Minimal Access Surgery for Repair of Congenital Diaphragmatic Hernia: Is it Advantageous?—An Open Review

Abstract

Introduction Congenital diaphragmatic hernia (CDH) is a congenital life-threatening condition requiring surgical repair in the neonatal period. Minimal access surgery (MAS) is gaining ground on the classical open approach by laparotomy or thoracotomy as it minimizes damage to the abdominal or thoracic wall. Using an open review of the literature, we aimed to determine whether MAS is safe and effective in treating CDH. Furthermore, we provide selection criteria for the optimal surgical approach, laid down in a decision algorithm.

Methods An online search of MEDLINE was performed (May 2012), followed by a citations search. All study types except case reports describing open and/or MAS repair of Bochdalek CDH were eligible. Primary outcome data, for example, surgical complications and mortality, were recorded, as well as secondary outcome measures, for example, operative time, duration of postoperative ventilation, tolerance of enteral nutrition, and total length of stay (LOS) in hospital. Analysis was performed in accordance with the standards of the Cochrane Handbook for Systematic Reviews of Interventions.

Results We identified 15 relevant studies, 5 of them describing MAS only and 10 comparing MAS to open repair of CDH. Numbers of included patients and selection criteria for MAS varied widely. Most studies have methodological limitations, such as the use of retrospective data or historical control groups. ECMO treatment and patch use were more frequent in the open repair group (both p < 0.0001). Recurrence risk seemed to be increased in the MAS group. The need for conversion in MAS series ranged widely, from 3.4 to 75.0%. The risk of general surgical complications did not vary between groups. Mortality seemed to be less in the MAS group. Operative time seemed to be longer in the MAS group. Duration of postoperative ventilation and total LOS appeared to be reduced in this group and patients returned quicker to enteral nutrition.

Conclusions We demonstrate that MAS for diaphragmatic hernia appears to be safe in terms of complications and mortality. Besides, it is associated with faster postoperative recovery. Growing experience with this technique is expected to lower the recurrence risk and to shorten the operative time. These findings should be interpreted cautiously because of methodological limitations of the studies included. Selection criteria used in various studies are associated with an important risk of selection bias. Nonetheless, these criteria can be used to identify patients who will benefit most from MAS.

Keywords

congenital diaphragmatic hernia - neonates - minimal access surgery - open repair

• References

• 1 Lao OB, Crouthamel MR, Goldin AB, Sawin RS, Waldhausen JH, Kim SS. Thoracoscopic repair of congenital diaphragmatic hernia in infancy. J Laparoendosc Adv Surg Tech A 2010; 20 (3) 271-276
• 2 Gander JW, Fisher JC, Gross ER , et al. Early recurrence of congenital diaphragmatic hernia is higher after thoracoscopic than open repair: a single institutional study. J Pediatr Surg 2011; 46 (7) 1303-1308
• 3 Gomes Ferreira C, Reinberg O, Becmeur F , et al. Neonatal minimally invasive surgery for congenital diaphragmatic hernias: a multicenter study using thoracoscopy or laparoscopy. Surg Endosc 2009; 23 (7) 1650-1659
• 4 Lansdale N, Alam S, Losty PD, Jesudason EC. Neonatal endosurgical congenital diaphragmatic hernia repair: a systematic review and meta-analysis. Ann Surg 2010; 252 (1) 20-26
• 5 Arca MJ, Barnhart DC, Lelli Jr JL , et al. Early experience with minimally invasive repair of congenital diaphragmatic hernias: results and lessons learned. J Pediatr Surg 2003; 38 (11) 1563-1568
• 6 Becmeur F, Reinberg O, Dimitriu C, Moog R, Philippe P. Thoracoscopic repair of congenital diaphragmatic hernia in children. Semin Pediatr Surg 2007; 16 (4) 238-244
• 7 Kim AC, Bryner BS, Akay B, Geiger JD, Hirschl RB, Mychaliska GB. Thoracoscopic repair of congenital diaphragmatic hernia in neonates: lessons learned. J Laparoendosc Adv Surg Tech A 2009; 19 (4) 575-580
• 8 Yang EY, Allmendinger N, Johnson SM, Chen C, Wilson JM, Fishman SJ. Neonatal thoracoscopic repair of congenital diaphragmatic hernia: selection criteria for successful outcome. J Pediatr Surg 2005; 40 (9) 1369-1375
• 9 Cho SD, Krishnaswami S, Mckee JC, Zallen G, Silen ML, Bliss DW. Analysis of 29 consecutive thoracoscopic repairs of congenital diaphragmatic hernia in neonates compared to historical controls. J Pediatr Surg 2009; 44 (1) 80-86 , discussion 86
• 10 Fishman JR, Blackburn SC, Jones NJ , et al. Does thoracoscopic congenital diaphragmatic hernia repair cause a significant intraoperative acidosis when compared to an open abdominal approach?. J Pediatr Surg 2011; 46 (3) 458-461
• 11 Gourlay DM, Cassidy LD, Sato TT, Lal DR, Arca MJ. Beyond feasibility: a comparison of newborns undergoing thoracoscopic and open repair of congenital diaphragmatic hernias. J Pediatr Surg 2009; 44 (9) 1702-1707
• 12 Keijzer R, van de Ven C, Vlot J , et al. Thoracoscopic repair in congenital diaphragmatic hernia: patching is safe and reduces the recurrence rate. J Pediatr Surg 2010; 45 (5) 953-957
• 13 McHoney M, Giacomello L, Nah SA , et al. Thoracoscopic repair of congenital diaphragmatic hernia: intraoperative ventilation and recurrence. J Pediatr Surg 2010; 45 (2) 355-359
• 14 Okazaki T, Nishimura K, Takahashi T , et al. Indications for thoracoscopic repair of congenital diaphragmatic hernia in neonates. Pediatr Surg Int 2011; 27 (1) 35-38
• 15 Szavay PO, Obermayr F, Maas C, Luenig H, Blumenstock G, Fuchs J. Perioperative outcome of patients with congenital diaphragmatic hernia undergoing open versus minimally invasive surgery. J Laparoendosc Adv Surg Tech A 2012; 22 (3) 285-289
• 16 Tsao K, Lally PA, Lally KP. Congenital Diaphragmatic Hernia Study Group. Minimally invasive repair of congenital diaphragmatic hernia. J Pediatr Surg 2011; 46 (6) 1158-1164
• 17 Bliss D, Matar M, Krishnaswami S. Should intraoperative hypercapnea or hypercarbia raise concern in neonates undergoing thoracoscopic repair of diaphragmatic hernia of Bochdalek?. J Laparoendosc Adv Surg Tech A 2009; 19 (Suppl. 01) S55-S58
• 18 Bishay M, Giacomello L, Retrosi G , et al. Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants. J Pediatr Surg 2011; 46 (1) 47-51
• 19 van den Hout L, Tibboel D, Vijfhuize S, te Beest H, Hop W, Reiss I. CDH-EURO Consortium. The VICI-trial: high frequency oscillation versus conventional mechanical ventilation in newborns with congenital diaphragmatic hernia: an international multicentre randomized controlled trial. BMC Pediatr 2011; 11: 98