Chapter 84 Congenital Diaphragmatic Hernia
INTRODUCTION
The standard approach for repairing a CDH in neonates remains the open approach. Laparoscopic and thoracoscopic repairs have been reported but have been fraught with high conversion rates, long operative times, and high recurrence rates.1–4 Yang and coworkers2 suggested anatomic (presence of the stomach in the abdomen) and physiologic (minimal ventilator requirements and no evidence of pulmonary hypertension) criteria for successful thoracoscopic repair in neonates.
OPERATIVE STEPS
Step 1 Infant is placed on operating table in supine position under warming lights with small roll placed under infant’s flank on affected side
Step 3 Gentle reduction of abdominal contents from chest to allow visualization of diaphragmatic defect
OPERATIVE PROCEDURE
Skin Preparation of Both Thoracic Cavities
Occasionally, these infants may develop a contralateral pneumothorax, severely compromising pulmonary function. This will require rapid placement of the chest tube on the contralateral thorax.
Gentle Reduction of the Abdominal Viscera from the Thoracic Cavity
Injury to Solid Organs or Hollow Viscus Organ
• Consequence
Inappropriate retraction of the small or large intestine can lead to intramural hematomas. More commonly, aggressive reduction of the liver and spleen can lead to hemorrhage.
• Repair
If hematomas of small and large bowel are identified, they should be closely inspected. If there is concern for a full-thickness injury to the involved intestine, resection should be carried out with a primary anastomosis in cases in which the infant is stable. The larger concern is for potential injury to the liver and spleen. When encountered, control of liver bleeding in a neonate is best achieved with compression of the liver and topical hemostatic agents. Further interventions are often more harmful than helpful. Initial management of splenic or renal lacerations should be handled in a similar fashion.
• Prevention
Gentle distraction of the bowel, either manually or with the use of atraumatic forceps, will help prevent bowel or mesenteric injury. When reducing the stomach, care must be taken to avoid excessive stretch on the short gastric vessels. With careful manual reduction of the solid viscera, injury can usually be avoided. In order to maintain the intra-abdominal position of each organ as it is reduced, placement of laparotomy pads under retractors can be helpful in avoiding solid organ injury.
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