# Neonatal Surgery Essentials — GCMD Library living collection

Updated: n/a · 7 episodes · 123 cited statements

## Episodes
### Congenital Anomalies
- [Congenital Diaphragmatic Hernia with Dr. Charlie Stolar](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303) — podcast · 1:22:05 · [machine version](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303.md)
- [Type of pledget and suture technique relative to esophageal tensile strength in long-gap esophageal atresia](https://library.globalcastmd.com/watch/type-of-pledget-and-suture-technique-relative-to-esophageal-tensile-strength-in-long-gap-esophageal-atresia-12065) — article · [machine version](https://library.globalcastmd.com/watch/type-of-pledget-and-suture-technique-relative-to-esophageal-tensile-strength-in-long-gap-esophageal-atresia-12065.md)

### Neonatal Emergencies
- [Neonatal Gastric Necrosis: Pediatric Surgery Difficult Cases-Innovative...](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436) — video · 15:51 · [machine version](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436.md)
- [Mucous fistula refeeding in neonates: a systematic review and meta-analysis](https://library.globalcastmd.com/watch/mucous-fistula-refeeding-in-neonates-a-systematic-review-and-meta-analysis-6961) — article · [machine version](https://library.globalcastmd.com/watch/mucous-fistula-refeeding-in-neonates-a-systematic-review-and-meta-analysis-6961.md)

### Perioperative Care
- [Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care](https://library.globalcastmd.com/watch/enhanced-recovery-after-surgery-society-recommendations-for-neonatal-perioperative-care-9227) — video · 0:59 · [machine version](https://library.globalcastmd.com/watch/enhanced-recovery-after-surgery-society-recommendations-for-neonatal-perioperative-care-9227.md)
- [Enhanced Recovery After Surgery (ERAS) Society Recommendations for Neonatal Perioperative Care](https://library.globalcastmd.com/watch/enhanced-recovery-after-surgery-society-recommendations-for-neonatal-perioperative-care-9242) — article · [machine version](https://library.globalcastmd.com/watch/enhanced-recovery-after-surgery-society-recommendations-for-neonatal-perioperative-care-9242.md)
- [Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery](https://library.globalcastmd.com/watch/reducing-unplanned-intubations-in-the-neonatal-intensive-care-unit-after-children-s-surgery-8774) — video · 0:53 · [machine version](https://library.globalcastmd.com/watch/reducing-unplanned-intubations-in-the-neonatal-intensive-care-unit-after-children-s-surgery-8774.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=0) Prenatal Counseling and Diagnosis (Ep 1)
- [7:14](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=434) Initial Neonatal Management and Respiratory Strategy (Ep 1)
- [17:48](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1068) ECMO Indications and Contraindications (Ep 1)
- [29:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1761) ECMO Technical Considerations (Ep 1)
- [36:24](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2184) Timing of Surgical Repair (Ep 1)
- [46:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2800) Surgical Approach: Open vs Thoracoscopic (Ep 1)
- [53:56](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3236) Technical Aspects of Repair (Ep 1)
- [59:19](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3559) Postoperative Management and Chest Tubes (Ep 1)
- [69:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4168) Long-term Complications and Follow-up (Ep 1)
- [74:54](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4494) Recurrence and Right-sided Hernias (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=0) Case Presentation: Neonatal Gastric Necrosis (Ep 3)
- [2:46](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=166) Initial Surgical Management Discussion (Ep 3)
- [4:25](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=265) First Operation and Early Postoperative Course (Ep 3)
- [7:45](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=465) Second Operation and Recovery to Reconstruction (Ep 3)
- [10:45](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=645) Reconstruction Strategy and Long-term Outcome (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- CDH occurs in approximately 1 out of every 3,000-4,000 pregnancies — Charlie Stolar (epidemiological) [Ep 1 · 2:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=165)
- CDH diagnosis is typically made at the 20-week anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart — Charlie Stolar (clinical) [Ep 1 · 3:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=217)
- CDH represents a growth arrest of both lungs, with the ipsilateral side more severely affected than the contralateral side — Charlie Stolar (clinical) [Ep 1 · 4:14](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=254)
- At birth, CDH lungs are affected by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation — Charlie Stolar (clinical) [Ep 1 · 4:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=263)
- CDH is a field defect; the most common neonatal comorbidity is foregut motility difficulty — Charlie Stolar (clinical) [Ep 1 · 4:39](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=279)
- CDH is a medical physiologic emergency but not a surgical emergency — Charlie Stolar (clinical) [Ep 1 · 5:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=300)
- The diagnosis of CDH alone is not an indication for cesarean section; elective spontaneous vaginal delivery is recommended assuming no obstetric issues — Charlie Stolar (guideline) [Ep 1 · 5:24](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=324)
- Antenatal interventions for CDH are no better than investigational and experimental at best — Charlie Stolar (opinion) [Ep 1 · 6:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=395)
- Babies with CDH should be born at a full-service children's facility with ECMO capability; maybe 10-15% will benefit from ECMO — Charlie Stolar (guideline) [Ep 1 · 7:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=443)
- In single-center experiences, presence of liver in the chest or stomach in the chest is of no prognostic value — Charlie Stolar (clinical) [Ep 1 · 8:31](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=511)
- Lung-to-head ratio is of limited prognostic value except when very low (less than 0.8), where prognosis is concerning — Charlie Stolar (clinical) [Ep 1 · 8:42](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=522)
- Associated congenital heart disease and central nervous system abnormalities augur for poor prognosis — Charlie Stolar (clinical) [Ep 1 · 9:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=547)
- If shown 100 children with CDH, 80-85% will survive to become teenagers — Charlie Stolar (epidemiological) [Ep 1 · 10:13](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=613)
- Antenatal steroids have tremendous value for preterm labor under 35 weeks but most CDH babies are near-term (37-39 weeks) where steroid role is arguable — Charlie Stolar (clinical) [Ep 1 · 10:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=637)
- Exit to ECMO for CDH is nonsense; it moves the goalposts on almost certainly non-viable babies — Charlie Stolar (opinion) [Ep 1 · 12:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=726)
- We are born with about 1/2 to 2/3 of our full complement of alveoli and can grow the balance sometime after birth — Charlie Stolar (clinical) [Ep 1 · 13:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=780)
- Initial evaluation of newborn with CDH includes looking for morphology, associated anomalies, respiratory distress, pre- and post-ductal oxygen gradients, and early cardiac echo for right heart function — Charlie Stolar (clinical) [Ep 1 · 14:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=885)
- Not every baby with CDH needs or is a candidate for ECMO; approximately 5% have insufficient lung to support life based on inability to saturate preductal blood — Charlie Stolar (clinical) [Ep 1 · 15:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=955)
- ECMO is a drug delivery system for oxygen; indication is when end organs aren't getting enough oxygen despite best care — Charlie Stolar (clinical) [Ep 1 · 17:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1026)
- The best way to assess end-organ function is urine output — Charlie Stolar (clinical) [Ep 1 · 17:44](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1064)
- ECMO indication is typically oxygenation index in excess of 40 for 4 hours or more — Charlie Stolar (guideline) [Ep 1 · 18:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1101)
- All therapy is guided by preductal oximetry, not postductal; if preductal saturation is 90% (PaO2 ~65 torr), the brain is doing fine with fetal hemoglobin — Charlie Stolar (clinical) [Ep 1 · 19:06](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1146)
- When managing dropping preductal saturation, first ensure adequate hemoglobin and circulating volume, then increase FiO2 or ventilator pressure, but avoid trying to control PCO2 as this will destroy the lungs — Charlie Stolar (clinical) [Ep 1 · 20:25](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1225)
- Neonatal ventilators would be thrown out as lethal devices if someone tried to invent them today — Charlie Stolar (opinion) [Ep 1 · 21:38](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1298)
- CDH babies are not paralyzed during ventilation; minimal sedation is used and babies should be awake and breathing spontaneously — Charlie Stolar (clinical) [Ep 1 · 21:56](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1316)
- Initial conventional ventilator settings (IMV rate ~40, peak pressure 25-28, PEEP ~5) are not tolerated by most CDH babies — Charlie Stolar (clinical) [Ep 1 · 22:15](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1335)
- Unconventional ventilation mode for CDH uses high rate (100 breaths/min), low peak pressure (turned down to zero due to stacking), and high gas flow rate with permissive hypercapnia — Charlie Stolar (clinical) [Ep 1 · 22:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1373)
- High-frequency oscillatory ventilation (HFOV) as rescue therapy rarely spares CDH babies from ECMO; when they get out the oscillator, it's time to prime an ECMO circuit — Charlie Stolar (clinical) [Ep 1 · 24:30](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1470)
- Nitric oxide is a waste of money for CDH; it's terrific for premature babies with immature lung disease but of no value in CDH — Charlie Stolar (opinion) [Ep 1 · 25:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1545)
- The best drug for CDH is oxygen — Charlie Stolar (opinion) [Ep 1 · 26:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1567)
- ECMO gestational age limit has been pushed from 36 weeks down to 35, maybe 34 weeks; below 32 weeks the intracranial hemorrhage rate takes off and neurologic outcomes become poor — Charlie Stolar (clinical) [Ep 1 · 26:22](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1582)
- The smallest ECMO arterial cannula is about 8 French; getting adequate flow out of small cannulas is problematic due to resistance related to both length and diameter — Charlie Stolar (clinical) [Ep 1 · 27:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1660)
- For ECMO candidacy, it's the gestational age that matters for intracranial hemorrhage risk (germinal matrix), not the size; size becomes an issue only when cannulas don't fit — Charlie Stolar (clinical) [Ep 1 · 28:15](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1695)
- The broad principle for ECMO candidacy is: do you have a reversible condition? Can you get out with reasonable confidence once you start? — Charlie Stolar (clinical) [Ep 1 · 28:45](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1725)
- VV ECMO is terrific if the heart works but problematic in CDH because heart function is often depressed and it's hard to get the cannula in with the shifted mediastinum — Charlie Stolar (clinical) [Ep 1 · 30:27](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1827)
- VV ECMO is for less sick patients who aren't in extremis; most CDH babies are sicker and do better on VA ECMO — Charlie Stolar (clinical) [Ep 1 · 31:00](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1860)
- VA bypass is basically dialing in a PaO2; VV has mixing issues, cannula position concerns, and is more annoying to manage — Charlie Stolar (clinical) [Ep 1 · 31:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1913)
- Echo guidance during ECMO cannulation is really helpful with the shifted mediastinum; the arterial cannula can go out the subclavian artery or the venous cannula into the innominate vein — Charlie Stolar (clinical) [Ep 1 · 32:17](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1937)
- If the arterial cannula goes out the subclavian artery, you'll have a well-perfused hand and think preductal sats look good, but the baby isn't seeing the oxygen — Charlie Stolar (clinical) [Ep 1 · 33:01](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=1981)
- Using a guide wire to position the venous cannula into the right atrium is helpful when the mediastinum is distorted — Charlie Stolar (clinical) [Ep 1 · 33:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2003)
- Use 3 stay sutures (5-0 Prolene, rubber-shod) to lift the venotomy and arteriotomy open to avoid shearing off the intima and creating a false passage — Charlie Stolar (clinical) [Ep 1 · 33:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2035)
- In the first hours on ECMO, hyperkalemia can cause cardiac arrest if blood isn't washed; just perfuse through it and give calcium — Charlie Stolar (clinical) [Ep 1 · 34:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2087)
- ECMO flow must be increased slowly over 45-90 minutes to reduce intracranial hemorrhage incidence — Charlie Stolar (clinical) [Ep 1 · 34:55](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2095)
- Target VA ECMO flow is 100-125 cc/kg/min, which is about 80% of cardiac output assuming an open duct — Charlie Stolar (clinical) [Ep 1 · 35:10](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2110)
- At target ECMO flow, preductal saturation will be good and mixed venous (from venous drainage) will come up to 65-70% — Charlie Stolar (clinical) [Ep 1 · 35:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2129)
- Regular cardiac echos during ECMO weaning are important to assess right heart function, dilation, tricuspid regurgitation, and pulmonary outflow tract jet — Charlie Stolar (clinical) [Ep 1 · 36:12](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2172)
- The hyperoxia test (turning ventilator FiO2 up to 1.0) demonstrates if the baby can use their lungs; if PaO2 rises, it gives courage to begin weaning ECMO — Charlie Stolar (clinical) [Ep 1 · 36:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2194)
- For babies unweanable from ECMO after 2+ weeks at high flow, ensure they are maximally dried out (bone dry, eyes sucked into head), making good urine, with good labs and chest X-ray before considering on-ECMO repair — Charlie Stolar (clinical) [Ep 1 · 38:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2298)
- Repairing the hernia on ECMO is unusual to get you out of trouble; the problem is lung growth arrest at 14-15 weeks gestation, not that bowel is in the chest — Charlie Stolar (clinical) [Ep 1 · 39:05](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2345)
- Heparin inhibits conversion of fibrinogen to fibrin, so only platelets (beat-up ones) are making clot; platelet thrombus lifespan is 48-72 hours — Charlie Stolar (clinical) [Ep 1 · 40:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2440)
- If operating on ECMO, you have about 48-72 hours to decannulate before bleeding starts; operate when nearly weanable (20 cc/kg/min), expect 1 day of post-op deterioration, then 2-3 days to get off — Charlie Stolar (clinical) [Ep 1 · 41:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2467)
- Operating off ECMO means the baby will get stiff post-operatively, pulmonary hypertension may relapse, and you risk needing a second ECMO run — Charlie Stolar (clinical) [Ep 1 · 41:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2511)
- When operating on ECMO, load with Amicar preoperatively, do abdominal approach, use low threshold for patch to avoid tension, place Jackson-Pratt drain under patch, and place chest tube — Charlie Stolar (clinical) [Ep 1 · 42:39](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2559)
- Futility on ECMO begins to rear its head after 2-3 weeks; it becomes easier to discuss withdrawal if there's been a CNS event like intracranial hemorrhage — Charlie Stolar (clinical) [Ep 1 · 44:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2651)
- For non-ECMO babies, repair timing is when they're on minimal ventilator settings (FiO2 0.4, conventional settings), which typically takes 3-4 days — Charlie Stolar (clinical) [Ep 1 · 45:42](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2742)
- Use the infant ventilator instead of anesthesia machine intraoperatively; infant anesthesia machines have high dead space and aren't very compliant — Charlie Stolar (clinical) [Ep 1 · 46:07](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2767)
- Anesthesia can be all intravenous (muscle relaxants and narcotics); you don't need an anesthesia machine — Charlie Stolar (clinical) [Ep 1 · 46:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2788)
- Pre-repair assessment includes pre/post-ductal gradient, echo showing RV not dilated, RV pressure no more than systemic (not super-systemic), acceptable tricuspid regurgitation, and acceptable pulmonary outflow tract acceleration times — Charlie Stolar (clinical) [Ep 1 · 46:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2807)
- Perioperative antibiotics (typically ampicillin-gentamicin) are given because a patch may be placed in a newborn — Charlie Stolar (clinical) [Ep 1 · 47:57](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2877)
- The thoracoscopic approach provides a gorgeous view and often the bowel reduces with chest insufflation, but only rock-stable kids are candidates because you're creating a tension pneumothorax in a potentially hypercapnic baby — Charlie Stolar (clinical) [Ep 1 · 48:32](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2912)
- In Dr. Stolar's series of 35 thoracoscopic CDH repairs in stable babies, recurrence rate was about 25% in under a year; APSA outcomes committee meta-analysis reached similar conclusions — Charlie Stolar (clinical) [Ep 1 · 49:37](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=2977)
- Laparoscopic CDH repair is problematic because the scaphoid abdomen has loss of abdominal domain; insufflating just puts air up in the chest — Charlie Stolar (opinion) [Ep 1 · 50:21](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3021)
- For open repair, key is adequate subcostal incision (not a small two-finger incision); rotate liver out of chest and abdomen to see the defect — Charlie Stolar (clinical) [Ep 1 · 54:58](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3298)
- Critical repair points are all medial where structures with names are located; mobilize posterior leaflet by unrolling it like a window shade down to the body wall until you feel rib — Charlie Stolar (clinical) [Ep 1 · 55:31](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3331)
- The medial repair is hardest because sometimes the esophagus or aorta hangs out with nothing to sew to; use an upside-down U-shaped pericardial flap rotated down to where the diaphragm would be to begin the repair — Charlie Stolar (clinical) [Ep 1 · 56:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3371)
- Favor monofilament suture (like PDS) because it doesn't saw through tissue when pulled, unlike braided suture like Vicryl — Charlie Stolar (opinion) [Ep 1 · 57:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3436)
- For patches, favor non-biologic material like 1mm Gore-Tex; laterally, anchor the patch to the ribs by getting a needle around the rib and into the patch — Charlie Stolar (clinical) [Ep 1 · 57:59](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3479)
- Make the patch somewhat balloon-shaped with redundancy so the baby doesn't rip sutures out with a deep breath; over time it gets incorporated into fibrous tissue — Charlie Stolar (clinical) [Ep 1 · 58:43](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3523)
- For thoracoscopic repair, use 3 ports (4mm camera with 30-degree lens, 3mm neonatal instruments), insufflation peak pressure 5-7 cm (no more), and reduce spleen last as it obturates the hole and keeps bowel in the belly — Charlie Stolar (clinical) [Ep 1 · 60:23](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3623)
- Thoracoscopically, mobilizing the posterior leaflet is difficult because it's rolled into the abdomen and hard to see around the corner — Charlie Stolar (clinical) [Ep 1 · 61:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3695)
- For thoracoscopic patch placement, use extracorporeal-intracorporeal suture technique: come from outside through skin around rib into patch and back out, tie externally, and bury the knot under the skin — Charlie Stolar (clinical) [Ep 1 · 62:03](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3723)
- If you can see through the diaphragm (it's just pleura and peritoneum with no muscle), resect it back to something that looks like muscle; plication of see-through tissue will fail — Charlie Stolar (clinical) [Ep 1 · 64:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=3856)
- The ipsilateral lung is small and not as big as the pleural space; that's how God made this lung. You won't inflate the lung to fill the chest — Charlie Stolar (clinical) [Ep 1 · 66:47](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4007)
- The pleural space will be obliterated either slowly by lung growth over 3-4 years or by filling with fluid; it's not a pneumothorax under pressure, it's pneumothorax ex vacuo — Charlie Stolar (clinical) [Ep 1 · 67:01](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4021)
- Chest tube on water-seal suction will distort the mediastinum and precipitate a pulmonary hypertensive crisis; there's no reason to put in a chest tube unless there's active air leak or bleeding — Charlie Stolar (clinical) [Ep 1 · 67:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4038)
- Typical stable post-op CDH baby will be unstable for about a day with increased ventilator requirements, then improve and get extubated in 4-5 days — Charlie Stolar (clinical) [Ep 1 · 68:53](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4133)
- CDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz; these kids have disordered motility throughout — Charlie Stolar (clinical) [Ep 1 · 69:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4174)
- All CDH patients should have a GI series showing dilated, ectatic, abnormal esophagus; manometry and impedance show abnormal esophageal and gastric motility and emptying — Charlie Stolar (clinical) [Ep 1 · 69:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4191)
- The foregut problem is not really reflux; calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture — Charlie Stolar (opinion) [Ep 1 · 70:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4209)
- CDH babies do well with continuous feedings slowly condensed to bolus; surgical intervention for foregut issues is unusual and should be approached as palliation — Charlie Stolar (clinical) [Ep 1 · 70:28](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4228)
- Nissen fundoplication is a poor operation for CDH kids (like for esophageal atresia) because their motility is abnormal; if surgery is needed, use a partial wrap with gastrostomy and real drainage procedure (Jaboulay-Finney type, not Heineke-Mikulicz) — Charlie Stolar (opinion) [Ep 1 · 70:40](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4240)
- Dr. Stolar's multidisciplinary CDH clinic follows 450-500 patients for life, addressing heart, lung, foregut, nutrition, neurodevelopmental, and axial skeleton issues that emerge over time — Charlie Stolar (clinical) [Ep 1 · 72:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4331)
- Dr. Stolar has 4 CDH teenagers with Barrett's esophagitis; he recommends lifelong proton pump inhibitors and regular endoscopic surveillance — Charlie Stolar (clinical) [Ep 1 · 73:18](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4398)
- CDH patients have increased incidence of attention deficit disorders and autism; early intervention for neuropsychiatric issues is recommended — Charlie Stolar (clinical) [Ep 1 · 73:57](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4437)
- As a field defect, CDH causes asymmetric chest growth leading to pectus-like distortion; some patients need Nuss-type operations to rebuild chest wall — Charlie Stolar (clinical) [Ep 1 · 74:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4449)
- Some CDH girls have no breast development on the hernia side as teenagers; combined Nuss operation and breast implant procedures have been performed — Charlie Stolar (clinical) [Ep 1 · 74:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4469)
- CDH patients develop thoracolumbar scoliosis (not idiopathic scoliosis, as it's mostly in boys); early bracing programs help minimize this — Charlie Stolar (clinical) [Ep 1 · 74:34](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4474)
- CDH recurrence is related to tension on tissues and tissue quality; it's a tough problem whether tissue-to-tissue or prosthetic repair — Charlie Stolar (clinical) [Ep 1 · 75:16](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4516)
- Recurrence is more common with left-sided CDH than right because the liver plugs up the hole on the right — Charlie Stolar (clinical) [Ep 1 · 77:35](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4655)
- For right-sided CDH, the most important consideration is determining where hepatic veins drain; not infrequently they enter directly into the right atrium, not the suprahepatic IVC — Charlie Stolar (clinical) [Ep 1 · 77:51](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4671)
- If hepatic veins enter the right atrium directly, attempting to reduce the liver into the abdomen will cause a troublesome moment; you should not try to put that liver in the abdomen — Charlie Stolar (clinical) [Ep 1 · 78:09](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4689)
- Hepatopulmonary fusion actually exists in right-sided CDH; the liver and lung are fused and cannot be separated surgically — Charlie Stolar (clinical) [Ep 1 · 78:29](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4709)
- Most patients with hepatopulmonary fusion don't survive; they often have associated severe congenital heart disease and IVC interruption with azygous continuation — Charlie Stolar (clinical) [Ep 1 · 79:11](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4751)
- For right-sided CDH, prep the baby for both thoracic and abdominal incisions; often need to be on both sides to figure out what's going on because the liver is in the way — Charlie Stolar (clinical) [Ep 1 · 79:48](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4788)
- For right-sided CDH, can put a scope through an open thoracotomy to see around corners where the liver might come up against the heart — Charlie Stolar (clinical) [Ep 1 · 80:12](https://library.globalcastmd.com/watch/congenital-diaphragmatic-hernia-with-dr-charlie-stolar-303?t=4812)
- Patient was a twin girl born at 27 weeks weighing just over 1 kg with prenatal diagnosis of twin-to-twin transfusion syndrome as the recipient twin (clinical) [Ep 3 · 0:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=0)
- Laser ablation for TTTS was performed at 22 weeks gestation (clinical) [Ep 3 · 0:50](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=50)
- Stat C-section performed due to maternal septic shock from E. coli sepsis (initially thought to be amniotic fluid embolus) with premature rupture of membranes, vertically transmitted to both neonates (clinical) [Ep 3 · 1:10](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=70)
- Apgar scores were 3 at 1 minute and 1 at 5 minutes, patient intubated at birth (clinical) [Ep 3 · 2:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=120)
- On day 3 of life, iatrogenic manipulation of umbilical venous line caused atrial flutter and significant tachycardia with hemodynamic instability requiring cardioversion (clinical) [Ep 3 · 2:20](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=140)
- At presentation for cardioversion, patient had significant abdominal distention with imaging showing very large amount of free air and unusual shadow in left upper quadrant appearing like loculated free air (clinical) [Ep 3 · 3:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=180)
- Operative findings showed longitudinal perforation along greater curvature with entire corpus extending into fundus and cardia necrotic and not holding stitches, with only margin at cardia and couple centimeters of antrum appearing healthy (clinical) [Ep 3 · 3:40](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=220)
- For subtotal gastric necrosis in unstable neonate, damage control approach should remove frankly necrotic tissue, control upper leakage with tie/vessel loop or drain, and create distal feeding access — Jack (clinical) [Ep 3 · 3:07](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=187)
- Drain placement for gastric necrosis with unidentifiable proximal extent should be positioned under the liver near the GE junction to drain whatever comes out — Jack (clinical) [Ep 3 · 3:52](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=232)
- First operation performed damage control: removed necrotic stomach, placed Foley catheter (0.5cc balloon) in distal esophagus, left Penrose drain under left lobe of liver, created ostomy from 2.5cm gastric remnant (clinical) [Ep 3 · 4:25](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=265)
- Small bowel was like wet toilet paper and multiple hematomas developed in bowel wall from handling, several of which perforated requiring multiple enterorrhaphies (clinical) [Ep 3 · 5:40](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=340)
- Patient was quite coagulopathic by end of first operation but became hemodynamically stable within 12 hours without pressors and with good urine output (clinical) [Ep 3 · 6:10](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=370)
- On postoperative day 3, bilious drainage appeared from Penrose drain; on day 4 patient re-distended with difficulty ventilating and imaging showed significant free air again (clinical) [Ep 3 · 6:50](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=410)
- Second laparotomy revealed no problem with distal esophagus or gastric remnant, but new intestinal perforations: 3cm proximal jejunal necrosis 5cm from ligament of Treitz and spontaneous distal ileal perforation, not at sites of previous repairs (clinical) [Ep 3 · 7:45](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=465)
- Jejunal necrosis treated with resection and primary anastomosis; ileal perforation debrided and repaired; gastrostomy and esophagostomy tubes left intact (clinical) [Ep 3 · 8:50](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=530)
- Patient required only CPAP after 7 days of mechanical ventilation despite extreme prematurity (clinical) [Ep 3 · 9:20](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=560)
- Contrast studies at 2 weeks post-op showed esophagus became like atresic esophagus with segment below diaphragm, no leak around Foley balloon, and esophagus had fibrosed around the catheter (clinical) [Ep 3 · 9:40](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=580)
- Distal contrast study showed gastric remnant emptied well with healed resections and no stenosis (clinical) [Ep 3 · 10:20](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=620)
- Initial gastric feeding was limited by gastric capacity at approximately 34cc, with leak around G-tube when larger volumes attempted (clinical) [Ep 3 · 10:40](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=640)
- Gastroduodenal feeding tube advanced through gastrostomy successfully weaned patient off TPN with all feeds through small intestine plus small amounts of sham feeds suctioned through esophageal tube (clinical) [Ep 3 · 11:05](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=665)
- For reconstruction with remaining proximal and distal stomach segments, attempting to connect the two stomach ends is reasonable but if unsuccessful a jejunal conduit should be used — Kathy (opinion) [Ep 3 · 11:44](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=704)
- Salvaging a 4 cubic centimeter stomach would create microgastria with attendant problems of reflux and other issues (clinical) [Ep 3 · 12:03](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=723)
- Two patients with Hunt-Lawrence pouch (not performed by speaker) had persistent trouble emptying with significant stasis and poor progression (clinical) [Ep 3 · 12:30](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=750)
- Pre-reconstruction contrast study showed small gastric segment remaining with esophagus distending nicely without strictures (clinical) [Ep 3 · 13:30](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=810)
- Reconstruction performed at 5 months of age, 55 weeks post-conception age, weight 5kg, using Roux-en-Y fundojejunostomy with segment 15cm distal to ligament of Treitz and 25cm limb (clinical) [Ep 3 · 14:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=840)
- Post-reconstruction contrast study on postoperative day 6 showed good emptying, allowing start of combination oral and gastrostomy feeds (clinical) [Ep 3 · 14:40](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=880)
- Patient discharged 52 days after reconstruction with total hospital stay of 207 days (clinical) [Ep 3 · 15:05](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=905)
- At 2.5 years old, patient takes normal diet for age on full oral feeds with only nighttime gastrostomy supplementation anticipated to be discontinued early in new year, and is larger than unaffected twin (clinical) [Ep 3 · 15:20](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=920)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Michigan group published case report of microgastria treated with Roux-en-Y esophago-fundojejunostomy similar to adult gastric cancer surgery — The host summarizing the discussion [Ep 3 · 13:00](https://library.globalcastmd.com/watch/neonatal-gastric-necrosis-pediatric-surgery-difficult-cases-innovative-436?t=780)

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