Kim Anne C, Bryner Benjamin S, Akay Begum, Geiger James D, Hirschl Ronald B, Mychaliska George B
Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School and The C.S. Mott Children's Hospital, Ann Arbor, MI 48109, USA.
J Laparoendosc Adv Surg Tech A. 2009 Aug;19(4):575-80. doi: 10.1089/lap.2009.0129.
We sought to characterize our recent experience with thoracoscopic congenital diaphragmatic hernia (CDH) repair and identify patient selection factors.
We reviewed the medical records of full-term neonatal (<1 month of age) patients who underwent thoracoscopic CDH repair between 2004 and 2008 (n = 15). We obtained data on prenatal diagnosis, characteristics of the CDH and repair, complications, and outcome.
All patients were stabilized preoperatively and underwent repair at an average of 5.7 +/- 1.3 days. Six patients were prenatally diagnosed, including the 5 inborn. Thirteen defects were left-sided. All were intubated shortly after birth and 2 required extracorporeal membrane oxygenation (ECMO). Twelve of 15 (80%) patients underwent successful thoracoscopic primary repair, including 1 of the patients who required ECMO prior to repair. Conversion to open repair occurred in 3 of 15 (20%) patients because of the need for patch closure or intraoperative instability. Among those converted to open, all had left-sided CDH defects and 3 had stomach herniation (of 5 such patients). Patients spent an average of 6.9 +/- 1.0 days on the ventilator following repair. The average time until full-enteral feeding was 16.7 +/- 2.25 days, and average length of hospital stay was 23.8 +/- 2.73 days. All patients survived to discharge, and average length of follow-up was 15.3 +/- 3.6 months.
Thoracoscopic repair of CDH is a safe, effective strategy in patients who have undergone prior stabilization. Stomach herniation is associated with, but does not categorically predict, conversion to open repair. ECMO use prior to repair should not be an absolute contraindication to thoracoscopic repair.
我们试图描述我们近期胸腔镜下先天性膈疝（CDH）修补术的经验，并确定患者选择因素。
我们回顾了2004年至2008年间接受胸腔镜下CDH修补术的足月新生儿（年龄<1个月）患者的病历（n = 15）。我们获取了有关产前诊断、CDH的特征及修补情况、并发症和结局的数据。
所有患者术前均病情稳定，平均在5.7±1.3天接受修补术。6例患者为产前诊断，其中5例为顺产。13处缺损位于左侧。所有患者出生后不久均行气管插管，2例需要体外膜肺氧合（ECMO）。15例患者中有12例（80%）成功接受了胸腔镜下一期修补术，其中包括1例修补术前需要ECMO的患者。15例患者中有3例（20%）因需要补片修补或术中不稳定而转为开放修补术。转为开放修补术的患者中，均为左侧CDH缺损，5例胃疝患者中有3例出现胃疝。修补术后患者平均机械通气时间为6.9±1.0天。完全经口喂养的平均时间为16.7±2.25天，平均住院时间为23.8±2.73天。所有患者均存活出院，平均随访时间为15.3±3.6个月。
胸腔镜下CDH修补术对于术前病情已稳定的患者是一种安全、有效的策略。胃疝与转为开放修补术有关，但不能绝对预测。修补术前使用ECMO不应成为胸腔镜修补术的绝对禁忌证。
