Thoracoscopic diaphragm plication in children and indications for conversion to open thoracotomy

Minimally invasive surgery for diaphragmatic diseases in neonates and infants

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.

Thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease in children

OBJECTIVE

The aim of this study was to clarify the role of thoracoscopic plication for diaphragmatic eventration after surgery for congenital heart disease (CHD) in children.

PATIENTS AND METHODS

We retrospectively reviewed the medical charts of pediatric patients who had undergone thoracoscopic plication of diaphragmatic eventration after surgery for CHD between 2008 and 2013 at our department.

RESULTS

Five patients were identified during the study period. The median age and body weight of the patients were 7.6 months and 6.6 kg, respectively. The associated CHDs were pulmonary artery atresia in 3 patients, truncus arteriosus in 1 patient, and double-outlet right ventricle in 1 patient. Four patients needed preoperative mechanical respiratory support. At operation, all the patients received CO2 insufflation (4 mm Hg), and single-lung ventilation was attempted in 3 patients using a bronchial blocker. A sufficient operative field was maintained by CO2 insufflation in all the patients regardless of single-lung ventilation. The procedure was not converted to open operation in any patient. Postoperative extubation was performed in the operating room in 1 patient, on the day of operation in 2 patients, and on postoperative Days 1 and 2 in 2 patients. Air embolism was not observed in any of the patients. Diaphragmatic eventration did not recur in any of the patients after thoracoscopic plication.

CONCLUSIONS

Thoracoscopic plication is a safe and effective procedure for pediatric diaphragmatic eventration after surgery for CHD. Considering the sufficient operative field maintained by CO2 insufflation, single-lung ventilation using a bronchial blocker would be unnecessary for this procedure. With its safety and good outcome, early thoracoscopic plication is a good treatment option for pediatric patients with symptomatic diaphragmatic eventration after surgery for CHD.