This document summarizes different surgical techniques for repairing congenital diaphragmatic hernias including Bochdalek and Morgagni hernias. It discusses moving from emergency to delayed repair, different surgical approaches (thoracotomy, laparotomy, thoracoscopy, laparoscopy), use of prosthetic materials versus biological materials, muscle flap techniques, and recurrence rates associated with patch repair. It also summarizes the fetal endoscopic tracheal occlusion technique used in some severe cases to promote lung growth before repair. Current status notes the procedure is considered investigational but being evaluated in a clinical trial for left-sided CDH and can be offered for severe right-sided cases.

1. Congenital diaphragmatic hernia
Surgical technique
SAMEH SHEHATA

3. Bochdalec hernia
Morgagni hernia
Fetal Surgery
Recent literature
1
2
3
4
CONTENTS

4. Bochdalec hernia

5. Emergency repair?
Before
1980

6. Why ?
 No improvement in gas exchange was
observed.
 thoracic compliance and PaC02 had a
tendency to deteriorate in the immediate
postoperative period

7. From Emergency To delayed repair
 delaying repair for at least 24–48 hours .
 up to 7–10 days.
 clinical stabilization
 fall in pulmonary vascular resistance

8. Till when?
 FiO2 <0.5
 Mean blood pressure normal
 Urine output >2mL kg-1h-1
 No signs of persistent pulmonary hypertension

9. Which
way
THORACOTOMY ?
LAPAROTOMY?
THORACOSCOPY?
LAPAROSCOPY?
ROBOTIC?

10. Trans Thoracic
 Right sided hernia.
 +ve pressure reduce contents.
 Sac adhesions.

12. the outcomes of open repair were almost identical to those of thoracoscopic repair.
A notable exception is the recurrence rate, which was significantly higher in the
thoracoscopic-repair group.
For the time being, thoracoscopic primary closure seems a safe and effective procedure,
but efficacy of thoracoscopic patch repair has not been established.

13. Transabdominal
 Bilateral hernia
 Abdominal pathology.
 Morgagni.

14. Prosthetic materials
 polypropylene mesh (Marlex)
 polytetrafluoroethylene (PTFE) patch (Goretex)
 expanded polytetrafluoroethylene (ePTFE)
 polyethylene terephthalate mesh (Dacron)
 Surgisis

15. None is ideal !

16. Biological
 dura
 bovine pericardium
 autologous tissues
 fascia
 muscle flaps

17. Muscle flaps
 Reverse latissimus dorsi.
Anterior abdominal wall.
 Less adhesive obstruction and infection.
 Body deformity.
 Reserved fro recurrence.

18. Is patch repair associated
with higher recurrence?

19.  synthetic patch repair for CDH can be performed
with a very low rate of recurrence
 High rates of recurrence reported
for patch repair may be technical rather than
intrinsic to the patch.

24. Morgagni hernia

27.  In MH, recurrence and complication rates are
comparable between MIS and open repairs.
 Use of patch appeared to confer additional benefit
in reducing recurrence.

28. Difficult
abdominal
closure!
 closure of skin
alone,
 inlay mesh
 creation of a
silo

30. FETO
 Occlude the trachea in utero (26 w)
 lung expansion
 Retrieval of balloon (34 w)
 Stabilize and assess (birth)
 Surgical repair CDH (48 hr.)

31. Patient Selection & Controls
 Only severe most life-threatening CDH cases
 20 week U/S - Lung area : head
circumference ratio < 1.0
 Controls same criteria who elected not to proceed

32. FETO instruments
 Specialized Endoscopic
Instrumentation
 – 1.2 mm fetoscope
 Custom-made Intra-
tracheal Balloon

33. 26 weeks
Balloon
insertion

35. Unplug: Balloon removal (34 weeks)
 Ultrasound guided puncture.
 Fetoscopic removal
 Removal at EXIT

36. Unplug : EXIT

37. EXIT

38. Results of Foetal Balloon Placement for
CDH
 Collaborative Team :
- King’s College Hospital, London UK – K Nicolaides,
G Morrison, S Blaney
- Catholic University of Leuven, Belgium - Prof Jan de Prest et al.
- Fetal Medicine Unit, Department of O&G, Hospital Clinic, Barcelona, Spain -
Prof Anne Debeer et al.
 Over 30 Balloon Placements
 Control Group = Balloon refusers with same severity >90 % Mortality

39. Results of Fetal Balloon Placement for CDH
 Increased incidence of premature rupture
of membranes
 75 % early neonatal survival
 66 % surgical repair of CDH
 58 % survival to 28 days
 50 % long-term survival.

41. Current status
For left-sided severe and moderate CDH, the
procedure is considered investigational
is currently being evaluated in a global randomized
clinical trial. TOTAL
The procedure can be clinically offered to fetuses with
severe right-sided CDH.