Shah Sohail R, Gittes George K, Barsness Katherine A, Kane Timothy D
Division of Pediatric General and Thoracic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, 3705 Fifth Ave., 4A-485, Pittsburgh, PA 15213, USA,
Surg Endosc. 2009 Jan;23(1):215. doi: 10.1007/s00464-008-0071-1. Epub 2008 Jul 15.
Minimally invasive techniques continue to expand in pediatric surgery; however, there has been some debate over the appropriate operative technique for the management of congenital diaphragmatic hernias in neonates. We present a video of a thoracoscopic patch repair of a right-sided Bochdalek congenital diaphragmatic hernia (CDH) in a 3-day-old male.
Our patient was noted to have a right-sided CDH on chest X-ray following respiratory distress at the time of birth. The patient's remaining neonatal workup also confirmed hypoplastic transverse aortic arch with coarctation, ventricular septal defect (VSD), and patent ductus arteriosus, which were initially diagnosed by prenatal ultrasound. After monitoring the patient for hemodynamic stability and discussion with the family and involved pediatric cardiothoracic surgeons, the decision was made to proceed with a thoracoscopic repair of the CDH.
The large right-sided CDH was noted to involve herniated small bowel, colon, and liver. The diaphragmatic defect was successfully repaired thoracoscopically using a 5 x 5 cm polytetrafluoroethylene (PTFE) patch. The patient was extubated on the second postoperative day and ultimately underwent aortic arch augmentation, VSD closure, and patent ductus arteriosus ligation and division at 1 month of age. There has been no evidence of CDH recurrence in follow-up.
As demonstrated by our video, large right-sided congenital diaphragmatic hernias requiring patch repair can be successfully repaired thoracoscopically with appropriate surgeon comfort and experience. This minimally invasive approach may also be used in neonates with associated cardiac defects with appropriate cardiothoracic surgical consultation and support. To our knowledge this is the first reported case of a thoracoscopic repair of a Bochdalek (posterolateral) hernia with a prosthetic patch in a neonate with significant congenital cardiac anomalies.
微创技术在小儿外科领域不断拓展；然而，对于新生儿先天性膈疝的合适手术技术一直存在一些争议。我们展示一段3日龄男婴右侧Bochdalek先天性膈疝（CDH）胸腔镜补片修补术的视频。
我们的患者出生时出现呼吸窘迫，胸部X线检查发现右侧CDH。患者其余的新生儿检查还证实存在发育不全的横位主动脉弓伴缩窄、室间隔缺损（VSD）和动脉导管未闭，这些最初是通过产前超声诊断的。在监测患者血流动力学稳定性并与家属及小儿心胸外科医生讨论后，决定进行CDH的胸腔镜修补术。
发现巨大的右侧CDH包含疝入的小肠、结肠和肝脏。使用一块5×5厘米的聚四氟乙烯（PTFE）补片成功地通过胸腔镜修复了膈缺损。患者术后第二天拔除气管插管，最终在1月龄时接受了主动脉弓扩大术、VSD修补术以及动脉导管未闭结扎和切断术。随访中未发现CDH复发的迹象。
正如我们的视频所示，需要补片修补的巨大右侧先天性膈疝，在外科医生具备适当的操作熟练度和经验的情况下，可通过胸腔镜成功修复。这种微创方法也可用于伴有相关心脏缺陷的新生儿，并进行适当的心胸外科会诊和支持。据我们所知，这是首例报道的在患有严重先天性心脏异常的新生儿中使用人工补片进行胸腔镜修补Bochdalek（后外侧）疝的病例。
