Great Ormond Street Hospital for Children, Surgery Offices, Zayed Centre for Research, UCL Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
, Present address: Evelina Children's Hospital, London, UK.
Pediatr Surg Int. 2023 Feb 20;39(1):135. doi: 10.1007/s00383-022-05303-y.
Minimal Access Surgery (MAS) for Congenital Diaphragmatic Hernia (CDH) repair is well described, yet only a minority of surgeons report this as their preferred operative approach. Some surgeons find it particularly difficult to repair the defect using MAS and convert to laparotomy when a patch is required. We present in this study our institutional experience in using an easy and relatively cheap methodology to anchor the patch around the ribs using Endo Close™. This device has an application in MAS for tissue approximation using percutaneous suturing.
We retrospectively reviewed our database for patients undergoing MAS repair of CDH between 2009 and 2021. Outcome measures included length of surgery and recurrence rates after patch repair. Endo Close™ was used in all patients who required patch repair. We declare no conflict of interest and to not having received any funding from Medtronic (UK). The technique is as follows: (1) The edges of the diaphragm are delineated by dissection. When primary suture repair of the diaphragmatic hernia was unfeasible without tension, a patch was used. (2) The patch is anchored in place by two corner stitches at the medial and lateral borders. (3) The posterior border of the patch is fixed to the diaphragmatic edge by running or interrupted stitches. (4) For securing the anterior border, a non-absorbable suture is passed through the anterior chest wall and the patch border is taken with intracorporeal instruments. (5) Without making another stab incision, the Endo Close™ is tunnelled subcutaneously through the anterior chest wall. (6) The suture end is pulled through the Endo Close™ and the knot is tied around the rib. This procedure can be performed as many times as required to secure the patch.
58 patients underwent MAS surgery for repair of CDH between 2009 and 2021. 48 (82%) presented with a left defect. 34 (58%) had a patch repair. The length of patch repair surgery for CDH ranged from 100-343 min (median 197). There was only one patient (3%) in the patch repair cohort that had a recurrent hernia, diagnosed 12 months after the initial surgery.
In our experience, MAS repair of CDH is feasible. We adopted a low threshold in using a patch to achieve a tension-free repair. We believe that the Endo Close™ is a cheap and safe method to help securing the patch around the ribs.
微创外科（MAS）治疗先天性膈疝（CDH）的修复方法已有详细描述，但只有少数外科医生将其作为首选手术方法。一些外科医生发现，使用 MAS 修复缺陷特别困难，当需要补片时，他们会转为开腹手术。我们在本研究中介绍了我们机构使用一种简单且相对廉价的方法，使用 Endo Close™将补片固定在肋骨周围的经验。该设备在使用经皮缝合进行组织吻合的 MAS 中具有应用。
我们回顾性地审查了 2009 年至 2021 年间接受 MAS 修复 CDH 的患者数据库。观察指标包括手术时间和补片修复后的复发率。所有需要补片修复的患者均使用 Endo Close™。我们声明没有利益冲突，也没有收到 Medtronic（英国）的任何资助。该技术如下：（1）通过解剖确定膈的边缘。当无法无张力地进行原发性膈疝缝合修复时，需要使用补片。（2）通过在内侧和外侧边界的两个角点缝线将补片固定到位。（3）通过连续或间断缝线将补片的后缘固定在膈缘上。（4）为了固定前缘，将不可吸收缝线穿过前胸壁，用体内器械将补片边缘带过来。（5）无需再做一个戳口，将 Endo Close™通过前胸壁皮下隧道。（6）将缝线末端穿过 Endo Close™，并在肋骨周围打结。可以根据需要多次进行此操作以固定补片。
2009 年至 2021 年间，58 例患者接受 MAS 手术治疗 CDH。48 例（82%）存在左侧缺陷。34 例（58%）接受了补片修复。CDH 补片修复手术的时间范围为 100-343 分钟（中位数 197 分钟）。在补片修复组中，只有 1 例（3%）患者在初次手术后 12 个月时出现复发性疝。
根据我们的经验，MAS 修复 CDH 是可行的。我们采用低阈值使用补片来实现无张力修复。我们认为，Endo Close™是一种廉价且安全的方法，可帮助将补片固定在肋骨周围。
