Becmeur F, Jamali R R, Moog R, Keller L, Christmann D, Donato L, Kauffmann I, Schwaab C, Carrenard G, Sauvage P
Division of Pediatric Surgery, University Hospital of Strasbourg, 67098 Strasbourg Cedex, France.
Surg Endosc. 2001 Oct;15(10):1163-6. doi: 10.1007/s004640090064. Epub 2001 Aug 16.
Delayed presentations of congenital hernia occurring outside of the neonatal period have been reported for all ages. Classically, repair of the hernia defect involves a transverse subcostal laparotomy in the pediatric age group and usually a thoracotomy in the adult. The first report describing a laparoscopic repair of a congenital diaphragmatic hernia in a 6-month-old infant was published in 1995. During the past 25 years, 17 patients with delayed presentation of congenital diaphragmatic hernias have been managed by our pediatric surgery team. The last three patients underwent surgery thoracoscopically.
This study involved two boys (ages, 8.3 and 19 months, respectively) and one girl (age, 9 months) weighing 8 to 13 kg. All three infants underwent surgery using a thoracoscopic approach with general anesthesia. A thoracic epidural catheter was placed systematically for postoperative analgesia during the first 24 hours. Reduction of the hernia contents using one optical trocar and two operating trocars was difficult in the case without any hernia sac. In the cases with a hernia sac, reduction was easily and quickly obtained with a pleural insufflation of carbon dioxide (~8 mmHg). The hernia defect was repaired using interrupted sutures of 2/0 Ethibond. For two of the three patients, this repair was reinforced with staples in the one case and a nonresorbable mesh in the other case.
The mean operative time was 78 min. The chest tube was removed on the first or second postoperative day and the patients were discharged on the fourth or fifth postoperative day. At the 19-month follow-up assessment in one case, the chest x-ray was perfectly normal and diaphragmatic motion also was confirmed to be normal by ultrasonography.
The thoracoscopic approach for the repair of delayed-presentation congenital diaphragmatic hernia is feasible. Our results demonstrate the safety and efficiency of this surgery, as well as a remarkable functional and cosmetic result and a very quick recovery.
各年龄段均有关于新生儿期以外出现的先天性疝延迟就诊的报道。传统上，小儿年龄组的疝缺损修复采用经肋下横切口剖腹术，而成人通常采用开胸术。1995年发表了首例关于6个月大婴儿先天性膈疝腹腔镜修复术的报告。在过去25年里，我们的小儿外科团队治疗了17例先天性膈疝延迟就诊的患者。最后3例患者接受了胸腔镜手术。
本研究纳入了两名男孩（年龄分别为8.3个月和19个月）和一名女孩（年龄为9个月），体重8至13千克。所有三名婴儿均在全身麻醉下采用胸腔镜手术方法。系统放置胸段硬膜外导管用于术后24小时内的镇痛。在没有疝囊的病例中，使用一个观察套管针和两个操作套管针回纳疝内容物很困难。在有疝囊的病例中，通过注入二氧化碳（约8 mmHg）进行胸膜腔充气，可轻松快速地回纳疝内容物。使用2/0 Ethibond间断缝合修复疝缺损。三名患者中的两名，一例用吻合器加固修复，另一例用不可吸收补片加固修复。
平均手术时间为78分钟。术后第一天或第二天拔除胸管，患者于术后第四天或第五天出院。在一例患者19个月的随访评估中，胸部X线检查完全正常，超声检查也证实膈肌运动正常。
胸腔镜手术修复延迟就诊的先天性膈疝是可行的。我们的结果证明了该手术的安全性和有效性，以及显著的功能和美容效果，且恢复非常迅速。
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