Thoracoscopic Repair of Congenital Thoracoscopic Repair of Congenital Thoracoscopic Repair of Congenital Thoracoscopic Repair of Congenital Diaphragmatic HerniaDiaphragmatic HerniaDiaphragmatic HerniaDiaphragmatic Hernia

Hye Kyung Chang, JungHye Kyung Chang, JungHye Kyung Chang, JungHye Kyung Chang, Jung----Tak Oh, Seung Hoon Choi, Seok Joo HanTak Oh, Seung Hoon Choi, Seok Joo HanTak Oh, Seung Hoon Choi, Seok Joo HanTak Oh, Seung Hoon Choi, Seok Joo Han

Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Division of Pediatric Surgery, Department of Surgery,Yonsei University College of MedicineYonsei University College of MedicineYonsei University College of MedicineYonsei University College of Medicine

Treatment of Congenital Diaphragmatic hernia (CDH) Treatment of Congenital Diaphragmatic hernia (CDH) Treatment of Congenital Diaphragmatic hernia (CDH) Treatment of Congenital Diaphragmatic hernia (CDH)

I.surgical repair via subcostal transverse laparotomy II.laparoscopic repair since 1995

III.thoracoscopic repair since 2001 in western report: tolerance to one lung ventilation depending on pulmonary function

in Korea,only one case report of thoracoscopic repair of right sided CDH in 2007

BackgroundBackgroundBackgroundBackground

PurposePurposePurposePurposepresentation of two cases of thoracoscopic repair of left sided CDH

� 3-month-old boy with delayed presentation of CDH

� neonate with prenatal presentation of CDH on U/S

CASE ICASE ICASE ICASE I3-month-old boy , 7.6 kgC/C : continuous irritability

referred from other hospital with diagnosis of diaphragmatic hernia, Lt.

herniated bowel shadow in the left lower lung fielddecreased bowel gas in abdomen

corresponding with Bochdalek hernia

Chest and abdominal XChest and abdominal XChest and abdominal XChest and abdominal X----rayrayrayray

Thoracoscopic repair of left sided CDHThoracoscopic repair of left sided CDHThoracoscopic repair of left sided CDHThoracoscopic repair of left sided CDH

single lung ventilation by CO2 inflation

herniation of the stomach, small bowel and liver in the left lower thoracic cavity

no adhesion between herniated organs and thoracic cavity or lung

reduction of the herniated organs to the abdominal cavity : simple & easy

four interrupted, non-absorbable sutures to close the diaphragmatic defect

operating time : 162 minutes

postoperative course : uneventful (discharge on POD#5)

Postop. Chest and Abdominal XPostop. Chest and Abdominal XPostop. Chest and Abdominal XPostop. Chest and Abdominal X----rayrayrayray

Immediate postop. Extubation on POD #1

수술 3주 후 OPD f/u

F/ 1 dayF/ 1 dayF/ 1 dayF/ 1 dayIUP 32 wks, birth weight 1.795 kgIUP 32 wks, birth weight 1.795 kgIUP 32 wks, birth weight 1.795 kgIUP 32 wks, birth weight 1.795 kgCCCC----sec delivered d/t PROM, preterm laborsec delivered d/t PROM, preterm laborsec delivered d/t PROM, preterm laborsec delivered d/t PROM, preterm laborApgar score 1Apgar score 1Apgar score 1Apgar score 1’’’’ –––– 4, 54, 54, 54, 5’’’’ –––– 6666Intubation, ambu baggingIntubation, ambu baggingIntubation, ambu baggingIntubation, ambu baggingPrenatal U/S : r/o CDH, r/o CCAM, hydramios on IUP 31 wks Prenatal U/S : r/o CDH, r/o CCAM, hydramios on IUP 31 wks Prenatal U/S : r/o CDH, r/o CCAM, hydramios on IUP 31 wks Prenatal U/S : r/o CDH, r/o CCAM, hydramios on IUP 31 wks

CASE IICASE IICASE IICASE II

Chest and abdominal xChest and abdominal xChest and abdominal xChest and abdominal x----rayrayrayray

OperationOperationOperationOperation

Thoracoscopic repair of left sided CDHBroviac catheter insertion

total operating time : 325 minutesoperating time of thoracoscopic CDH repair : 160 minutes

3mm troca for camera on 6th ICS on mid. Ax.L

3mm troca working port on 7th ICS on ant. Ax.L.

chest tube insertion

3mm troca working port on 8th ICS on post. Ax.L.

sutures b/w lat. diaphragm & chest wall

Postoperative XPostoperative XPostoperative XPostoperative X----ray findingsray findingsray findingsray findings

Discharge on POD #23Discharge on POD #23Discharge on POD #23Discharge on POD #23 수술수술수술수술 한달한달한달한달 후후후후 OPD f/uOPD f/uOPD f/uOPD f/u

Immediate postop.Immediate postop.Immediate postop.Immediate postop.Chest tube removal Chest tube removal Chest tube removal Chest tube removal

on POD #3on POD #3on POD #3on POD #3Extubation Extubation Extubation Extubation on POD #6on POD #6on POD #6on POD #6

� Thoracoscopic hernioplasty is easy, feasible and safe techniqueThoracoscopic hernioplasty is easy, feasible and safe techniqueThoracoscopic hernioplasty is easy, feasible and safe techniqueThoracoscopic hernioplasty is easy, feasible and safe techniquefor delayed CDH without pulmonary comorbidityfor delayed CDH without pulmonary comorbidityfor delayed CDH without pulmonary comorbidityfor delayed CDH without pulmonary comorbidity

in infants or children.in infants or children.in infants or children.in infants or children.

� Premature baby with adequate fetal pulmonary developmentPremature baby with adequate fetal pulmonary developmentPremature baby with adequate fetal pulmonary developmentPremature baby with adequate fetal pulmonary developmentand late presentation of diaphragmatic hernia may be considered and late presentation of diaphragmatic hernia may be considered and late presentation of diaphragmatic hernia may be considered and late presentation of diaphragmatic hernia may be considered as as as as

indication of thoracoscopic repair of CDH.indication of thoracoscopic repair of CDH.indication of thoracoscopic repair of CDH.indication of thoracoscopic repair of CDH.

� In consideringIn consideringIn consideringIn considering1) morbidity and pain on postop. course1) morbidity and pain on postop. course1) morbidity and pain on postop. course1) morbidity and pain on postop. course

of thoracotomy or laparotomy,of thoracotomy or laparotomy,of thoracotomy or laparotomy,of thoracotomy or laparotomy,2) recovery time, and 2) recovery time, and 2) recovery time, and 2) recovery time, and

3) cosmesis, 3) cosmesis, 3) cosmesis, 3) cosmesis, thoracoscopic approach may prove to be an alternativethoracoscopic approach may prove to be an alternativethoracoscopic approach may prove to be an alternativethoracoscopic approach may prove to be an alternative

to classical methods for the repair of CDH with good results.to classical methods for the repair of CDH with good results.to classical methods for the repair of CDH with good results.to classical methods for the repair of CDH with good results.

ConclusionConclusionConclusionConclusion