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. 2023 Sep 29:S0022-3468(23)00578-X.

 doi: 10.1016/j.jpedsurg.2023.09.040. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/37867043/

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects?

Nikhil R Shah ¹, Cory N Criss ², Keerthi Burgi ³, Niki Matusko ⁴, James D Geiger ⁴, Erin E Perrone ⁴, George B Mychaliska ⁴, Matthew W Ralls ⁴

Affiliations expand

• PMID: 37867043
• DOI: 10.1016/j.jpedsurg.2023.09.040

Abstract

Introduction: Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.

Methods: This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO₂, operative time, and complication rates.

Results: Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H₂O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver “up” in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO₂ did not differ; neither did overall median pH or pCO₂. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities.

Conclusions: Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence.

Level of evidence: II.

Keywords: Congenital diaphragmatic hernia; Minimally invasive; Patch repair; Thoracoscopy.

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