ORIGINAL ARTICLE

Early experience with thoracoscopic repair of congenitaldiaphragmatic hernias in pediatric age group: resultsand lessons learned

Rahul Kumar Gupta • Sandesh V. Parelkar •

Sanjay N. Oak • Beejal Sanghvi • Advait Prakash •

Mitesh Bachani • Rajashekhar Patil

Published online: 26 January 2011

� Springer-Verlag 2011

Abstract

Purpose To describe the surgical technique, initial

results, and overview indications of thoracoscopic repair of

congenital diaphragmatic hernia.

Patients and methods A retrospective review was

undertaken of patients with CDH who underwent tho-

racoscopic repair from January 2006 to July 2010, in

department of pediatric surgery in a tertiary care institute in

India. Patients underwent surgery under general anesthesia.

Reduction of the hernia contents was carried out using one

trocar for telescope and two operating trocars. Pleural

insufflation with carbon dioxide was maintained at a

pressure of 6–10 mmHg. The hernia defect was repaired

using nonabsorbable interrupted sutures.

Results: There were 17 patients, including 12 boys and 5

girls. Among 12 infants, there were 6 patients younger than

30 days. The other 5 patients were older than 1 year. The

hernia was located in the left side in 14 patients and in the

right side in 3 patients. The mean operative time was

110 min. Conversion was required in three patients. There

were one recurrence and one postoperative death.

Conclusions Thoracoscopic repair is feasible and safe for

children with CDH, including selective newborn. The

technique causes minimal trauma, results in good respira-

tory function, and promotes early recovery.

Keywords Thoracoscopic repair of congenital

diaphragmatic hernia � Pediatric age � Laparoscopy

Introduction

Congenital posterolateral diaphragmatic hernia (CDH) is a

challenge in pediatric surgery. Mortality is still high even

with modern treatments [1–4]. Many efforts in resuscita-

tion and surgical techniques have been done to reduce the

mortality rate. Since 1995, laparoscopic repair has been

performed for CDH [5–8]. The thoracoscopic approach has

been tried; however, the number of patients is limited,

especially in newborns [9–12]. Since January 2005, the

thoracoscopic approach has been used for CDH in our

hospital. The purpose of this report was to present the

surgical technique, initial results, and overview indications

from 17 children operated on by the thoracoscopic

approach.

Patients and methods

From January 2006 to July 2010, 17 children with CDH

were operated on thoracoscopically, by the same surgeon.

Patients with severe metabolic acidosis, severe pulmonary

hypertension and preoperative ventilator support were

excluded. Preoperative X-ray chest was used as a diag-

nostic modality in every patient (Fig. 1).

Standard endotracheal tube ventilation was used. The

patient was placed in the lateral decubitus position with the

head elevated. A 5-mm trocar was introduced at the mid-

axillary line in the fourth intercostal space for a telescope, a

second 3-mm instrument was placed in the sixth intercostal

space mid-axillary line which was subsequently used for

ICD placement, and the third 3-mm direct instrument was

placed in the fourth intercostal space anteriorly (Fig. 2).

Carbon dioxide insufflation was initially kept at

8–10 mmHg to reduce hernial contents and after reduction

R. K. Gupta (&) � S. V. Parelkar � S. N. Oak �B. Sanghvi � A. Prakash � M. Bachani � R. Patil

Department of Pediatric Surgery,

King Edward Memorial Hospital,

Parel, Mumbai, Maharashtra, India

e-mail: drrahulg78@yahoo.co.in

123

Pediatr Surg Int (2011) 27:563–566

DOI 10.1007/s00383-010-2827-7

it was maintained at a pressure of 6–8 mmHg in the tho-

racic cavity. After reducing the contents, the hernia defect

was repaired using nonabsorbable interrupted sutures

(polyester 2/0 or polypropylene 2-0 or polyamide 2-0)

encompassing two borders of the diaphragmatic muscle

defect with extracorporeal knots (Fig. 3a–d). The rim of

the defect was sewn to the thoracic wall when adequate rim

was not present. A needle was passed through one of the

port sites and after taking bites from both rims of dia-

phragm extracorporeal knot was made and slided. Similarly

the process was repeated putting interrupted sutures till the

defect was closed. A chest drain was inserted in the lowest

port posteriorly. It was withdrawn when the thoracic X-ray

result was normal (Fig. 4).

Results

There were 17 patients, including 12 boys and 5 girls.

Among 12 infants, there were 6 patients younger than

30 days. The other five patients were older than 1 year.

Presenting symptoms included respiratory distress, cyano-

sis, dyspnoea in newborns, and bronchopneumonia and

vomiting in infants and older children.

The hernia was located in the left side in 14 patients and

in the right side in 3 patients. Hernia sac was present in 15

patients while it was absent in 2 patients. The contents of

the hernia included intestine in all patients, stomach in 12

patients, spleen in 10 patients, and liver in 2 patients.

Reduction of hernia content was easily accomplished in 12

cases and difficult in 5 cases. The diaphragmatic defect was

repaired by closing directly 2 hernia borders in 13 patients

and by suturing the anterior hernia border of the defect with

the thoracic wall in 4 patients. The hernia sac was plicated

in all 15 cases.

Conversion was required in three patients, because of

difficulty in reducing the hernia content down to the

abdominal cavity and decrease in oxygen saturation. A

laparotomy was used according to the institutional protocol

of open repair. A prosthetic patch was not required in any

patient. All patients had minimal blood loss, and none

required blood transfusion.

The mean operative time was 110 min (range

70–160 min). A chest drain was inserted in all patients.

There was no intra-operative death. After the operation, a

conventional ventilator was required in seven patients: five

newborns and two infants. The mean time on the ventilator

was 3.3 days (range 2–5 days). Wound infections occurred

in one patient. There was one postoperative death (due to

severe pulmonary hypertension). The mean postoperative

hospitalization was 6.4 days (range 4–10 days).

Follow-up for these patients ranged from 1 to

24 months. One patient had a recurrence at 10 months after

the operation. Upon reoperation of this patient, a small

hernia was seen at the lateral aspect of the diaphragm.

Discussion

We present our series of thoracoscopic procedures for CDH

repair during 4-year-period. Our study showed that tho-

racoscopic repair is safe and feasible for CDH in children

and selective newborns. As our experience with the tho-

racoscopic approach increased over time, indications for a

thoracoscopic approach shifted. We started with a few late

presenting cases. Subsequently, we selected neonates.

The conversion rate is low, two in newborns and one in

a 4-month-old child. The conversion was required because

of the fall in oxygen saturation, rise in endotracheal tube

CO2 level, and difficulty in pushing the hernia content

down to the abdominal cavity and not because of the dif-

ficulties in suturing. Reduction of the hernia contents was

not difficult in the patients whose hernia sac was present.

Fig. 1 Preoperative X-ray chest showing left side diaphragmatic

hernia

Fig. 2 Showing port sites

564 Pediatr Surg Int (2011) 27:563–566

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However, it could be difficult when there is no hernia sac,

especially in the newborns. Use of slightly high flow rate

without raising the pressure could facilitate the reduction.

The thoracoscopic approach is a satisfactory procedure

for CDH. However, precautions should be taken for new-

borns younger than 7 days without a hernia sac, with low

birth weight, and with hernia located on the right side

containing liver and small intestine. The liver is an obstacle

preventing the reduction of the small intestine.

To prevent the high end tidal PCO2 and low oxygen

saturation during the operation, we used a low CO2 pres-

sure insufflation (6–8 mmHg) in newborns. With this

pressure, the thoracic cavity is large enough to allow for

the required surgical manipulation because the hypoplastic

lung is always encountered in CDH. In patients more than

7 days old, this pressure caused no adverse effects on vital

signs and SaO2. However, the SaO2 could be reduced in

newborns younger than 7 days. The hernia was closed

successfully with the extracorporeal knots. The patch was

not required in our series.

However, the closure of the hernia was difficult in five

cases when the posterior border of the hernia was very

hypoplastic. Closing the hernia was successful by suturing

the anterior hernia border with the thoracic wall.

The result of our study revealed that thoracoscopic

repair for CDH was safe. There were no deaths among

patients older than 7 days. One postoperative death

occurred in patient younger than 7 days, weighing 1,800 g.

The cause of death was not associated with the operation.

A number of surgeons have used laparoscopy to repair

CDH [5–8, 12]. However, the thoracoscopic approach has

some advantages compared to the laparoscopic approach.

The laparoscopic approach resulted in several technical

difficulties [12]. It was difficult to bring the spleen back

into the abdominal cavity [12]. The sutures could be dif-

ficult to place because the intestine is an obstacle to

observe the diaphragmatic defect. With the thoracoscopic

approach, one could directly visualize the hernia and the

organs, and gently push them down into the abdominal

cavity. Suturing of the hernia defect was performed easily

because there was unobstructed access to the posterior

lateral defect. Also, the insufflation facilitates the return of

the hernia contents into the abdominal cavity [12].

Fig. 3 a Thoracoscopic view

showing hernial contents.

b Showing suturing of anterior

and posterior rim of hernial

defect. c Suturing in progress.

d Completed repair

Fig. 4 Postoperative X-ray chest

Pediatr Surg Int (2011) 27:563–566 565

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Thoracoscopy is a better approach when compared with

an open procedure because muscles are not divided; hence,

postoperative respiratory function is minimally impaired.

Fifteen patients did not require a postoperative ventilator.

The remaining patients required ventilatory support for a

short period. After the surgery, the patient can rapidly

return to a normal life. The length of hospitalization was

relatively short.

In conclusion, thoracoscopic repair for CDH is feasible

and safe. It could be indicated for selective newborn

patients as well as for infants and elders. Easy access,

minimal trauma, good cosmetic results, and rapid recovery

are all important advantages of this technique.

Acknowledgments The author thanks Dr Sanjay N. Oak, Dean and

director, Seth G.S.M.C. & K.E.M. Hospital, Mumbai.

Conflict of interest None.

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