1. Thoracoscopic Congenital Diaphragmatic Hernia repair considerations
Mario Riquelme, MD1; Arturo Aranda, MD2
1 Department of Pediatric Surgery, Christus Muguerza Hospital, University of Monterrey and San Jose Tec Hospital, Monterrey, NL, Mexico
2 Surgery department. Wright State University, - Dayton Children’s Hospital
Introduction: Thoracoscopic results of Congenital Diaphragmatic Hernia (CDH) repair are still no where near as good as open repair. The Congenital Diaphragmatic Hernia Study Group reports on JPS 2011 an overall recurrence of 8.8% for thoracoscopy compared to 2.6% for open operations. When the defect is too large and a mesh in needed, the degree of difficulty obviously increases. Having such a small working space, pitfalls are present while reducing the hernia contents, sac dissection, introducing the mesh, and suturing.
Methods: This is a literature review specifically on the technical details of Thoracoscopic repair, with the objective of evaluating and discussing options to decrease recurrence.
Results: Multifilament sutures offer the advantage of easier suturing and knot tying, non-absorbable being preferred through-out the literature. Safe hernia reduction includes atraumatic grasper, increasing intrathoracic pressure to 6mmHg and stitching the middle of the defect first. A new generation of mesh are now available. Most authors use: Dacron, Gore-Tex, composite mesh like Gore-Tex/Marlex, Biosynthetic absorbable collagen-based, and even Neuro-patch. Mesh introduction is uniform by rolling it thru the trocar incision. Some authors recommend large patches freely to decrease tension on the repair. Transthoracic wall stiches are used by many, especially if believed that suturing the posterolateral angle to the thoracic wall with rib anchoring is crucial to avoid recurrence. The anterior rim of the defect is sewn to the thoracic wall if the posterior rim is not present.
Conclusions: Thoracoscopic CDH repair is a highly challenging surgery that has a higher recurrence in most literature. There are many technical potential pitfalls that might be the reason for this. There is not a single technique or material that has proven to decrease recurrence of thoracoscopic CDH repair.