Neonatal Surgery Essentials

Congenital diaphragmatic hernia (CDH) occurs in approximately 1:3,000–4,000 pregnancies, typically diagnosed at the 20-week anatomy scan when the stomach appears in the same plane as the heart [e303-c1, e303-c2]. CDH represents a growth arrest of both lungs at 14–15 weeks gestation, with the ipsilateral side more severely affected; it is a field defect affecting the entire foregut from pharynx to ligament of Treitz [e303-c3, e303-c5, e303-c49]. At birth, lungs are affected by pulmonary hypoplasia and altered pulmonary vascular resistance . CDH is a physiologic emergency but not a surgical emergency; babies should be born at full-service children's facilities with ECMO capability, though only 10–15% will require ECMO [e303-c6, e303-c9]. Antenatal interventions remain experimental, and cesarean section is not indicated for CDH alone [e303-c7, e303-c8]. Overall survival to teenage years is 80–85% . Management centers on gentle ventilation (high rate, low pressure, permissive hypercapnia), preductal oximetry targets, and avoiding lung injury [e303-c22, e303-c23, e303-c27]. ECMO indication is oxygenation index >40 for ≥4 hours when end organs (assessed by urine output) are inadequately perfused [e303-c19, e303-c20, e303-c21]. Repair timing is when babies are stable on minimal ventilator settings, typically 3–4 days for non-ECMO patients . Thoracoscopic repair offers excellent visualization but carries ~25% recurrence risk; open subcostal approach remains standard [e303-c60, e303-c61, e303-c63]. Long-term sequelae include foregut dysmotility (not true reflux), neurodevelopmental issues, chest wall asymmetry, and scoliosis, necessitating lifelong multidisciplinary follow-up [e303-c77, e303-c82, e303-c84, e303-c85, e303-c87].