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.
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
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.
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.
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.
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
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.
40.
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.