorrhage increases. We sought to compare bleeding complications between repair types.

METHODS

We retrospectively reviewed 2010-2016 on-ECMO CDH repairs.

RESULTS

Twenty-nine patients met criteria: 13 patch (44.8%) and 16 flap (55.2%). Eight patch (61.5%) and 13 flap (81.2%) patients had left-sided defects (p = 0.223). All defects were Type C or D (Type C: patch 53.8%, flap 56.2%, p = 0.596). There was no difference in gestational age at delivery (patch 37.5 ± 0.9 weeks, flap 37.2 ± 1.3 weeks, p = 0.390) or age at repair (patch 7.46 ± 6.6 days, flap 6.00 ± 4.3 days, p = 0.476). Seven patch (53.8%) and 9 flap (56.2%) patients survived to discharge (p = 0.596). Estimated intraoperative blood loss was equivalent (patch 35.3 ± 53.9 mL, flap 24.2 ± 18.4 mL, p = 0.443). One patch patient (7.6%) and two (12.5%) flap patients required reoperation in the first 48 h for bleeding (p = 0.580). 48-h postoperative transfusions were the same for those that required reoperation (patch 282.0 mL/kg, flap 208.5 ± 21.9 mL/kg, p = 0.054) and those that did not (patch 120.7 ± 111.7 mL/kg, flap 118.4 ± 89.9 mL/kg, p = 0.561).

CONCLUSIONS

On-ECMO bleeding complications are equivalent for both flap and patch CDH repair.

LEVEL OF EVIDENCE

Type III (retrospective comparative study).

Controversies in the management of severe congenital diaphragmatic hernia

Despite years of progress in perinatal care, severe congenital diaphragmatic hernia (CDH) remains a clinical challenge. Controversies include almost every facet of clinical care: the definition of severe CDH by prenatal and postnatal criteria, fetal surgical intervention, ventilator management, pulmonary hypertension management, use of extracorporeal membrane oxygenation, surgical considerations, and long-term follow-up. Breakthroughs are likely only possible by sharing of experience, collaboration between institutions and innovative therapies within well-designed multicenter clinical trials.

Musculoskeletal deformities following repair of large congenital diaphragmatic hernias

PURPOSE

Large congenital diaphragmatic hernias (CDH) can be repaired with either a muscle flap or prosthetic patch. The purpose of this study was to assess the frequency and severity of scoliosis, chest wall, and abdominal wall deformities following these repairs.

METHODS

Neonates who underwent CDH repair (1989-2012) were retrospectively reviewed. We then validated our retrospective review by comparing results of a focused radiologic evaluation and clinical examination of patients with large defects seen in prospective follow-up clinic. Tests for association were made using Fisher's exact test.

RESULTS

236 patients survived at least 1year. Of these patients, 30 had a muscle flap, and 13 had a patch repair. Retrospectively, we identified pectus in 9% of primary repairs, 47% of flap repairs, and 54% of patch repairs. We identified scoliosis in 7% of primary repairs, 13% of flap repairs, and 15% of patch repairs. Prospectively, 75% of flap patients and 67% of patch patients had pectus and 13% of flap patients and 33% of patch patients had scoliosis. There was no significant difference between flap and patch patients.

CONCLUSIONS

Scoliosis and pectus deformity were common in children with large CDH. The operative technique did not appear to affect the incidence of subsequent skeletal deformity.

Management of prenatally diagnosed congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a congenital anomaly that presents with a broad spectrum of severity that is dependent upon components of pulmonary hypoplasia and pulmonary hypertension. While advances in neonatal care have improved the overall survival of CDH in experienced centers, mortality and morbidity remain high in a subset of CDH infants with severe CDH. Prenatal predictors have been refined for the past two decades and are the subject of another review in this issue. So far, all randomized trials comparing prenatal intervention to standard postnatal therapy have shown no benefit to prenatal intervention. Although recent non-randomized reports of success with fetoscopic endoluminal tracheal occlusion (FETO) and release are promising, prenatal therapy should not be widely adopted until a well-designed prospective randomized trial demonstrating efficacy is performed. The increased survival and subsequent morbidity of CDH survivors has resulted in the need to provide resources for the long-term follow up and support of the CDH population.

Innovations in the surgical management of congenital diaphragmatic hernia

Surgical management of congenital diaphragmatic hernia (CDH) remains a challenge for all clinicians. While the treatment strategies for CDH have evolved from emergent surgical intervention to initial hemodynamic stabilization with delayed surgical repair, surgical innovations have remained limited in the last 20 years. Advances in surgical approaches, such as minimally invasive surgery and alternatives to diaphragmatic replacement, have focused on improvements in surgical morbidity.

Recent advances in the management of congenital diaphragmatic hernia

PURPOSE OF REVIEW

Congenital diaphragmatic hernia (CDH) is a rare developmental defect resulting in variable degrees of lung and pulmonary vasculature hypoplasia. Whereas many high-volume centers have recently reported increased survival rates, this has not been the collective trend. One potential explanation for this is inconsistent perinatal care among centers.

RECENT FINDINGS

Significant efforts have been made to identify prenatally those fetuses that will be most severely affected. A number of radiologic features have shown promise for achieving this goal as well as identifying fetuses that may benefit from prenatal intervention. When CDH is antenatally diagnosed, early referral to a tertiary center is recommended. Centers that routinely use postnatal management protocols have demonstrated improved overall survival rates including increased survival in high-risk CDH patients.

SUMMARY

As a result of advancements in perinatal care, more severely affected newborns with CDH are now surviving. These patients may experience a number of associated morbidities which affect not only their health but overall quality of life. A multidisciplinary approach to the long-term care of these patients will allow early identification and management of these morbidities.

Patch repair for congenital diaphragmatic hernia: is it really a problem?

BACKGROUND

Large congenital diaphragmatic hernia (CDH) defects often require the use of synthetic patches for tension-free repair. Although high rates of recurrence and other morbidities have been previously reported, our favorable perception of patch repair prompted this review.

METHODS

A single-center retrospective chart review of CDH cases repaired between January 1, 1999, and October 1, 2010. Patch repairs were performed by multiple surgeons with an effort to construct a tension-free dome-shaped patch.

RESULTS

One hundred eighty-four children underwent CDH repair of whom 99 (53.8%) required a patch. Seventy-four (74.7%) of the 99 patients who underwent patch repair survived to discharge and were compared with 75 primary repair survivors. Of those undergoing patch repair, 88% were prenatally diagnosed, 55% had liver herniation, and 22 (29.9%) were repaired on extracorporeal membrane oxygenation. Two patients experienced a recurrence after a patch repair and 3 after a primary repair for a rate of 5.4% and 4.0%, respectively (P = 1.0).

CONCLUSIONS

These results demonstrate that synthetic patch repair for CDH can be performed with a very low rate of recurrence challenging the need for alternative approaches to diaphragmatic replacement. High rates of recurrence reported for patch repair may be technical rather than intrinsic to the patch.

Congenital diaphragmatic hernia

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

Split abdominal wall muscle flap repair vs patch repair of large congenital diaphragmatic hernias

PURPOSE

Large congenital diaphragmatic hernias are commonly repaired with a prosthetic patch. We hypothesized that a split abdominal wall muscle flap would reduce the risk of recurrence.

METHODS

A retrospective review of neonates with congenital diaphragmatic hernia in whom primary repair was not possible was performed. Kaplan-Meier analyses and Cox proportional hazards modeling were performed.

RESULTS

Of 153 patients, 46 could not have repair with primary closure of the diaphragm. Thirty-three survived to discharge and were subjected to analysis for recurrence. Ten underwent repair with a patch, whereas 23 had a muscle flap (internal oblique and transversalis) patch. The groups were similar with regard to demographics, need for extracorporeal membrane oxygenation, repair on extracorporeal membrane oxygenation, and size of the defect. Fifty percent of patch repairs recurred with a median time of 0.5 years. Only one (4.3%) of the patients who had muscle flap patch developed a recurrence. This was significant on Kaplan-Meier analysis (P = .0009) and had a hazard ratio of 14.3 on Cox regression (P = .018). Median follow-up exceeded 4 years. No children required surgery for an abdominal wall hernia.

CONCLUSIONS

The split abdominal wall muscle flap allows for closure of large congenital diaphragmatic hernia defects with autologous tissue. This approach is associated with significantly fewer recurrences than patch repairs.

Free fascia lata repair for a second recurrent congenital diaphragmatic hernia

Repair of recurrent congenital diaphragmatic hernia (CDH) continues to be a difficult problem. Although several materials have been used to repair recurrent CDH, the ideal material has yet to be established. We report the successful use of an autologous free fascia lata graft to repair the diaphragm following a second recurrence of CHD. The fascia lata is one of the strongest fascia in the body and is easy to obtain without extremity functional loss even in children. This procedure is regarded as effective for the repair of recurrent CDH.

Multimodality imaging of the pediatric diaphragm: anatomy and pathologic conditions

Apart from serving as an important landmark for description and staging of pathologic conditions, the diaphragm is also affected by various types of pathologic conditions in children. Congenital abnormalities affecting the diaphragm include aplasia or hypoplasia, accessory diaphragm, eventration, and hernias. Congenital diaphragmatic hernias (CDHs) include Bochdalek, Morgagni, and hiatal hernias. Although survival rates are improving with the advent of new therapies, there is still significant morbidity and mortality associated with CDH. The morbidity and mortality depend on the associated congenital anomalies, the size of the hernia, and the degree of lung hypoplasia. Newer surgical repair techniques for the diaphragm have resulted in new postoperative complications and imaging appearances. Ultrasonography has become the modality of choice for evaluation of diaphragmatic paralysis. The diaphragm is uncommonly affected by trauma in children; when diaphragmatic injury is present, it usually indicates high-impact trauma associated with other severe injuries. Primary diaphragmatic tumors are very rare in children, with rhabdomyosarcoma being the most common. The diaphragm may also be secondarily involved by invasion of an adjacent tumor. Radiologists should have an understanding of the embryology, anatomy, and anatomic variations of the diaphragm and should be aware of the imaging appearances of pathologic conditions affecting the diaphragm in children.

Diagnosis and surgical management of diaphragmatic agenesis in an adult: Report of a case

Unilateral diaphragmatic agenesis is a rare finding in adult patients. We herein present the case of a 24-year-old male patient who was diagnosed and surgically treated for the complete absence of the left hemidiaphragm. His symptoms included acute respiratory distress, ipsilateral absence of breath sounds, and vague abdominal discomfort. A neodiaphragm was created via a left thoracotomy using synthetic material. The postoperative course was uneventful, and the patient is in satisfactory condition 9 months after the operation. This is only the seventh known case of unilateral diaphragmatic agenesis reported in the literature.

Outcomes after muscle flap vs prosthetic patch repair for large congenital diaphragmatic hernias

BACKGROUND

Repair of large congenital diaphragmatic hernia (CDH) defects still pose a significant challenge, as the defects cannot be repaired primarily. Two techniques have been widely used: autologous anterior abdominal wall muscle flap and prosthetic patch. The latter has been used more often. Our goal was to compare the short-term and long-term outcomes of these 2 approaches.

METHODS

This is a retrospective review of all neonates undergoing CDH repair at our institution from 1969 to 2006.

RESULTS

Of 188 children undergoing surgery for CDH, primary repair could not be accomplished in 51 infants (27%). Nineteen had muscle flap repair, and 32 had prosthetic patch repair (Gore-Tex [W.L. Gore and Associates, Flagstaff, AZ], n = 15; Marlex [Bard Inc, Cranston, NJ], n = 9; Surgisis [Cook, Bloomington, IN], n = 5; SILASTIC [Dow Corning, Midland, MI], n = 3). There was no significant difference in gestational age or birth weight between groups. Three patients developed an abdominal wall defect at the muscle flap donor site, but none required surgical intervention. Chest wall deformities were found in 9 patients, 3 after a muscle flap and 6 after a prosthetic patch (P = .7). Postoperative bowel obstruction occurred in 3 muscle flap patients and 1 patch patient (P = .2). There were 10 recurrences among survivors: 2 after a muscle flap and 8 after a prosthetic patch (P = .3) There were 2 deaths among the muscle flap patients (10%), and 3 deaths among the prosthetic patch repair patients (9%) (P = .1). Results were confirmed after controlling for age and comorbidities between both groups in a multivariate logistic regression.

CONCLUSION

These results suggest that autologous anterior abdominal wall muscle flap and prosthetic patch repairs provide similar short-term and long-term outcomes.

Postnatal management and long-term outcome for survivors with congenital diaphragmatic hernia

Significant advances in the postnatal management of patients with congenital diaphragmatic hernia (CDH) have resulted in a remarkable improvement in survival rates over the past two decades. The success of current postnatal management of CDH patients has rendered fetal intervention to be limited to the most severe cases, and the role for prenatal treatment of CDH patients remains unclear. The adoption of lung-preserving strategies including high-frequency oscillatory ventilation (HFOV) and extracorporeal membrane oxygenation (ECMO) have improved CDH outcomes especially in those patients with significant ventilatory or circulatory compromise. Survival rates of up to 90% are being reported in some high-volume centers. However, the increased survival in CDH patients has been accompanied by an increase in neurological, nutritional and musculoskeletal morbidity among the long-term survivors. This has resulted in the need to provide resources for the long-term follow-up and support of this patient population. In this article, the postnatal management strategies and primary and secondary outcomes of high-volume international pediatric surgical centers will be reviewed. Finally, the role of a multidisciplinary management team for the follow-up of long-term CDH survivors will be discussed.

Evaluation of diaphragmatic hernia repair using PLGA mesh-collagen sponge hybrid scaffold: an experimental study in a rat model

Patch closure is necessary to achieve tension-free repair in large congenital diaphragmatic hernia. However, the use of prosthetic material may lead to granulation, allergic reaction, infection, recurrence of hernia, and thoracic deformity. Tissue engineering may become an alternative treatment strategy for diaphragmatic hernia repair, since the regenerated autologous tissue is expected to grow potentially without rejection or infection. We evaluated the efficacy of diaphragmatic hernia repair in a rat model using a poly-lactic-co-glycolic acid (PLGA) mesh-collagen sponge hybrid scaffold, designed for in situ tissue engineering. Twenty-four F344 female rats were used. Oval-shaped defects were surgically created in the left diaphragm and repaired with three different grafts, including PLGA mesh in group 1 (n = 7), PLGA mesh-collagen sponge hybrid scaffold in group 2 (n = 7), and PLGA mesh-collagen sponge hybrid scaffold seeded with bone marrow-derived mesenchymal stem cells (MSCs) in group 3 (n = 10). The animals were killed at 1, 2, and 3 months after operation. The specimens were examined macroscopically and microscopically. No recurrence or eventration was observed. In all animals, autologous fibrous tissue with vascularization was generated at the graft site. Although no muscular tissue was detected, scattered desmin-positive cells were observed in groups 2 and 3. The 'neodiaphragm' in groups 2 and 3 was significantly thicker compared with that in group 1. There was no significant difference in the 'neodiaphragm' between groups 2 and 3. The PLGA mesh-collagen sponge hybrid scaffold provided better promotion of autologous in situ tissue regeneration in the diaphragm, suggesting its potential application to diaphragmatic repair in place of other prosthetic patches.

Effectiveness of diaphragmatic repair using an abdominal muscle flap in patients with recurrent congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Recurrent congenital diaphragmatic hernia (Re-CDH) is a well-known complication of CDH repair. Although surgical treatment is required for Re-CDH, the question regarding which technique is the optimal treatment has not yet been elucidated. We performed a repair using an abdominal muscle flap (AMF) for Re-CDH and herein report our experience.

PATIENTS AND RESULTS

Four patients using AMF had left Re-CDH. The patient's age at operation was around 1 year old in all patients. In the first repair during the neonatal period, a Gore-Tex patch was required for the large defect in 3 patients, whereas a primary closure was selected in 1 patient because the anterior diaphragm remained as a partial remnant. In the 3 patients in whom a Gore-Tex patch was used in the first operation, recurrence occurred twice. All of the patients suffered from both pulmonary hypertension and growth retardation. A repair using AMF (the flap of both the internal oblique and the transversalis abdominal muscle) was performed in all patients. The clinical course was good in all patients, with an improvement of both pulmonary hypertension and growth retardation without any recurrence of CDH.

CONCLUSION

The use of an AMF was thus found to be an effective technique for repairing a large defect in Re-CDH.

The split abdominal wall muscle flap repair for large congenital diaphragmatic hernias on extracorporeal membrane oxygenation

BACKGROUND

Numerous techniques exist for repairing large congenital diaphragmatic hernias (CDHs) including prosthetic patches, tissue-engineered grafts, and various muscle flaps. A split abdominal wall muscle flap is a simple, durable way to repair a large diaphragmatic hernia. This technique has not gained widespread use, and some have suggested that it would be inappropriate in the setting of extracorporeal membrane oxygenation (ECMO) because of bleeding risk. We present our series of diaphragmatic hernias with a focus on those repaired with the split abdominal wall technique while on ECMO.

METHODS

A retrospective, single-institution chart review was performed on all patients who underwent surgical repair for CDH over 6 years beginning in August 2000.

RESULTS

Seventy-five patients underwent repair. Sixteen were performed with patients on ECMO. Of these, 4 were closed primarily, 7 used a prosthetic patch, and 5 used a split abdominal wall muscle flap. Two patients in the prosthetic group developed a recurrent hernia, and 2 required reoperation for bleeding while on ECMO. No reoperations for bleeding were required in the abdominal muscle flap group.

CONCLUSIONS

The split abdominal wall muscle flap can be safely performed on anticoagulated patients. We believe it is a practical option for repairing large CDHs.

Temporary abdominal vacuum-packing closure in the neonatal intensive care unit

BACKGROUND

Temporary abdominal vacuum-packing (vac-pac) closure is well known in adult literature, yet has not been reported in infants.

METHODS

A review of children in the neonatal intensive care unit who underwent vac-pac closure from 2000 to 2006 was performed.

RESULTS

During this time, 7 infants underwent vac-pac closure after abdominal surgery. Median age was 39 days, with a median weight of 3.2 kg. Reasons for vac-pac included abdominal compartment syndrome (3), ongoing intraabdominal sepsis (1), anticipated second-look procedures (2), and abdominal observation after repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation (1). PaCO2 revealed a drop from a median preoperative level of 50.3 to 44.0 mm Hg postoperatively. Median preoperative urine output was 3.9 and 3.1 mL/(kg h) postoperatively. One patient died with an open abdomen from overwhelming Escherichia coli sepsis, and all surviving patients (85.7%) proceeded to definitive abdominal closure with the median time of vac-pac use being 4 days.

CONCLUSION

Vac-pac closure in infants is a safe and effective method of temporary abdominal closure. The detrimental effects of intraabdominal hypertension as well as risk of hemorrhage after repair of congenital diaphragmatic hernia while on extracorporeal membrane oxygenation also make this an important technique for abdominal observation.

Congenital diaphragmatic hernia: onset of respiratory distress and size of the defect: analysis of the outcome in 104 neonates

The purpose of this study was to evaluate the outcome in neonates with congenital diaphragmatic hernia (CDH) either presenting within the first 24 h of life or diagnosed prenatally. The study was particularly focused on the time of onset of respiratory distress and on the use of the Gore-Tex (GT) patch for diaphragmatic reconstruction. Records of 104 neonates with CDH were retrospectively reviewed. The data were analyzed by ANOVA, Kruskal-Wallis test or chi (2) test as appropriate. The result showed that the overall survival rate was 73.1% (76/104). Survival of operated neonates was 91.6% (76/83). Postnatally diagnosed neonates with the onset of respiratory distress within the first minute of life survived in 67%, with the onset between 2 and 10 min survived in 89%, whilst neonates with the onset of respiratory distress after l0 min survived in 100% (P = 0.007). Birth weight, gestational age, time of onset of respiratory distress and Apgar score significantly differed between survivors and nonsurvivors. Primary closure of the diaphragmatic defect was performed in 62 patients while the GT patch was used in 21 patients. The survival of patients with a large defect treated with a GT patch was lower (76.2 vs. 96.8%, P = 0.003). There was only one case of recurrence in our series with the GT patch. Survival depends on the time of onset of respiratory distress and size of the defect, both of which correlate with the degree of pulmonary hypoplasia. The term high-risk CDH is appropriate only for children with respiratory distress within the first 10 min of life and those diagnosed prenatally. The GT patch is a suitable material for the diaphragmatic reconstruction; we suppose that the recurrence is caused by incorrect attachment of the patch to the thoracic wall.

The whole truth: comparative analysis of diaphragmatic hernia repair using 4-ply vs 8-ply small intestinal submucosa in a growing animal model

BACKGROUND

Diaphragmatic reconstruction remains a challenging problem. There is limited information concerning the use of small intestinal submucosa (SIS) in congenital diaphragmatic hernia repair. A canine model was used to evaluate the use of a SIS patch in diaphragmatic reconstruction.

METHODS

Eleven beagle puppies (1.6-4.2 kg, 8 weeks old) underwent left subcostal laparotomy, central left hemidiaphragm excision (2 x 7 cm, 50% loss), and reconstruction with a 4-ply group I (n = 5) or 8-ply group II (n = 6) SIS patch. Chest radiographs were taken at time of operation and 3 and 6 months postoperatively. Animals were killed at 6 months. Adhesion formation (both pleural and abdominal), gross visual evaluation of the patch, and histology were compared.

RESULTS

In group I (4-ply), 1 animal died at 3 months from patch deterioration accompanied by stomach herniation that resulted in respiratory failure. In the 4 remaining animals, chest radiographs showed no evidence of herniation or eventration. On physical examination, there was no evidence of chest wall deformity. During gross surgical examination, the 4-ply patches showed thinning, multiple defects, and liver herniation in 3 animals. In 1 pup, the patch was thickened, intact, well incorporated at the repair site, and adherent to the liver and spleen. In group II (8-ply), 1 animal died of cardiopulmonary failure in the early postoperative period. In the other 5 animals, chest radiographs showed evidence of eventration in 1. On gross examination the patch adhered to the liver in all 5 surviving animals. In 4, the patches were thickened, viable, but had some shrinkage. One patch pulled away from the native diaphragm laterally; however, no visceral herniation was present. In the 1 animal with eventration, there was no evidence of a patch. Adhesion scores (AS) were graded and determined by the sum of extent (0-4), type (0-4), and tenacity (0-3). Average abdominal AS in group I was 5.6 +/- 0.8 vs 10.2 +/- 0.2 (P = .079) for group II. Average lung AS was 0.6 +/- 0.6 in group I vs 3.8 +/- 1.1 (P = .0476) for group II. Histological examination showed group II patches had greater collagen deposition with central calcification and mild inflammation within the residual graft, whereas group I patches were much thinner and were composed of granulation tissue without evidence of residual graft.

CONCLUSIONS

These data indicate that 8-ply SIS repair of diaphragmatic defects was superior (80%; 4/5 to 4-ply, 20%; 1/5, success). Organ adherence appears to be necessary for neovascularization of the SIS composite. Eight-ply grafts appear to be more durable and persist for a longer period, which may improve neovascularization. Long-term follow-up to evaluate remodeling characteristics of the patch material is required.

Abdominal muscle flap repair for large defects of the diaphragm

Repair of a large diaphragmatic defect in congenital diaphragmatic hernia (CDH) and eventration of the diaphragm (DE) is difficult, especially when this is an unexpected finding at surgery. A patch of synthetic material may not be available at short notice, especially in developing countries. We describe the repair of nine such defects by using an abdominal muscle flap comprising the transversus abdominis and internal oblique muscles based on the intercostal and subcostal vessels. Although reports of similar flap repairs have been published in the literature [1-5], these employed a subcostal incision for abdominal entry, which we believe jeopardizes the flap's vascularity. Thus, we prefer to use an upper abdominal midline incision for abdominal entry in all cases of CDH and DE.

Toldt's fascia flap: a new technique for repairing large diaphragmatic hernias

The most popular techniques for repairing large diaphragmatic defects involve the use of synthetic patches. We present an alternative approach using living tissue. We reviewed our cases of congenital diaphragmatic hernia (CDH) diagnosed within the first 24 h of life from 1991 to 2003. Toldt's fascia (TF) flap was used to repair defects that were too large to repair primarily even though the anterior rim of the diaphragm was present. After confirming that a small medial muscle remnant of the diaphragm was present, its mesothelial covering was incised, and the incision was extended to the TF far enough to create a flap sufficiently large to repair the defect. The TF flap, consisting of the small medial muscle remnant, TF, peritoneum, and retroperitoneal connective tissue, was mobilized carefully from the ipsilateral kidney and adrenal gland, and the repair completed with interrupted sutures using nonabsorbable material. We used this TF flap approach in seven of 43 patients with CDH. Two had right-sided CDH. Six survived. The mean size of the diaphragmatic defects in the seven TF flap cases was 5.43+/-0.53 x 3.86+/-1.07 cm, which was significantly larger than the defects in direct primary repair cases (3.40+/-0.77 x 2.03+/-0.59 cm) (p<0.01). The six survivors had good outcomes, and none of them have had recurrence of herniation or required any additional surgical intervention (mean follow-up period: 4.7 years). To the best of our knowledge, this is the first report of TF being used to repair large diaphragmatic hernias. Our technique is simple and has proven to be reliable for durable restoration of the diaphragm, suggesting that it could reduce the dependence on synthetic patch repair, which is associated with certain long-term complications.