Thoracoscopic Repair for Congenital Diaphragmatic Hernia:Experience with 139 Cases

Nguyen Thanh Liem, MD, PhD,1 Lo Quang Nhat, MD, PhD,1 To Manh Tuan, MD,1 Le Anh Dung, MD,1

Nguyen Quang Ung, MD,2 and Tran Minh Dien, MD, PhD3

Abstract

Purpose: To analyze indications and to present details of surgical technique and outcomes of thoracoscopicrepair for congenital diaphragmatic hernia (CDH) in 139 patients.Methods: We reviewed medical records of all patients with CDH who underwent thoracoscopic repair by thesame surgical team from June 2001 to October 2009. Patients were placed in the lateral decubitus position. Theoperations were performed using three trocars. Pleural insufflation with carbon dioxide was maintained at apressure of 2–6 mm Hg. The hernia defect was repaired using nonabsorbable interrupted sutures with extra-corporeal 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 64were infants or children. The hernia was located on the left side in 113 patients (81.3%) and on the right side in 26patients (18.7%). The mean operative time for thoracoscopic approach was 66� 27 minutes. Conversion wasrequired in 11 patients (7.9%) from 2001 to 2007. There were no conversions in 2008 or 2009. A prosthetic patchwas 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 con-version rate decreased, and indications increased with surgical team experience.

Introduction

Silen et al. performed the first thoracoscopic repair forcongenital diaphragmatic hernia (CDH) in an adolescent

in 1995.1 In 2001, Becmeur et al. reported using thoracoscopicrepair for a child aged 8.3 months.2 We performed the firstsuccessful thoracoscopic repair for a newborn in February,2002.3 To date, thoracoscopic repair has been used in manycenters for CDH.4–21 However, most case series have reportedonly a small number of patients, especially newborns. Debatestill exists about indications for this procedure.4,7,9,21

The purpose of this study is to analyze indications and topresent details of surgical techniques and outcomes of athoracoscopic approach for CDH with 139 cases, including 75newborns.

Materials and Methods

We reviewed medical records of all children with CDHoperated by a thoracoscopic approach from June 2001 toOctober 2009. Indications: From 2001 to 2007, thoracoscopic

repair was indicated for infants, toddlers, and selected new-borns. The procedure was not indicated for newborns whosecondition could not be stabilized with resuscitation and con-ventional mechanical ventilation or who had associated car-diac anomalies. Beginning in 2008, the surgical indicationwas extended to newborns whose condition was stabilizedwith high-frequency oscillatory ventilation (HFOV) and forchildren with simple associated cardiac anomalies.

Surgical technique

Patients are placed in the lateral decubitus position with thehead elevated. The upper arm is left free. Anesthesia withbilateral ventilation is used for newborns, and one-lung ven-tilation is applied for infants and toddlers. The surgeon standsat the patient’s head, with the monitor positioned at the pa-tient’s feet. A 5-mm trocar is introduced at the mid-axillaryline in the third intercostal space for a thoracoscope, a second5-mm trocar is placed in the fourth intercostal space anteri-orly, and the third 5-mm trocar is inserted in the fourthintercostal space behind the scapular tip. Carbon dioxide

1Department of Surgery, 2Operating Theater, and 3Surgical Intensive Care Unit, National Hospital of Pediatrics, Hanoi, Vietnam.

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 21, Number 3, 2011ª Mary Ann Liebert, Inc.DOI: 10.1089/lap.2010.0106

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insufflation is maintained at a pressure of 2–4 mm Hg in thethoracic cavity. Pressure is increased up to 6 mm Hg if re-duction of herniated abdominal organs is difficult. A con-ventional ventilator with high frequency (from 80 to 100respirations per minute), and low-peak airway pressure isused for newborns. Since January 2009, HFOV was used forpatients who required HFOV preoperatively and could notswitch to a conventional ventilator.

After reducing the herniated organs into the abdominalcavity, the hernia defect is repaired using nonabsorbable in-terrupted sutures (Ethibon 2/0 or 3/0; Ethicon France,Neuilly/Sein, France) encompassing two borders of the dia-phragmatic defect with extracorporeal knots. The first stitch isplaced at the middle of the hernia defect, and the insufflationis turned off. The anterior rim of the defect is sewn to thethoracic wall if the posterior rim is not present. The two rimsof the defect at the posterolateral angle are sewn to the tho-racic wall when the defect is large (Fig. 1). A patch (Neuro–Patch manufactured by BBraun Aesculap-Platz, Tutlingen/Germany) is introduced and secured thoracoscopically whenrequired.

Results

There were 91 boys and 48 girls. Seventy-five patients werenewborns, and 64 patients were infants or toddlers. Pre-operative ventilator support was required in 53 patients(38.1%) including 50 newborns and 3 infants. Forty patientsrequired a conventional ventilator, and 13 patients requiredHFOV. Associated cardiac anomalies included patent ductusarteriosus in 21 patients and atrial septal defect in 1 patient.

Anesthesia with conventional ventilator support was usedin 135 patients and with HFOV in 4 patients. Operations werecarried out in the operating theater in 135 patients and inintensive care unit (ICU) in 4 patients.

The hernia was located on the left side in 113 patients (81.3%)and on the right side in 26 patients (18.7%). There was a herniasac in 77 patients (55.4%) and no hernia sac in 62 patients(44.6%). The hernia contents included small intestine in 124patients, colon in 100 patients, spleen in 41 patients, liver in 26

patients, and stomach in 20 patients. A diaphragmatic incisionto widen the hernial orifice was performed in 2 patients.

Conversion to laparotomy was required in 11 patients(7.9%), including 7 newborns and 4 infants. All conversionswere performed during the period from 2002 to 2007. Noconversion was required in 2008 or 2009. Indications forconversion included a large hernia defect in 3 patients, in-ability to reduce herniated organs in 3 patients, oxygen de-saturation in 2 patients, intestinal adhesions in 2 patients, andpulmonary sequestration in 1 patient.

The diaphragmatic defect was repaired by directly closing2 hernia borders in 50 patients and by suturing the dia-phragmatic border to the thoracic wall in 82 patients. Aprosthetic patch was required in 7 patients. The patch wassecured thoracospically in 5 patients. In 2 patients, the patchwas secured with the diaphragmatic rims and thoracic wallduring laparotomy. The hernia sac was plicated in 29 patientsand removed partially in 48 cases.

Mean operative time for single thoracoscopic operation was66� 27 minutes (range from 15 to 180 minutes). Thoracoscopicoperation plus laparotomy required 97� 33 minutes (rangefrom 55 to 180 minutes).

A chest drain was inserted in the first 9 patients and con-nected to underwater seal. In 128 patients, the drain wasconnected to a syringe and aspirated manually every 6 hours.There was no chest drain in 2 cases.

There were no intraoperative deaths or complications.Intraoperative blood loss was insignificant. There were 14postoperative deaths (10%), all of them in newborns. Cause ofdeath included pulmonary arterial hypertention in 8 patientsand septicemia in 6. For survivors whose operation was car-ried out completely by a thoracoscopic approach, meanpostoperative stay was 17.3� 12.9 days (range 3–91 days).Follow-up was obtained in 114 patients, ranging from 1 to84 months (mean 26.3� 24.7 months). Five patients hadrecurrence (3.6%).

Discussion

Most surgeons have reported performing the thoracoscopicrepair using three trocars. However there are differences inpositioning of patients and trocars. Ferreira and Kim et al.placed the first trocar for the thoracoscope below the tip of thescapula. Two other trocars were introduced through thefourth or fifth intercostal space.7,10 Yang placed the first trocarin the anterior axillary line in the fourth intercostal space, andtwo additional trocars were inserted in the fifth or sixth in-tercostal space posteriorly and in the sixth or seventh inter-costal space below the nipple.21

We try to place trocars as high as possible. The first trocar isplaced in the second or third intercostal space for the thor-acoscope, two other trocars are introduced in the fourth in-tercostal space. With this placement, we always have enoughworking space to perform operative maneuvers. The workingspace for surgery would be narrower if trocars were placed atlower levels. This might explain a high conversion rate insome reports.4,7

The hernia defect can be closed with extracorporeal or in-tracorporeal knots.9,14 We prefer extracorporeal knots, be-cause they can be easily done. After reduction of the herniacontents, we perform the first stitch at the middle of the herniadefect. This stitch can prevent abdominal organs returning to

FIG. 1. Two rims of the defect at the posterolateral angleare sewn to the thoracic wall.

268 LIEM ET AL.

the thoracic cavity, allowing us to turn off the insufflationto avoid further hemodynamic or blood gas disorders due toCO2 pressure.

In our series, two borders of the hernia defect were closeddirectly together in 36%. We had to close the diaphragm withthe thoracic wall in 59%, and used the patch in 5%. The dia-phragm is very fragile in newborns. With a large herniadefect, any attempt to close two borders directly togethercould tear the diaphragm and increase risk of recurrence. Theposterolateral angle between the two hernia rims and thethoracic wall is always a weak point, and the defect could notbe closed completely in many cases. The remaining defect atthis angle might lead to recurrence. To avoid this risk, wealways close two rims of the hernia defect with the thoracicwall when direct closure of the two rims is not feasible.

When a patch was required, it was introduced easily throughthe trocar’s incision. The patch was secured to the thoracic wallusing a running suture. Interrupted sutures were used on othersides. We performed this suturing without difficulty.

We performed thoracoscopic repair safely in the ICU for 4patients. We believe that operation in the ICU should beindicated for severe patients at increased risk during trans-portation to operating theater.

Our results show that thoracoscopic repair is feasible forCDH, not only in children but also in newborns. The con-version rate was not significantly different between newbornsand infants or children. Published reports show conversionrates varying from 11% to 42%.4,7,10 Need for conversion maydrop with surgical team experience. All conversions in ourseries were performed before 2008. There were no conversionsin 2008 or 2009, whereas indications for thoracoscopic repairwere extended to more severe patients. A patch was intro-duced and secured thoracoscopically in 5 patients in our se-ries, as has been reported by other authors.9,14,19 The need fora patch is no longer an indication for conversion in thoraco-scopic repair for CDH.

Oxygen desaturation is a great concern during thoraco-scopic repair for CDH, especially in newborns. This leads toconversion or a requirement of high intraoperative peak in-spiratory pressure levels.7,10,11,14 HFOV was first successfullyused in 1 patient in 2009.13 This was used for 4 patients inour study. Oxygen saturation and cardiovascular parameterswere stable during operation. This new approach couldavoid oxygen desaturation and, thus, reduce the rate ofconversion. We operated on the patient under HFOV with-out difficulty.

Inability in reducing herniated abdominal organs has beenreported.7,11 We recently overcame this obstacle by increasingPCO2 pressure to 6 mm Hg for a short time combined withmaximizing the dose of muscle relaxant. For a small herniadefect, we inspect the orifice and then incise the diaphragm towiden the orifice as needed. To gain adequate space for op-erative maneuvers, we place trocars at higher levels thansome authors.4,10,21 With these modifications, there has beenno conversion in our series during 2008 and 2009 due to dif-ficulty in reducing herniated organs.

Before 2008, associated cardiac anomalies were a contrain-dication for thoracoscopic repair in our series. However since2008, thoracoscopic repair was safely performed for CDHassociated with patent ductus arteriosus or atrial septal defect.Thoracoscopic repair has also been safely carried out by othersurgeons for CDH combined with cardiac anomalies.10,14

Presence of the stomach in the thoracic cavity was consid-ered a contraindication for thoracoscopic repair in some re-ports.21 In our series, the stomach was present in the thoraciccavity in 20 cases. In 15 of those cases, thoracoscopic repairwas successfully carried out. Kim et al. also successfullyperformed thoracoscopic repair for CDH with the stomachpresent in the thoracic cavity.10 The presence of the stomach inthe thoracic cavity is no longer a contraindication for thor-acoscopic repair for CDH.

There were no intraoperative deaths or complications inour series. This shows that thoracoscopic repair is a safeprocedure for CDH both in children and in newborns. Therewere 14 patients who died postoperatively in our study.The mortality rate was 10%. All patients were newborns. Thecause of deaths was pulmonary arterial hypertension in 8patients and septicemia in 6 patients. Characteristics of thosepatients are presented in Table 1. This rate is higher than inother series. However, those series included more selectedpatients.7,9,21

The recurrence rate in our series was 3.6%, lower than inother series.7,9,14 We believe that the closure of two dia-phragmatic rims to the thoracic wall at the posterolateralangle is an important factor to prevent recurrence.

In our series, all newborns were operated by the samesurgeon. Infants and children were operated by one of 2 seniorsurgeons. Surgeon experience is associated with recurrencerate, as mentioned by Guner et al.9

In conclusion, thoracoscopic repair is feasible and safe forCDH. The conversion rate decreased, and indications in-creased with surgical team experience.

Acknowledgment

The authors thank John Taylor, MD, PhD, from the De-partment of Pediatrics, School of Medicines at the Universityof Washington, Seatle, WA, for his careful reading and valu-able comments on the manuscript.

Disclosure Statement

No competing financial interests exist.

Table 1. Characteristics of Patients Who Died

Number

Age atoperation

(days) LocationWeight at

operation (g) Cause of death

1 9 Left 3500 Septicemia2 3 Left 2700 Septicemia3 3 Left 2800 PAH4 17 Left 2300 PAH5 30 Right 3000 Septicemia6 2 Left 3000 PAH7 4 Left 3400 Septicemia8 2 Left 3000 PAH9 3 Left 3500 Septicemia10 4 Left 3400 PAH11 3 Left 2200 Septicemia12 5 Left 2200 PAH13 3 Left 3000 PAH14 4 Left 2000 PAH

PAH, pulmonary arterial hypertension.

THORACOSCOPIC REPAIR FOR CONGENITAL DIAPHRAGMATIC HERNIA 269

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Address correspondence to:Nguyen Thanh Liem, MD, PhD

Department of SurgeryNational Hospital of Pediatrics

18/879 La Thanh RoadDong Da District

HanoiVietnam

E-mail: liemnhp@hotmail.com

270 LIEM ET AL.