CONGENITAL DIAPHRAGMATIC HERNIA- PEDIATRIC SURGERY #surgicaleducator #congenitaldiaphragmatichernia #usmle #babysurgeon #surgicaltutor Subscription Link: http://youtube.com/c/surgicaleducator... • Dear Viewers, • Greetings from “Surgical Educator” • Today I have uploaded a video on Congenital Diaphragmatic Hernia • I have discussed definition, pathology, antenatal diagnosis, postnatal diagnosis, pre-op stabilization, prognostic factors, treatment and long-term followup of CDH. • I hope the video will be very useful and you will enjoy it. • You can watch all my surgical teaching videos in the following link: • youtube.com/c/surgicaleducator • Thank you for watching the video.

1. L/O/G/O
Congenital Diaphragmatic
Hernia- CDH Dr.B.SELVARAJ

2. Congenital Diaphragmatic
Hernia
Antenatal assessment & counseling
Postnatal management & role of ECLS
Long term multidisciplinary follow-up
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Learning Objectives

3. www.themegallery.com
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4. Congenital Diaphragmatic Hernia
& Eventration of diaphragm
Herniation of abdominal contents into the thorax
through a defect in diaphragm
In Eventration, diaphragm is replaced by a thin
membrane
Incidence 1 in 4000 live births

5. Congenital Diaphragmatic Hernia

6. Congenital Diaphragmatic Hernia
Pathology
Posterolateral Bochdalek Hernia: Commonest
Lt side 80% Rtside 19% Bilateral 1%
Anteromedial Morgagni’s Hernia: 2%
Hypoplastic ipsilateral lung due to compression by
herniated viscera
Persistent pulmonary hypertension(PPHN) due to
abnormal pulmonary vasculature

7. Congenital Diaphragmatic Hernia
Associated Anomalies
Neural tube defects
PDA,VSD,Coarctation of Aorta- Commonest
Midgut Malrotation
Cleft palate
Exomphalos
1/3 rd of CDH Children

8. Congenital Diaphragmatic
HerniaClinical Features
Respiratory distressTachypnea,
Cyanosis,Tachycardia,Etc
Scaphoid Abdomen/ Barrel shaped chest
Mediastinal shift to opposite side
In Lt sided CDH: Pseudodextrocardia
Absence of breath sounds & presence of bowel sounds
in ipsilateral hemithorax

9. Congenital Diaphragmatic
HerniaClinical Features
Barrel shaped chest
Scaphoid abdomen

10. Congenital Diaphragmatic
Hernia—Imaging Studies
Antenatal USG & MRI of Chest of the fetus
Postnatal CXR1.Presence of bowel shadows in the
hemithorax 2. Mediastinal shift to the opposite side
3.Diaphragmatic margin is absent
In EventrationFrontal&lateral CXR show elevated
diaphragm with smooth unbroken margin
Flouroscopy:Paradoxical movement of diaphragm in
eventration

11. Congenital Diaphragmatic Hernia-
Antenatal Fetal USG Chest

12. Congenital Diaphragmatic Hernia-
Antenatal Fetal MRI
LHR- <1; >1.4
TFLV

13. Congenital Diaphragmatic Hernia-
Antenatal Fetal MRI

14. Congenital Diaphragmatic Hernia-
Postnatal CXR

15. Congenital Diaphragmatic Hernia-
Postnatal CXR

16. Congenital Diaphragmatic Hernia
Pre op Management
In Utero transfer to a maternity unit close to
Pediatric surgical centreElectively deliver,
promptly resuscitate & operate
NGT aspiration to decompress GIT
ET tube ventilation; “No face mask ventilation”
“EXIT” Extrauterine Intrapartum Treatment
Correct acidosis with NaHCO3 & Tromethamine
(THAM)

17. Congenital Diaphragmatic Hernia
Pre op Management
Delayed Repair after preop stabilisation aimed at
correcting hypoxia, hypoperfusion& PPHN
Correct PPHN with Tolazolin, iNO- Nitric oxide or
Sildenafil
Pre&post ductal O2 saturation to assess the degree of
arterial oxygenation &ductal shunting
In intractable PPHNECMO/ECLS may be tried

18. Congenital Diaphragmatic Hernia
Bad Prognostic Indicators
Infants born to mothers with Polyhydramnios
Stomach in thorax
Lung to Head ratio: LHR < 1
Presentation within first 6Hrs of birth
Very low blood pH & high PCo2
Rt sided hernia

19. Congenital Diaphragmatic Hernia
Prognostic Indicators
Alveolar-arterial O2 tension difference (AaDo2)
If>500mmHg bad prognosis
Ventilatory Index: VI=RRxMAPxPaco2
When Paco2 is <40mmHg & VI is <1000 all babies
survive
O2Index:OI=MAPXFiO2X100/Pao2
OI<6 Survival rate 98%
OI>17 No Survivors

20. Congenital Diaphragmatic Hernia
Clinical Prediction Scoring
Birth weight of the baby
5-minute Apgar Score
Congenital heart anomalies/Chromosomal anomalies
PPHN-Persistent Pulmonary Hypertension
Total Score= 0 to 8
Low=0 Intermediate= 2 High= >4

21. Congenital Diaphragmatic Hernia
Fetoscopic endoluminal tracheal occlusion

22. Congenital Diaphragmatic Hernia
EXIT to ECMO

23. Congenital Diaphragmatic Hernia
Management Algorithm

24. Congenital Diaphragmatic Hernia
CDH Study Group Staging

25. Congenital Diaphragmatic Hernia
Operative Management

26. Congenital Diaphragmatic Hernia
Operative Management

27. Eventration of Diaphragm
Plication

28. Congenital Diaphragmatic Hernia
Post op Management in NICU
Ventilatory support to maintain postductal Po2 80 to
100mmHg; Pco2 < 30mmHg & pH > 7.4
This can be achieved by high frequency ventilation
with low airway pressures & low tidal volume
Weaning from ventilator should be meticulous & slow
as small variation in pH, Po2& Pco2 will lead to
PPHN

29. Congenital Diaphragmatic Hernia
Long-term Follow-up
Weight gain is problematic and needs dietary advice
Regular CXR may detect asymptomatic recurrence
Audiology review for late onset hearing loss
Neurodevelopment follow-up including Bayley Score
Sildenafil dose should be tapered and stopped once
PPHN resolved
CVS and Respiratory function testing should be done

30. Congenital Diaphragmatic Hernia
Take Home Message
CDH remains a challenging neonatal problem
Antenatal detection aids counselling and safe delivery
PPHN+Pulmonary hypoplasia-determine survival
Surgical repair delayed until PPHN is controlled
ECLS should be considered if conventional treatment
fails
Long-term multi-disciplinary follow-up is essential

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