Thoracoscopy Vs Laparoscopy for CDh

1. Thoracoscopy Vs Laparoscopy-
Technical Feasibility and
Complications in Congenital
Diaphragmatic Hernia
Prakash Agarwal
Prof & HOD, Dept. of Pediatric Surgery, SRMC.
Consultant Paediatric Surgeon, Apollo Childrens’
Hospital, Chennai

2. Types of CDH
• Morgagni’s hernia
• Paraesophageal hernia Delayed Presentation
• Eventeration
• Bochdalek’s hernia Presentation at birth

3. MIS in Diaphragmatic Hernia
• Minimally invasive surgery (MIS) has become
more common in the pediatric population,
and this approach has been extended to
patients with congenital diaphragmatic hernia
(CDH)
• Since the 1st report in 1995, of
MIS in CDH for neonates has
grown

4. Advantages of MIS in CDH
• In addition to reducing pain, surgical stress
and length of hospital stay, and encouraging
early recovery, MIS for CDH repair has
beneficial effects over conventional open
surgery, especially because of
• reduced duration of postoperative mechanical
ventilation,
• less need for narcotics,
• and lower incidence of skeletal deformities

5. Minimally Invasive Surgery for CDH
• Laparoscopic –Morgagni’s & Paraesophageal
• Thoracoscopic – Bochdalek’s and Eventeration

6. AIM
• A new procedure should be safe,
acceptable, reproducible and results should
be same if not better than the standard
procedure
• Not to claim superiority of MIS in the
treatment of CDH in the neonatal period,
but to access the feasibility
and the safety of this
technique.

7. ISSUES
• Many studies have reported comparable outcomes
of MIS with open surgery to repair a CDH
• However, some concerns remain about the high
recurrence rate of CDH after MIS repair.
• In MIS for CDH, which is better
- Thoracoscopy or Laparoscopy
- Technically which is more feasible

8. Issues
• CO2 absorption during insufflation for creating a
pneumothorax/pneumoperitoneum, can lead to
significant metabolic and physiologic changes.
• Wide discrepancies in the severity of pulmonary
hypoplasia (PH) and persistent pulmonary
hypertension (PPH) between patients and different
management protocols resulting in the indications
for MIS to vary from center to center.

9. CRITERIA FOR BETTER OUTCOME
SELECTION
• Hemodynamically stable.
• Absence of PH & use of min
vent support pre-op.
• Delayed presentation (a
diagnosis more than 30 days
after birth) – Morgagni,
Paraesophageal and
Eventeration.
• Small diaphragmatic defect of
3 cm or less.
• Presence of stomach in abd.
EXCLUSION
• High pulmonary arterial
pressure not resolving with
conventional ventilation
• Hemodynamically unstable
during surgery
• Larger defects
• The need for patch repair
• Combined anomalies
• Conventional ventilation,
peak inspiratory pressure <
25mm Hg
• No need for inhaled nitric
oxide (iNO)
25% - 30% of neonates with CDH could be eligible for MIS repair

10. Surgery- Thoracoscopy
SURGEON
Position
• The patient is placed in the
lateral decubitus position with
• the head elevated. The upper
arm is left free.
• The surgeon stands at the
patient’s head, with the
• monitor positioned at the
patient’s feet
MONITOR

11. Technique- Thoracoscopy
• 5-mm canula for the videoscope is
placed in the 3rd intercostal
space, mid-axillary line
• The second trocar is placed in the
fourth intercostal space anteriorly,
and the third trocar is inserted in
the fourth intercostal in the space
behind the scapular tip.
• Insufflation of CO2 is initiated
with 1–2 L/min, creating an
intrathoracic pressure increasing
from 2 to a maximum of 6mmHg
in order to facilitate easy reducing
of the enterothorax.

12. Technique - Thoracoscopy
• Inspect the contents thoroughly. Try
to identify the orifice of the
diaphragmatic defect if possible
• If a true hernia sac is found, the sac is
excised / plicated
• Reduction of herniated organs is the
most difficult step. The small intestine
is gently reduced into the abdominal
cavity using blunt graspers. The
direction of the reduction is
important.
• It is better if the surgeon can identify
the diaphragmatic defect before
reducing.
• The reduction should start with the
small intestine, then the colon.
• Reduction of the spleen is the last
step and should be performed
carefully

13. Technique - Thoracoscopy
• Manual approximation of both
the diaphragm rims is done in
order to assess the feasibility of
the closure of the hernia.
• The defect was then closed,
using 2/0 or 3/0 nonabsorbable
(Ethibond/ silk) interrupted
sutures. The first stitch is placed
at the middle of the hernia
defect
• intracorporeally knotted.
• If a posterior rim of the
diaphragm could not be readily
recognized or is absent, sutures
are placed encircling the lowest
rib.
• A chest drain is put under direct
vision through the dorsal axillary
line trocar site.

14. Surgery- Laparoscopy
• Supine with reverse
Trendelenburg position.
• Surgeon stand at the foot.
• Monitor at the head end more
towards side of defect.
• 3 trocars – telescope at
umbilicus & operating ports at
the R & L
• Contents are reduced by pulling
and CO2 pressure is maintained
till suturing is over.

15. Thoracosocopy Vs Laparoscopy
Advantages
Thoracoscopy
• Extensive Thoracic examination.
• Easier Reduction.
• Insufflation facilitates return of
hernia contents into abdomen.
• A large working space after
reduction for suturing.
• Intermittent CO2 insufflation.
Laparoscopy
• Abdominal viscera
examination.
• Secure suturing without risk of
visceral injury.
• Easy conversion if needed.

16. Thoracoscopy Vs Laparoscopy
Disadvantages
Thoracoscopic
• Does not allow examination of
the intra-abdominal viscera.
• Bowel is pushed down without
any control below the
diaphragm – mising out
malrotation & meckels.
• Risk of abdominal viscera
puncture while suturing
• Thoracotomy – if conversion is
required.
Laparoscopic
• Difficult to reduce the contents.
• Difficult to suture as intestines
come on the way
• Limited working space after
reduction of contents.
• Sustained CO2 insufflation
• Use of 4th trocar to maintain the
defect open during reduction.
• Insufflation causes a pressure
gradient, impairing reduction.

17. Tip to overcome difficulties in reducing
herniated organs
• Placing trocars as high as possible to gain
enough working space in the thoracic cavity,
• Increasing temporarily CO2 insufflation pressure,
• Widening the orifice of the diaphragmatic hernia
when it is narrow, and
• Using maximal dosage of relaxant medicament.

18. Post op complications of MIS in CDH repair
• Hypercapnia with metabolic acidosis &
hemodynamic instability.
• Bowel injury & perforation during reduction.
• Injury to liver and spleen- Hemoperitoneum
• Pneumothorax due to trocar / barotrauma
• Pleural effusion or Chylothorax
• Subcutaneous Emphysema
• Recurrence
• Death

19. Conclusion
• Minimally invasive surgery seems to offer
advantages for selected patients with CDH.
• Decision making on how to approach patients and
especially neonates surgically should remain
interdisciplinary and should include
-the surgeon,
-the anesthesiologist,
-the neonatologists or pediatrician
-as well as the parents

20. Conclusion
• Thoraoscopic and laparoscopic approaches
have their respective advantages and
disadvantages.
• Success rate of Thoracoscopy (76%) is higher
than laparoscopy (58%).
• Presently Thoracoscopy is considered the gold
standard for postero-lateral diaphragmatic
hernia in newborns with
- Absence of pulm hypertension
- Min pre-op ventilatory support
- Stomach in the abdomen

21. Our experience (N=27)
• Neonatal CDH –12
• Late CDH - 02
• Eventeration - 08
• Morgagni’s Hernia – 03
• Paraesophageal hernia - 02
• Death = 2 cases of Neonatal CDH
• Complications: 1 recurrence & 1 Chylothorax

22. References

23. Minimising scars for lifetime
CHERUBS
The Association of Congenital
Diaphragmatic Hernia Research,
Awareness, and Support

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