IPEG 2020 TOP ABSTRACT: Thoracoscopic Repair of Right Congenital Diaphragmatic Hernia on ECMO

We present a thoracoscopic repair of a right congenital diaphragmatic hernia while on ECMO support. This male infant was prenatally diagnosed with a right congenital diaphragmatic hernia. Measurements on ultrasound included a lung to head ratio of 1 to 1, and the liver appeared to have herniated into the chest. No other abnormalities were identified. The child was born at 39 weeks and was intubated in the delivery room. The infant quickly showed signs of respiratory failure requiring escalation of support to the high frequency oscillatory ventilator, along with the use of vecurronium and inhaled nitric oxide. The head ultrasound was normal and an echocardiogram showed a moderate sized PDA with systemic arterial pressures. Due to worsening hypoxia, the infant was cannulated to VAEC mode approximately 18 hours of life. After cannulation, the decision was made to repair the diaphragmatic defect early as per our institutional protocol. This was performed on day of life too after stabilization, which occurred approximately 24 hours after cannulation. As this was a right-sided defect and the patient was on ECMO, a thoracoscopic approach was selected. The patient was placed right side up while maintaining the ECMO catheters in place. The ECMO catheters were far from the operative field and did not interfere with the operation. A 5 millimeter port was placed just below the right scapula, with two other incisions made in the posterior and anterior chest inferiorly under direct vision. All of the bowel was located within the chest. The right lobe of the liver was also in the chest and had flipped up on itself. The bowel was reduced into the abdominal cavity along with the liver after the liver was flipped back into normal anatomic position. The diaphragmatic defect was large in size and was unable to be closed primarily. However, there was a moderate rim of diaphragmatic tissue medially and a thin rim posteriorly. There was no diaphragmatic hernia sac. A single 20 silk was first placed in the lower aspect of the defect to partially close the defect and keep the liver from trying to re-herniate into the chest. At this point there was no need for additional insufflation. A 5 by 10 centimeter biologic mesh was brought into the chest to be used as an underlay under the diaphragmatic rim. It was secured using 20 silk suture. The right stitch incorporated the posterior lateral rim. A small stab incision was then made over a rib, and a 20 silk suture was then placed around the rib and through the mesh, securing it to the rib. Before being placed in the chest, 20 braided permanent sutures were placed on the lateral and posterior lateral edges of a 5 by 7.5 centimeter polytetrafluoroethylene mesh. A medial stab incision was made, and a suture passing device was used to bring each of those sutures around a rib. This was done sequentially to secure the mesh to the ribs. The mesh was then secured medially and posteriorly to the muscular rim of the diaphragm using 20 silk allowing for good coverage without undue tension. Upon final inspection, no bleeding or other abnormalities were noted. A blake drain was then inserted through the port incision site. The patient's abdomen remained soft and nondistended. Total operating time was 2 hours and 19 minutes. Post-operatively, the patient was able to be briefly extubated, allowing for long rest. He unfortunately developed seizures on postoperative day 13, for which he required multiple epileptics to control. He was able to be decanulated on post-op day 18, extubated at just over 1 month of age, and was able to wean to room air within a week of extubation. Due to poor oral feeding skills, a laparoscopic gastrostomy tube was placed prior to discharge home on postoperative day 67. Since his repair, he has been readmitted once for viral bronchiolitis but was able to be discharged home in time for Christmas. This picture shows the intact repair 2 months later when the patient received his gastrostomy tube. Thank you.